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The present state of the art in psychosomatic research on reflex sympathetic dystrophy or Sudeck's atrophy (also known as Sudeck's disease) is reviewed. The survey confirms the impression prevailing with surgeons and orthopaedists that patients suffering from this disease are "psychically peculiar", i.e. they appear strange or odd. Psychometric examinations show that they suffer from enhanced anxiety, are emotionally rather unstable and display a tendency to depressiveness associated with a marked self-esteem rating problem complex. Basing upon these criteria the occurrence of reflex sympathetic dystrophy in the postoperative course of patients with Dupuytren's contracture could be correctly predicted in 43 of 47 patients, the remaining 4 patients being forecast with a false-positive prediction (Zachariae 1964). Studies on Children with reflex sympathetic dystrophy likewise confirmed these characteristic features. In a study of our own we examined in 12 patients their biographical development as well as life events that had happened 6 months before onset of the disease. We obtained a surprisingly uniform result: In all patients we found that at least one or in most cases several severely stressful life events had occurred; all patients had been suffering from chronic headache and/or pain in the lumbar vertebral column for many years; and all of them had shown signs in the course of their development in childhood and adolescence that have been described by Engel as "pain proneness". Over and above this, the anamnesis of most patients revealed other psychogenic and psychosomatic diseases or signs and symptoms. The case reports of all the 12 patients served as basis for initial approaches to a psychosomatic disease concept of reflex sympathetic dystrophy.
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PMID:[Psychosomatic correlations of sympathetic reflex dystrophy (Sudeck's disease). Review of the literature and initial clinical results]. 169 17

Based primarily on anecdotal evidence, patients with reflex sympathetic dystrophy (RSD) have often been suspected of having a high degree of psychosocial disturbance prior to the onset of symptoms as well as in reaction to the disorder. In the present study, patients presenting to a pain center with RSD were compared to patients with low back (LBP) and headache pain (HAP) on a variety of self-reported demographic, behavioral, pain, and mood measures. Typical of most patients experiencing chronic pain, all three groups demonstrated elevations indicative of pain, emotional distress, and behavioral disturbance. However, although the RSD patient group reported the highest level of pain intensity, the most employment disruption, and contained the highest percentage of patients receiving financial compensation, this same group paradoxically reported less emotional distress on the Symptom Checklist-90R than did LBP and HAP patients. This paradox may be due to the lesser chronicity of the RSD patients as well as to their apparently experiencing a more sympathetic response from doctors, employers, and insurance carriers than their LBP and HAP counterparts. On balance, the present data do not support the hypothesis the RSD patients, relative to other pain patients, are uniquely disturbed in psychosocial functioning.
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PMID:A psychosocial and behavioral comparison of reflex sympathetic dystrophy, low back pain, and headache patients. 823 46

In Germany patients with chronic pain are often undertreated. It is necessary to establish more specialized institutions for pain therapy. As pain therapy is time consuming and labor intensive the costs must be justified by quality and efficiency. METHODS. We analyzed the new patients who came to our pain clinic in 1990 and compared the previous nonspecialist pain-related treatment with our pain therapy. For each patient we recorded the duration of pain therapy in the past, the number of physicians involved in the treatment, the number and duration of hospital stays and the number of operations carried out to relieve pain. For our pain therapy we recorded the number of treatments on an outpatient basis, the number of patients who were hospitalized and the number of hospital days. The outcome of our pain therapy was determined on a visual analogue scale (VAS). Pain relief of more than 50% was defined as adequate pain therapy. RESULTS. In 1990 we treated 379 new patients in our pain clinic. The largest group (140, 37%) had pain of the muscle or skeletal system. A further 75 patients (18%) had neuropathic pain, 66 (17%) suffered from cancer pain, several types of headache were found in 57 patients (15%), 19 patients (5%) had phantom limb pain, 11 (3%) suffered from reflex sympathetic dystrophy, and we diagnosed psychogenic pain in 11 patients (3%). On average the patients had been treated for their pain over a period of 10 years by eight different physicians. Patients suffering from migraine had the longest duration of preliminary therapy (19.2 years), while patients with cancer pain were pretreated for 2, 3 years in the period before. 80% (n = 302) of all patients were hospitalized at least once. A total of 20,959 hospital treatment days was registered. At least one operation was performed in 34% of the patients (n = 130) to relieve the pain. For all patients the pain relief afforded by the preliminary therapy was insufficient. In our pain therapy the patients had on average 6.5 outpatient appointments. We hospitalized 45 patients (12%), for a mean of 11 days. During the observation period 74% of the patients (n = 280) obtained pain relief of more than 50% in comparison with the start of treatment. CONCLUSION. The findings of our retrospective study demonstrate that specialized pain therapy is evidently effective. If such therapy is instituted early enough, chronic pain can be prevented. Shorter duration of disease, fewer stays in hospitals and less absence from work could reduce the economic costs of chronic pain. It is necessary to make specialised pain therapy a regular component of clinical practice; this means redoubling our efforts concerning education and experimental and clinical studies. The efficiency of pain therapy must be documented in order to improve the care of patients with chronic pain.
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PMID:[Analysis of the therapy of chronic pain. A comparison of previous therapy and specialized pain therapy]. 848 Sep 4

The alteration of extracranial blood flow in conjunction with clinical signs of autonomic nervous system dysfunction have led to various explanations concerning the pathophysiology of migraine headache. Reflex sympathetic dystrophy, a painful disorder of the sympathetic nervous system, can be treated by blocking the sympathetic nerves located in the stellate ganglion, resulting in vasodilation, ptosis, miosis, and anhydrosis. In theory, these changes could trigger a migraine headache attack secondary to autonomic dysfunction reflecting an imbalance between sympathetic and parasympathetic nervous systems. This may be especially true in a patient with a previous history of meningitis that may have resulted in a disorder of cerebrovascular regulation. We report a 56-year-old man with no previous history of migraine who developed migraine with aura after a stellate ganglion block. These episodic headaches occurred with decreasing frequency and severity for over 6 months, with eventual complete resolution. This interesting phenomenon has not been reported in the English literature and may help to better understand the pathophysiology of migraine.
Headache 1996 May
PMID:Migraine headache following stellate ganglion block for reflex sympathetic dystrophy. 868 79

A variety of conditions are frequently associated with the occurrence of head and neck pain. The purposes of this review are: to describe the characteristics of several musculoskeletal, neurological, and systemic conditions frequently cited as possible causes of head and neck pain and to suggest a new technique for treating head and neck pain. The characteristics of musculoskeletal conditions, such as muscle spasm, tendinitis, trigger points, and joint inflammation, and their relationship to head and neck pain are considered. The features and clinical implications of neurologic conditions, such as atypical facial pain, trigeminal and glossopharyngeal neuralgia, reflex sympathetic dystrophy, and neurogenic inflammation, are also described. The distinguishing characteristics of headaches, including cluster, tension, chronic daily, rebound, posttraumatic, and postlumbar puncture, are detailed. This review also addresses the contributions of systemic disorders, such as osteoarthritis, rheumatoid arthritis and the variants, and rheumatoid-related conditions, like dermatomyositis, temporal arteritis, Lyme's disease, and fibromyalgia, to head and neck pain. The results of a recent pilot study of the effectiveness of intraoral circulating ice water for resolving symptoms related to head and neck pain secondary to neurogenic inflammation are presented in this work. Ice water circulating through hollow metal tubes was placed intraorally for 15 minutes in the posterior maxillary area on 12 individuals with cervical pain and muscle spasm. In nine of these individuals, reduced cervical pain perception, upper trapezius electromyography signal reduction, and increased cervical range of motion was produced. Six out of 12 individuals had accompanying headache, which was reduced or eliminated in four cases. These findings suggest a strong trigemino-cervical relationship to neck pain and headache.
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PMID:Head and neck pain review: traditional and new perspectives. 889 41

Complex Regional Pain Syndrome (CRPS) is the new name for entities formerly known mostly as Reflex Sympathetic Dystrophy and Causalgia. Treatment of CRPS with either the calcium channel blocker nifedipine or the alpha-sympathetic blocker phenoxybenzamine was assessed in 59 patients, 12 with early stages of CRPS, 47 with chronic stage CRPS. In the early stage CRPS patients, 3 of 5 were cured with nifedipine and 8 of 9 (2 of whom had earlier received nifedipine) with phenoxybenzamine, for a cure rate of 92% (11 out of 12). In the chronic stage CRPS patients, 10 of 30 were cured with nifedipine; phenoxybenzamine cured 7 of 17 patients when administered as a first choice and another 2 of 7 patients who received nifedipine earlier, for a total late stage success rate of 40% (19 out of 47). The most common side effects necessitating discontinuing the drug were headaches for nifedipine and orthostatic dizziness, nausea and diarrhoea for phenoxybenzamine. All male patients on phenoxybenzamine experienced impotence, but this did not lead to discontinuing this agent and immediately disappeared after stopping the drug. These results once again stress the importance of early recognition of CRPS, and treatment with either of these drugs could be considered as a first choice for early CRPS, especially because in this series this treatment was not combined with physical therapy making it very cost-effective. In the chronic stage of CRPS, treatment with these drugs was much less successful (40%), even though it was always combined with physical therapy, but it can still be considered, either as a first choice or when other types of treatment have failed.
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PMID:Complex regional pain syndrome (reflex sympathetic dystrophy and causalgia): management with the calcium channel blocker nifedipine and/or the alpha-sympathetic blocker phenoxybenzamine in 59 patients. 910 64

A 37-year-old man developed an ipsilateral headache which fulfilled the criteria for cluster headache after orbital extenteration because of a traumatic lesion of the bulb. The headache could be treated successfully by drugs usually applied in the therapy of cluster headache. Six similar cases of cluster headache after orbital exenteration could be identified in the literature suggesting that the eye itself is not necessarily part of the pathogenesis of cluster headache. We hypothesize that orbital exenteration can cause cluster headache by lesions of sympathetic structures. Possibly, these mechanisms are similar to those of sympathetic reflex dystrophy (Sudeck-Leriche syndrome) causing pain of the limbs.
Cephalalgia 1997 Oct
PMID:Cluster headache after orbital exenteration. 935 Mar 91

Complex regional pain syndromes (CRPS) (formerly reflex sympathetic dystrophy and causalgia) are neuropathic pain conditions that are initiated by an extremity trauma or peripheral nerve lesion. Clinical definition and scientific understanding of CRPS are still evolving; however, both the clinical picture and therapeutic options are significantly influenced by a dysfunction of the sympathetic nervous system. Recent investigations suggest functional central abnormalities and a peripheral inflammatory component in the pathophysiology of CRPS. Interdisciplinary treatment includes physical, pharmacologic, and invasive interventional therapy, as well as stimulation techniques.
Curr Pain Headache Rep 2001 Apr
PMID:Complex regional pain syndromes. 1125 45

Ziconotide intrathecal infusion was recently approved by the United States Food and Drug Administration for the treatment of intractable severe chronic pain. Patients with neuropathic pain make up a significant population among those who experience chronic pain for which there are less than optimal pharmacotherapeutic options. Published clinical trials provide a global view of ziconotide efficacy and safety. A subset of patients in clinical trials obtained complete pain relief, a remarkable finding given the history of drug treatment for neuropathic pain. To provide more information regarding those who respond to ziconotide therapy, we discuss three patients with neuropathic pain who received ziconotide infusion. Two patients with longstanding neuropathic pain, one with complex regional pain syndrome (formerly known as reflex sympathetic dystrophy) of the leg and one with lumbar radiculitis, achieved temporary but complete pain relief from single 5- and 10-microg epidural test doses. In the third case, a patient with longstanding bilateral leg and foot neuropathic pain from acquired immunodeficiency syndrome and antiretroviral drug therapy achieved considerable pain relief from a long-term continuous intrathecal infusion. The patients who received a single dose had mild central nervous system adverse effects such as sedation, somnolence, nausea, headache, and lightheadedness. The patient who received the intrathecal infusion experienced mild-to-severe adverse effects depending on the rate of infusion; these effects included sedation, confusion, memory impairment, slurred speech, and double vision. This patient could sense impending adverse effects and made rate adjustments or suspended infusion to avert untoward symptoms. In all three cases, patients achieved considerable pain relief that was long-lasting and persisted well after dose administration or suspension of infusion.
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PMID:Ziconotide infusion for severe chronic pain: case series of patients with neuropathic pain. 1650 20

The objective of this paper is to investigate the effect of gabapentin in the earlier stage of reflex sympathetic dystrophy syndrome (RSD). Twenty-two patients diagnosed with RSD were enrolled. Initial gabapentin dosage was 600 mg/day. This dosage is increased gradually until a satisfactory pain level was reached. After this level, this dosage was maintained throughout the study. An exercise program was also applied to the patients. Provoked and static pain scores of the patients were obtained initially, at 3-day intervals for maintenance dosage determining, and at 6 weeks after the discharge. Functional improvement parameters were volumetric measurement; dynamometric measurement and third finger pulp-distal palmar crease distance measurement for hands; and metric circumferential measurement and range of motion for elbow, knee, and foot initially, at baseline, on the tenth day, upon discharge, and 6 weeks after the discharge. The mean maintenance dose of gabapentin was 1,145.46+/-377.6 mg/day (range, 900-1,800 mg/day). Improvements in spontaneous and provoked pain intensities were statistically significant. No statistically significant difference was obtained in functional improvement parameters. Dizziness in three patients, headache in two patients, and mild burning feeling in the tongue in one patient were the reported side effects. These symptoms resolved spontaneously in few days. Gabapentin cannot be recommended as the drug of choice, but it may be considered as one of the therapeutic alternatives in the management of pain due to RSD. We suggest that it is effective only for the pain and not for other symptoms of RSD. Serious side effects that will cause the patient to stop using the drug are rare.
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PMID:The effect of gabapentin in earlier stage of reflex sympathetic dystrophy. 1689 21


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