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Reflex Sympathetic Dystrophy (RSD) In The Elderly: A Real Cause For Concern Or More ‘Funny Medicine’?

iStock_000004809750XSmallSeveral years ago my office represented an elderly woman who suffered a broken arm related to a fall at an assisted living facility.  The severity of the fracture required the application of a cast to align the bones.  A round of physical therapy also ensued after removal of the cast.  Despite the efforts of the doctors and physical therapists, pain originally thought to originate from the fracture continued on long after the bones had healed.  As it turned out, our client was suffered from a relatively little known medical condition known as reflex sympathetic dystrophy (RSD), also referred to as complex pain syndrome.

During the course of litigation, I learned a fair amount of information regarding RSD, but ultimately I was left with the impression that this disabling condition is grossly misunderstood amongst many in both the medical and legal communities.

What is Reflex Sympathetic Dystrophy?

Reflex Sympathetic Dystrophy Syndrome is a chronic pain condition that usually affects your arm or leg and displays a group of typical symptoms including pain (intense burning or aching pain), tenderness, swelling, discoloration, and altered temperature. Type 1 occurs after an injury or illness that does not directly damage the nerves in the affected limb; whereas, Type 2 (causalgia) occurs after a distinct nerve injury. Oftentimes, the pain is disproportionate to the severity of the injury.

What are the causes of RSD?

The cause of RSDS is still poorly understood. It usually follows a trauma-related injury, but again, it is not well understood why injuries can trigger this condition. Theories include irritation and abnormal excitation of nervous tissues which leads to abnormal impulses along the nerves affecting blood vessels and skin.

What are the symptoms of RSD?

RSDS can display a gradual or rapid onset of symptoms, and it may not display all typical symptoms. The symptoms may change over time and will vary from person to person. Typical symptoms include:

  • Burning pain
  • Increased skin sensitivity (allodynia)
  • Changes in skin temperature, color, and texture
  • Changes in hair and nail growth
  • Joint stiffness, swelling, and damage
  • Muscle spasms, weakness, and loss (atrophy)
  • Decreased ability to move the affected body part

RSDS often starts with swelling, redness, changes in temperature, hypersensitivity.  In many RSD patients the symptoms may worsen over time, the involved limb may become cold and pale, displaying skin and nail changes, and suffering muscle spasms and tightening.  Like most medical conditions, the symptoms associated with RSD differ from person to person.

What are the treatments for RSD?

There is no cure for RSDS. Instead, most treatment options seek to relieve the painful symptoms of the disease. Treatment for RSDS is most effective when started early. Usually, once the limb becomes cold and pale and the limb has muscle spasms and tightening, the condition is often irreversible.

A doctor will usually perform a physical exam and collect your medical history. Sometimes bone scans, x-rays, and MRIs (magnetic resonance imaging) can provide important clues in diagnosing RSDS. These tests can show increased circulation to affected joints, loss of minerals from your bones, and tissue changes.

The treatment for RSDS is specifically tailored for each case. Treatment options include various medications and therapies. Doctors might prescribe over-the-counter nonsteroidal anti-inflammatory drugs (aspirin, ibuprofen, and Aleve) to ease pain and inflammation, antidepressants to treat pain from damaged nerves, corticosteroids (prednisone) to reduce inflammation, and bone-loss medications (Fosamax and Miacalcin) to help treat symptoms.

Your doctor might also recommend various therapies to help treat and improve symptoms. These therapies can include: applying hot and cold compresses, topical analgesics to reduce hypersensitivity, physical therapy to help improve range of motion, spinal cord stimulation for pain relief, electrical nerve stimulation to help ease chronic pain, and sympathetic nerve-blocking medication to block pain fibers in the affected nerves. Most medications and therapies merely help treat the pain and inflammation caused by the disease.

Complications associated with RSD

If RSDS is not properly diagnosed and treated at an early stage (within a few months of your first symptoms), the disease can progress into more severe symptoms including muscle wasting (atrophy) and contracture (tightening of your muscles which can leave your limb contracted in a fixed position).

RSDS can also occasionally spread from its source to another area of your body. The symptoms can travel from the initial site of the pain to a nearby area, or spread to an opposite limb, or even leap to a distant part of your body.

RSD & Nursing Home Patients

The mystery surrounding the cause and treatments for RSD leaves many nursing homes ill-equipped to adequately treat patients who suffer from this condition. When a resident is suffering from Reflex Sympathetic Dystrophy Syndrome (RSDS), the resident might experience pain that is more severe than one would expect with the sort of injury or trauma that they sustained.

Many times, nursing home staff do not properly diagnose the condition, leaving the resident in horrible and unnecessary pain as the condition worsens. This is because residents with RSDS often have pain and disability that cannot be explained on the basis of objective physical findings. For this reason, it is important to ensure that a nursing home facility takes your pain seriously.

It is imperative that nursing home facilities properly train their staff to recognize symptoms of RSDS because early treatment is so important in preventing the continuing progression of the disease. Facility staff should monitor residents’ pain and notify a doctor if the resident experiences constant, severe pain in a limb especially when moving the affected limb.

Elderly nursing home residents have an increased risk for dangerous slips and falls. These falls can result in broken hips, which often require surgery, bone fractures, bruising, head injuries, and other injuries. These injuries, which often affect the limbs, can be a source of trauma that puts them at increased risk to develop RSDS. If the nursing home facility does not properly monitor the resident’s pain and recovery following an injury, the resident might not be properly diagnosed with RSDS, which can lead to additional and often irreversible damage to the limb.

Many nursing home residents are often unable to communicate with nursing home staff members because of disease or mental illness. The facility staff might notice the resident crying out in pain for no apparent reason, but this pain, especially if constant and severe, can be an indicator of RSDS. Many nursing homes have large resident populations, which increases the likelihood of a resident’s pain being ignored or concern over constant pain being minimized.

If you or a family member experiences constant and ongoing pain, it is important to notify the nursing home facility and ensure that the pain is properly managed and treated. There is no excuse for nursing home facilities to ignore a resident’s pain, even if there is no apparent source. This pain could be an indicator of Reflex Sympathetic Dystrophy Syndrome or other underlying medical conditions.

Thank you to Heather Keil, J.D. for her assistance with this Nursing Homes Abuse Blog entry

Resources:

Medicine Net: Reflex Sympathetic Dystrophy Syndrome (RSDS)

Mayo Clinic: Complex Regional Pain Syndrome

National Institute of Neurological Disorders and Stroke: Complex Regional Pain Syndrome Information 

Indiana University: Reflex Sympathetic Dystrophy (RSD) After Blunt Trauma: A Survey of Recent Literature

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  • One of the key points about RSD is that it is never truly “cured”. It goes into remission, but is subject to coming back full force with only the slightest provocation.
    It is one of the most devastating conditions that anyone can have. The first case I had involving it, the client elected to have his arm amputated rather than live with the amount of pain that he was experiencing. I had a hard time wrapping my head around having that degree of pain, anmd sometimes still do.

  • Barry-
    Thanks for your input. This certainly is a medical condition that deserves more attention and needs more research. Although there are some objective methods to assist in making the diagnosis: changes in surface temperature of the area and changes in the physical appearance of the skin ect., one of the most harmful aspects of this condition is the fact that some of the people suffering with RSD are looked at with a sense of disbelief by both the general public and the medical community. Hopefully, the more information that gets distributed on this condition will lead to a more compassionate view from others.

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