What is Reflex Sympathetic Dystrophy (RSD)?

December 11, 2013June 24, 2014 / Thomas Cohn, MD

Reflex sympathetic dystrophy is one of the older terminologies for what is currently known as Complex Regional Pain Syndrome (CRPS). Other terms used include:

Causalgia syndrome
Sudeck’s atrophy
Algodystrophy
Algoneurodystrophy
Reflex neurovascular dystrophy

History of RSD and CRPS

At this time the preferred medical term is CRPS. In 1993 the terminology changed from RSD to CRPS to better define underlying problems associated with the syndrome. Two types of CRPS were further defined:

CRPS Type 1 has the characteristic painful limb, but has no definite nerve injury as the cause
CRPS Type 2 has obvious previous nerve damage

Quality of Treatment

Quality of treatment for RSD/CRPS depends on the knowledge and experience of the practitioner coordinating care. CRPS is a complex problem, many physicians work with the syndrome on an occasional basis. A pain physician who treats this condition almost daily is likely the best source to turn to for management and treatment options. Experience in recognizing the problem and offering a comprehensive multi-disciplinary approach is essential.

It truly requires a “hands on” physician who coordinates all aspects of care. The mark of a good physician is one who not only recognizes what is wrong, but one who can determine all the contributing factors to the syndrome and what is maintaining the problem. Few pain specialists truly understand the condition, finding a good physician may seem like finding a needle in the haystack.

Diagnosis and treatment of CRPS and RSD depends on finding the right physician. It is not guess work at management. It often takes time and patience by both the physician and patient. Experienced physicians will be much more successful in management, do not settle for just anyone who just claims to have treated the condition.

Complex Regional Pain Syndrome (CRPS) – Causes & Treatment

September 30, 2013November 17, 2015 / Thomas Cohn, MD

Complex regional pain syndrome (CRPS) is a pain problem manifested by severe pain. It is a poorly understood disorder that causes intense pain.

With CRPS, the nervous system becomes hyper sensitized – normal sensations become amplified. The thermostat for pain sensitivity becomes set at the wrong level. The sympathetic autonomic nervous system also becomes hyperactive. This combination of problems leads to severe pain in the affected area, often a hand or foot.

2 Types of CRPS

There are two basic types of CRPS:

Type I occurs with no known nerve injury
Type II occurs in association with a known nerve injury

CRPS describes an array of painful conditions characterized by regional symptoms seemingly disproportionate to the usual course of trauma or injury. The pain is regional, not in a specific nerve or muscle distribution. The patient will report sensory changes such as:

Hyperesthesia
Changes in skin color
Edema and temperature changes
Motor changes – inability to move the affected region

It usually begins in one limb, often diagnosed months after onset, and is 3 times more common in females. The initial injury is usually minor, such as an ankle sprain. Because of this, there is often a delay in finding an expert who recognizes the diagnosis and can initiate treatment.

How to Treat CRPS

Treatment of CRPS is difficult, but should be done in four steps:

The first step is evaluating and treating any treatable injuries that contribute to the pain. This may include surgical interventions for injuries such as ankle sprains.
The second aspect is controlling the sympathetic aspects of pain and the neuropathic pain with injections and medications.
The third part is rehabilitation and physical therapy, restoring mobility and decreasing pain sensitivity.
The last part is psychology to use cognitive strategies to control central pain perceptions.

Complex regional pain can be devastating. The earlier it is diagnosed, the better the prognosis. Experienced pain management physicians are essential in improving the outcome. It can be successfully treated and there are many good interventions available. Find an experienced Pain physician, and find a solution.

Fibromyalgia: Symptoms & Pain Management Options

August 26, 2013September 27, 2016 / Thomas Cohn, MD

Fibromyalgia is a disorder characterized by diffuse musculoskeletal pain throughout the whole body. It is often accompanied by sleep issues, jaw pain, headaches, stomach problems, and depression. There is no special test, blood work, nerve or muscle test, or X-ray that confirms the diagnosis. Rather, diagnosis of Fibromyalgia is based on a patient’s history, medical exam, and the exclusion of other diseases that may cause similar problems.

Symptoms of Fibromyalgia

There are 2 core symptoms of fibromyalgia:

Diffuse muscle pain
Fatigue

With diffuse muscle pain even a light touch of the skin produces pain. Typical locations of muscle pain include all four extremities, head and trunk. Muscle pain often interferes with sleep, and contributes to fatigue and depression. This constellation of problems is thought to be driven by an over-active nervous system, which is hypersensitive to sensory inputs.

Treatment Options

Treatment of fibromyalgia is aimed at minimizing symptoms and maximizing function. People with fibromyalgia often greatly diminish activity and withdraw from normal interactions. A comprehensive strategy that teaches a person to understand the physical and mental aspects of the disease is often helpful. A multidisciplinary team that includes medical management, lifestyle, psychology, and physical therapy is one of the most effective strategies. Physical Medicine based pain clinics often coordinate such programs.

Medication Management

Medication management of fibromyalgia is aimed at modifying symptoms. There are 3 drugs now approved specifically for fibromyalgia. All these medications are considered neuropathics. They reduce the sensitivity of the nervous system so that stimuli are not perceived as intensely. Analgesics can be helpful when used judiciously, especially acetaminophen, anti-inflammatories, and occasionally tramadol. Symptom treatment for depression, and sleep management is also extremely important.

Fibromyalgia is a disorder that affects the whole body and every aspect of daily function. At this time, there is not a known cause and no definitive cure. Management of symptoms is the key to treatment. An experienced pain physician with a multidisciplinary team will often lead to the most beneficial personalized treatment strategy.

Opioid Use can Lead to Low Testosterone

July 24, 2013September 27, 2016 / Thomas Cohn, MD

Opioids are medications that include many of the common pain drugs that are prescribed for acute and chronic conditions. A few common examples of these drugs include:

Morphine
MS Contin
Oxycontin
Percocet
Oxycodone
Vicodin
Hydrocodone
Methadone
Dilaudid
and many are trade name medications

How Opioids Impact Testosterone

They are effective medications for management of pain at times, and block transmission and perception of sensory signals related to pain. However, in recent studies long-term use has been shown to cause significant hormone problems, especially androgen deficiency and low testosterone.

Androgen deficiency affects both males and females and may have a significant impact on quality of life. Common symptoms and complaints include loss of libido, fatigue, erectile dysfunction, hot flashes and depression. Physical findings may be:

Loss of muscle mass
Body hair loss
Anemia
Osteoporosis
Hypogonadism

Diagnosis & Treatment

Diagnosis is made by history of symptoms, exam, and laboratory analysis of blood for hormone levels. Treatment can be two-fold:

Reduce opioids
Hormone replacement

Opioids can affect the brain and the regions that control hormone production. Specifically, they affect the hypothalamus region and inhibit the gonad releasing hormone. This causes a decrease in critical hormones for both males and females including FSH, LH, and testosterone. Opioids also are thought to increase enzymes that metabolize and breakdown the above hormones in the body. Thus, these medications decrease these critical hormones in several ways causing significant side affects.

Long-term opioids are not a benign treatment for pain. If the pain is better, why would a person want to have depression, loss of hair and muscles? The problems associated with opioids are significant, and treatment with hormone replacement is often helpful, but may not reverse the damage these medications can cause.

No silver bullet exists for treating pain. Every treatment has risks and benefits. A good pain physician looks at problems in a comprehensive manner to reduce all risks and maximize benefits.

How the Body Feels Pain

July 8, 2013September 27, 2016 / Thomas Cohn, MD

Pain is a complex issue. Acute pain is usually related to one of the following:

Tissue damage
Perceived damage
Injury

Chronic pain can be associated with chronic damage or a short circuit in the transmission of pain signals. Treatment of pain depends on the cause. In acute pain, if you treat the cause the pain will normally go away. However when pain becomes chronic, treatment often does not take away all the symptoms.

Pain Signals & Sensory Stimuli

Chronic pain is generally defined as pain lasting longer than 3 to 6 months. Often, it outlasts the initial injury. In some ways it becomes independent of the initial stimulus or cause. Damage may be ongoing, and there may be a chronic inflammatory response, all causing ongoing sensory stimuli, which are subsequently linked in the spine and brain, to the perception of pain. Often, non-painful sensory signals then become linked to nerves that previously transmitted pain signals. Normal signals then become perceived as pain.

All sensory signals are processed in the brain at some level. The brain has an incredible ability to determine the importance of each signal and then form a response. Depending on the circumstance, the brain can ignore the same signal that would be horrific pain. For example, we all have heard about soldiers in war who have been shot, but continue fighting with no loss of focus. Therefore, the real key player in all responses to pain signals is the brain and its interpretation of the signals.

Blocking Pain Signals

The key to treatment of pain then is altering the brain’s ability or desire to interpret sensory signals as pain. Blocking signals can be done anywhere along the path from the sensory receptor including:

The peripheral nerve to the spinal cord
Along the spinal cord pathways
In the brain itself

Although pain can be treated in multiple ways, all treatments try to prevent transmission and interpretation of sensory signals that are perceived as pain. There is no magic bullet and no one treatment alone that will work for everyone.

The simple reason why there are so many treatments for pain is that there are so many ways to alter signals that are perceived as pain. Medications have been designed to affect sensory impulses at a variety of locations from the skin and periphery to the spine and brain. Furthermore, there are a variety of techniques from proper movement, to acupuncture, to psychological training that can effectively treat pain.