eMedicine Specialties > Orthopedic Surgery > Trauma

Reflex Sympathetic Dystrophy: Treatment & Medication

Author: Satishchandra Kale, MD, FRCS(Edin), FRCS Ed(UK), Dip Sports Med, Honorary Assistant Professor of Trauma and Orthopedics, University of Bombay; Consultant, Department of Orthopedics, Dr R N Cooper Hospital, Brahmakumaris Global Hospital, India
Contributor Information and Disclosures

Updated: Jul 2, 2008

Treatment

Medical Care

The goals of treatment of reflex sympathetic dystrophy are reduction of edema, reduction of reflex muscular contractures, reduction of articular stiffening, and pain blockage with mobilization under sympathetic blockade.12,13,14

Prophylaxis
There is evidence that vitamin C (oral administration) may reduce the incidence of complex regional pain syndrome after wrist fractures. A daily dose of 500 mg for 50 days is recommended.15
 
Physical therapies

  •  The following physical therapies may be useful:
    • Active and passive range-of-motion exercises
    • Transcutaneous electrical nerve stimulation (TENS)
    • Desensitization techniques
    • Sensory reeducation of the extremity

Pharmacologic therapy

  • Pharmacologic agents used are classified as follows:
    • Analgesics: Drugs with a long half-life are preferred (eg, codeine)
    • Antidepressants: These drugs modulate sympathetic activity and provide analgesia (eg, amitriptyline)
    • Anticonvulsants (eg, phenytoin)
    • Membrane-stabilizing agents (eg, lidocaine, tocainide)
    • Adrenergic compounds
      • Phentolamine - Relief with IV phentolamine is pathognomic of sympathetically maintained pain (SMP). Patients with a positive response to IV phentolamine are likely to respond to other forms of sympatholytic interventions.
      • Phenoxybenzamine - Nonselective adrenergic agent16
      • Clonidine - Alpha 2 -adrenergic agonists
    • Calcium channel blockers - Reduce sympathetic tone by blocking calcium release following stimulation of adrenergic receptors (eg, nifedipine, amlodipine)
    • Corticosteroids - Membrane-stabilizing action (prednisolone 60 mg rapidly tapered over 5-10 d is commonly used)
  • Various routes of administration for pharmacologic interventions include the following:
    • Intravenous regional infusions
      • Guanethidine sulfate
      • Phentolamine
      • Bretylium tosylate
      • Reserpine
      • Cortisone sulfate
    • Epidural injections (eg, clonidine) may provide relief in selected patients
    • Intra-articular injections of steroid preparations (eg, triamcinolone)
    • Intra-arterial injections (eg, reserpine, guanethidine)
    • Continuous autonomic blockade using local anesthetic agents for scalene/axillary/brachial/stellate ganglion blocks

Other therapies

  • Newer interventions include the following:
    • Biofeedback
    • Acupressure
    • Acupuncture

Surgical Care

  • Surgical/ablative therapies include the following:
    • Chemical sympathectomy
    • Surgical sympathectomy
    • Implantable electrical stimulators
    • Bilateral anterior cingulotomy

Activity

  • Intensive physical therapy following a successful sympathetic blockade is key to faster rehabilitation in patients with reflex sympathetic blockade (RSD).
  • IV blocks with rigorous mobilization techniques must be implemented early in the treatment process for RSD.
  • Active and passive mobilization and heat and cold modalities all have been used with good effect in RSD, acting via the gate theory. The gate theory suggests that a finite amount of information can be received at the spinal cord or at the cortical level. The gate is the dorsal horn of the spinal cord. Therefore, painful stimuli, if displaced or modified by less noxious stimuli, cannot be processed through the gate.

Medication

In patients with reflex sympathetic dystrophy, the goals of pharmacotherapy are to reduce morbidity and prevent complications.

Sympatholytic drugs

Suppress sympathetic nerve function / noradrenaline inhibitor.


Reserpine (Serpalan)

Inhibits vesicular uptake of noradrenaline and thus stops excitation of sympathetic nervous system; inhibits beta-hydroxylation of dopamine to noradrenaline.
Lewis et al reported good results in 90% of patients at 18 months, with 93% of patients experiencing pain relief.

Adult

1.25 mg PO for upper extremity and 2.5 mg PO for lower extremity, diluted in isotonic sodium chloride solution; 1-2 blocks needed

Pediatric

Not established

Tricyclic antidepressants may decrease antihypertensive effects of reserpine when used concurrently; cardiac arrhythmias may occur when either digitalis or quinidine is administered concurrently with reserpine

Documented hypersensitivity; diagnosed mental depression

Pregnancy

D - Unsafe in pregnancy

Precautions

Procedure must be performed in facility with resuscitation equipment; nasal congestion, abdominal cramps, and orthostatic hypotension may occur

Alpha-adrenergic blocking agents

May exert effect by causing blockade of postganglionic synapses.


Phenoxybenzamine (Dibenzyline)

May have effect through long-lasting noncompetitive alpha-adrenergic blockade of the postganglionic synapses in smooth muscle.

Adult

10 mg PO bid, increasing by 10 mg qod until optimum dose achieved
Dose range: 20-40 mg PO bid/tid

Pediatric

1-2 mg/kg/d PO divided q6-8h

Used concurrently, alpha-adrenergic agonists decrease effects of medication; beta-blockers increase toxicity

Documented hypersensitivity; those in whom a fall in blood pressure would be undesirable

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cerebral or coronary arteriosclerosis and renal impairment; can worsen symptoms of respiratory tract infections


Phentolamine (Regitine)

Alpha-1 and alpha-2 adrenergic blocking agent that blocks circulating epinephrine and norepinephrine action.

Adult

5-20 mg IV/IM; repeat prn q2-4h until hypertension controlled

Pediatric

0.05-0.1 mg/kg/dose IV/IM; not to exceed 5 mg/dose; repeat prn q2-4h until hypertension controlled

Concurrent administration of epinephrine or ephedrine may decrease phentolamine effects; ethanol increases phentolamine toxicity

Documented hypersensitivity; coronary or cerebral arteriosclerosis and renal impairment

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in tachycardia, peptic ulcer, and gastritis; cerebrovascular occlusions and myocardial infarctions can occur following phentolamine administration

Alpha-adrenergic agonists

May act to decrease muscle tone.


Clonidine (Catapres)

Stimulates alpha2-adrenoreceptors in brain stem, activating an inhibitory neuron, which in turn results in reduced sympathetic outflow.

Adult

Initial: 0.1 mg PO bid
Maintenance dose: 0.2-1.2 mg/d PO in 2-4 divided doses; not to exceed 2.4 mg/d

Pediatric

Not established

Tricyclic antidepressants inhibit hypotensive effects of clonidine; coadministration of clonidine with beta-blockers may potentiate bradycardia; tricyclic antidepressants may enhance hypertensive response associated with abrupt clonidine withdrawal; hypotensive effects of clonidine are enhanced by narcotic analgesics

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cerebrovascular disease, coronary insufficiency, sinus node dysfunction, and renal impairment


Guanethidine (Ismelin)

Acts on postganglionic fibers at the presynaptic level, releasing noradrenaline and inhibiting reuptake and rerelease. Fiscat et al reported good results in 63% of cases; Bensigner et al reported good results in 58.6% of cases.
For administration, IV access is gained as close as possible to the involved part. A BP cuff is tied well above the site of pain and inflated above the systolic pressure; a second BP cuff is tied below the first cuff as in a Bier block. Pressure is maintained for 20 min, the limb manipulated, and pressure is reduced while alternating between the 2 cuffs.
Six blocks are performed on alternate days with rigorous rehabilitation; repeated blocks even if the first block fails.

Adult

Up to 30 mg in 30 mL isotonic sodium chloride solution IV

Pediatric

Not established

Tricyclic antidepressants, methylphenidate, thioxanthenes, phenothiazines, sympathomimetics, anorexiants, and haloperidol may reduce effects of guanethidine; minoxidil, epinephrine, and norepinephrine may increase the toxicity of guanethidine

Documented hypersensitivity; pheochromocytoma; MAO inhibitor use within the last 14 d

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Procedure must be performed in facility with resuscitation equipment; clonic movements, orthostatic hypotension, and minor sexual problems possible

Calcium channel blockers

Inhibit calcium ions from entering slow channels; select voltage-sensitive areas, or vascular smooth muscle.


Nifedipine (Adalat, Procardia)

May have a relaxant effect on certain muscles. Inhibits transmembrane influx of calcium ions into smooth muscle, which, in turn, inhibits contraction of the muscle fibers.

Adult

10-30 mg SL 30 min ac; hs prn if nocturnal regurgitation and cough are prominent

Pediatric

Not established

Fentanyl and alcohol may increase hypotensive effects; calcium channel blocker may increase cyclosporine levels; H2 blockers (cimetidine), erythromycin, nafcillin, and azole antifungals may increase toxicity (avoid combination or monitor closely); carbamazepine may reduce bioavailability (avoid this combination); rifampin may decrease levels (monitor and adjust dose of calcium channel blocker)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause lower extremity edema; allergic hepatitis has occurred but is rare


Amlodipine (Norvasc)

May have a relaxant effect on certain muscles. Inhibits transmembrane influx of calcium ions into smooth muscle, which, in turn, inhibits contraction of the muscle fibers.

Adult

2.5-5 mg PO qd; 10 mg PO qd maximum

Pediatric

Not established

Fentanyl and alcohol may increase hypotensive effects; calcium channel blocker may increase cyclosporine levels; H2 blockers (cimetidine), erythromycin, nafcillin, and azole antifungals may increase toxicity (avoid combination or monitor closely); carbamazepine may reduce bioavailability (avoid this combination); rifampin may decrease levels (monitor and adjust dose of calcium channel blocker)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in renal/hepatic impairment; may cause lower extremity edema; allergic hepatitis has occurred but is rare

Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.


Prednisolone (Articulose-50, Delta-Cortef, Pediapred)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.

Adult

Oral: 60 mg PO initially, rapidly tapered over 5-10 d
Alternatively, 20 mg/mL intra-articularly

Pediatric

Not established

Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects of corticosteroids

Documented hypersensitivity; viral, fungal, or tubercular skin lesions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis

Anesthetics

Local anesthetics stabilize the neuronal membrane and prevent the initiation and transmission of nerve impulses.


Lidocaine (Anestacon, Dermaflex, Lidoderm, Zilactin-L)

Decreases permeability to sodium ions in neuronal membranes. This results in the inhibition of depolarization, blocking the transmission of nerve impulses.

Adult

Apply to the affected area prn

Pediatric

Administer as in adults

Documented hypersensitivity; Adams-Stokes syndrome, Wolf-Parkinson-White syndrome

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

For external or mucous membrane use only; do not use in eyes

Tricyclic antidepressants

A complex group of drugs that have central and peripheral anticholinergic effects and sedative effects. They have central effects on pain transmission. They block the active reuptake of norepinephrine and serotonin.


Amitriptyline (Elavil)

Analgesic for certain chronic and neuropathic pain.

Adult

30-100 mg/d mg PO hs

Pediatric

Children: 0.1 mg/kg PO hs; increase as tolerated over 2-3 wk to 0.5-2 mg/d hs
Adolescents: 25-50 mg/d PO initially; increase gradually to 100 mg/d in divided doses

Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine and quinidine) may increase amitriptyline levels; amitriptyline inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram

Documented hypersensitivity; MAO inhibitor use in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, and urinary retention

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid using in the elderly

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.


Codeine

Binds to opiate receptors in CNS, causing inhibition of ascending pain pathways, altering perception and response to pain.

Adult

10-20 mg/dose PO q4-6h prn for cough; not to exceed 120 mg/d

Pediatric

<2 years: Not established
2-6 years: Not to exceed 30 mg/d PO
6-12 years: Not to exceed 60 mg/d PO
>12 years: Administer as in adults

Toxicity increases with concurrent administration of tricyclic antidepressants, MAO inhibitors, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics

Documented hypersensitivity; high altitude cerebral edema or elevated ICP

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Use to treat cough in patients diagnosed with high altitude pulmonary edema only if absolutely necessary; may depress hypoxic ventilatory rate and respiratory drive during sleep

More on Reflex Sympathetic Dystrophy

Overview: Reflex Sympathetic Dystrophy
Differential Diagnoses & Workup: Reflex Sympathetic Dystrophy
Treatment & Medication: Reflex Sympathetic Dystrophy
Follow-up: Reflex Sympathetic Dystrophy
Multimedia: Reflex Sympathetic Dystrophy
References
Further Reading
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References

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  2. Koman LA, Poehling GG, Smith TL. Complex regional pain syndromes: Reflex sympathetic dystrophy and causalgia. In: Green DP, Lampert R, eds. Greens Operative Hand Surgery. 4th ed. Churchill Livingstone;1998:636-62.

  3. Mitchell SW, Morehouse GR, Keen WW. Gunshot Wounds and Other Injuries of Nerves. Philadelphia:. JB Lipincott;1864.

  4. Mitchell SW. Injuries of Nerves and their Consequences. Philadelphia:. JB Lippincott;1972.

  5. Bonica JJ, ed. The Management of Pain. 2nd ed. Philadelphia:. Lea & Febiger;1990:220-243.

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  15. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am. July 2007;89(7):1424-31. [Medline].

  16. Inchiosa MA Jr, Kizelshteyn G. Treatment of complex regional pain syndrome type I with oral phenoxybenzamine: rationale and case reports. Pain Pract. Mar-Apr 2008;8(2):125-32. [Medline].

  17. Birch R. Pain. In: Surgical Disorders of the Peripheral Nerves. Churchill Livingstone;1994:385-93.

  18. Clinical Orthopaedics. Reflex sympathetic dystrophy. In: Bailliere's Clinical Orthopaedics. Vol 1. WB Saunders Co;1996.

  19. Tan AK, Duman I, Taskaynatan MA, Hazneci B, Kalyon TA. The effect of gabapentin in earlier stage of reflex sympathetic dystrophy. Clin Rheumatol. Apr 2007;26(4):561-5. [Medline].

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Further Reading

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Keywords

reflex sympathetic dystrophy, RSD, algodystrophy, Sudeck atrophy, painful dysfunction syndrome, reflex neurovascular dystrophy, shoulder-hand syndrome, chronic regional pain syndrome, CRPS, causalgia, complex regional pain syndrome, sympathetically mediated pain syndrome, SMP, algodystrophy complex regional pain syndrome, chronic pain syndrome

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Contributor Information and Disclosures

Author

Satishchandra Kale, MD, FRCS(Edin), FRCS Ed(UK), Dip Sports Med, Honorary Assistant Professor of Trauma and Orthopedics, University of Bombay; Consultant, Department of Orthopedics, Dr R N Cooper Hospital, Brahmakumaris Global Hospital, India
Satishchandra Kale, MD, FRCS(Edin), FRCS Ed(UK), Dip Sports Med is a member of the following medical societies: British Orthopaedic Association
Disclosure: Nothing to disclose.

Medical Editor

James F Kellam, MD, Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center
James F Kellam, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Samuel Agnew, MD, FACS, Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center
Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania
Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association
Disclosure: Nothing to disclose.

 
 
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