Treatment of Reflex Sympathetic Dystrophy

Functional Rehabilitation

Functional restoration and remobilization of the affected limb is the most important goal of therapy for reflex sympathetic dystrophy (RSD). Any other treatments, such as drug therapy, or nerve blocks are instituted in order to reduce pain so that the patient can take advantage of intensive efforts to restore function. There are four components to functional rehabilitation: physical therapy, occupational therapy, recreational therapy, and vocational therapy. Treatment should begin as soon as possible after diagnosis of RSD. Restoration of function requires active participation from the patient, not passive cooperation. They must undertake to practice skills that they learn in various therapy settings and remain motivated to move to the next level of function under the watchful eye of the therapist even though it may cause a temporary increase in pain.

Each of these functional therapies involves helping the patient increase the range of motion, strength, and flexibility of the affected limb. Although the patient may find that exercises and tasks may cause an initial increase in pain, it is important to "stay the course" and work through the difficulty since for most patients the pain will dissipate and function will return.

Some of the components of functional rehabilitation include:

• Progression from gentle movements of the limb to bearing increasing weight
• Desensitization of the limb to sensory stimuli in order to "reprogram" or "reset" the way the nervous system processes this information

Adjunct treatments for pain control may be needed if the patient does not progress at a steady rate within a reasonable time frame. In general, professionals need to be flexible regarding when to consider the initiation of adjunct treatment as some patients may derive more benefit from rehabilitation if also offered adjunct therapy (including interventional therapy) early in the treatment process. Each success in rehabilitation therapy motivates the patient to continue working towards recovery even though it may be arduous and difficult. Adjunct therapy for coexisting conditions such as depression may need to be initiated at any stage of treatment because the patient's mental and emotional health has a significant impact on rehabilitation and recovery.

The information provided in this section is based primarily on informal guidelines published in the Clinical Journal of Pain in 2006 by RN Harden et al. For further information, please click on the following link: http://www.ncbi.nlm.nih.gov/pubmed/16772795

Physical Therapy

Physical therapy is considered a most important, first-line treatment for RSD and may be employed alone or in combination with other treatments such as nerve blocks and drug therapy. The primary goals of physical therapy include:

• Restore function of the affected limb
• Alleviate pain
• Strengthen muscles in the affected limb
• Reduce swelling and joint stiffness in the affected limb

The steps to achieve these goals include:

• Raising the awareness of and educating the patient regarding the need to use the limb despite the pain. The patient participates in the process by working with the physical therapist to set goals and a timetable of increasing demand and intensity.

• Educating the patient regarding avoidance of situations that will add stress to the affected limb. It is important for all physical therapy to take place at the patient's level of tolerance since more aggressive therapy can trigger more pain and increase inflammation. Patients should also be counseled to avoid inactivity of the limb, prolonged bed rest, prolonged use of cold compresses, and bathing in water that is too cold.

• Raising the tolerance level for touch and desensitizing the affected area by providing sensory stimulation of increasing intensity and duration. The patient's actual participation is important since it provides motivation for success of treatment.

• Increasing functional use of the limb through:

  • increasing flexibility with increased range of motion exercises
  • increasing muscle strength with isometric exercises
  • increasing strength and flexibility through weight bearing exercises
  • exercising on a mat which provides a non-weight bearing setting
  • improving posture and balance (for lower extremity RSD)
  • movement training to teach proper movement patterns
  • gait training (if a leg is involved)
  • treatment for myofascial pain of proximal joints (the membrane that surrounds muscle tissue which can become inflamed and very painful)
  • aquatic therapy (hydrotherapy) in a pool or whirlpool offers the advantage of added resistance during exercise (with or without weight bearing) but less stress to the joints. The compression of water may also help if the limb is edematous (swollen).
  • massage therapy to manage edema or myofascial pain
  • contrast baths in warmer and cooler temperatures to help increase blood circulation to the affected limb

Motion exercises are important for the whole limb, not just for the joint that is affected, since the movement increases blood circulation around the joints which provides nutrition for the cartilage and decreases the hypersensitivity of the area. This prevents or minimizes contracture of the limb.

As mentioned above, while undergoing physical therapy, some patients benefit from drug therapy and psychotherapy so that the pain of physical therapy does not discourage them from fully cooperating and carrying out the treatment plan. Current data has shown benefit from physical therapy for the short-term but long-term benefit has not yet been determined by clinical trials.

Occupational Therapy

The role of occupational therapy (OT) is to promote functional rehabilitation by managing edema, increasing activity of the affected limb by progressive desensitization, and initiating active movement of the limb.

Management of Edema

Edema is managed by the use of:

• Special compression garments- elasticized sleeves customized to fit the patient's arm or leg
• Manual lymph drainage (MLD) is a gentle manual treatment technique that is designed to stimulate the flow of lymph from the congested area where it has accumulated into more centrally located lymphatic vessels that eventually return the lymph back into the venous circulation.

Desensitization

Desensitization of the skin (to reverse allodynia) is achieved through progressive stimulation of the affected limb using different textures such as feathers, silk, terrycloth, other cloth materials, and environmental textures.

Initiating Active Movement

The occupational therapist initiates gentle, active movement and gradually increases the intensity with functional activities such as:

• Stress loading - motion of the extremity while bearing weight, for example by executing a scrubbing motion while holding a brush. The weight of the object being held is gradually increased.
• Carrying - holding objects of increasing weight while walking, progressing to carrying a bag with objects in it while walking. This is effective for upper and lower extremities.

• Exercise - structured exercises to encourage:

  • dexterity
  • increased range of motion
  • strengthening
  • proprioceptive neuromuscular facilitation - an advanced form of flexibility training that includes systematic stretching and contraction of targeted muscle groups.

Recreational Therapy

Because the recreational therapist promotes leisure activities that are pleasurable, they are often effective in motivating patients to work hard in rehabilitation. "Fun" activities can also be instrumental in helping the patient overcome fear of using the affected limb (kinesphobia). While focusing on the enjoyable activity, such as videogames, the patient "forgets" and begins to use the limb. The patient is also encouraged to make independent decisions about leisure activities and lifestyle modifications or changes which increase their sense of self-esteem and being in control of their lives. In addition, by coordinating with the occupational therapist and physical therapist, the recreational therapist can choose activities that augment the goals set for the patient.

Another role the recreational therapist plays in the rehabilitation of the patient with RSD is helping them become more involved in social and community activities. By practicing skills needed for activities the patient enjoys doing with friends or family, the recreational therapist helps motivate the patients to actively participate in their recovery.

Vocational Therapy

Vocational therapy is an important step in the rehabilitation process since it impacts strongly on the patient's health status and quality of life as well as how patients perceive themselves. It is often the last stage of therapy and serves to prepare the patient for return to the workplace - either to their former job or to a new job which will fit their skill level. This step is also important since relapse seems to be more likely when a person is inactive.

The role of the vocational therapist includes:

• Determining if the patient can successfully go back to their former place of employment or to assess skills that the patient should be working on to prepare for returning to their former workplace
• Determining if the work environment needs to be modified for the level of the patient's skills
• Investigating new employment opportunities that would be appropriate for the patient who cannot return to their former workplace. Sometimes the vocational therapist may visit the prospective workplace to identify modifications that need to be implemented so that the patient can once again be employed.

The vocational therapist may see the patient after they have been unemployed for an extended period of time due to RSD by which point, their self image, motivation to work, and motivation to recover may have suffered significantly. While coordinating with the physical therapist and occupational therapist, the vocational therapist can help the patient set realistic expectations regarding the opportunity for employment and can help them focus on acquiring the skills that will be needed in the workplace.

In addition, the vocational therapist may be helpful to the patient by explaining the steps they need to take to collect disability insurance, health insurance, and other governmental or legal claims which may need to be filed.