Calcitonin and reflex sympathetic dystrophy syndrome

Summary Reflex sympathetic dystrophy syndrome is a difficult condition to treat. Many modalities have been proposed, all of them being clinically effective but whose efficacy is often difficult to assess, and has not been properly compared. A regimen of physical therapy (pressure therapy, antalgic electrotherapy and exercise therapy) with or without calcitonin was investigated in 24 patients randomly assigned to 2 groups, one given physical therapy alone (Group I) and the other physical therapy plus salmon calcitonin 100 MRC units daily for 3 weeks (Group II). Efficacy assessment was based on clinical (pain, oedema and movement in the affected parts), biochemical (blood and urinary phosphorus and calcium levels, plasma 25-OH-D, plasma parathyroid hormone (PTH), creatinin, alkaline phosphatases and urinary hydroxyproline) and scintigraphic parameters, as well as on the patient's ability to resume working. There was significant improvement in pain in the Group II patients after one week of treatment. As a result the authors advocate the use of calcitonin in addition to physical therapy in reflex sympathetic dystrophy syndrome — and even of calcitonin alone where physical therapy is not possible.     

Sympathetic skin responses in reflex sympathetic dystrophy

This study was performed to determine the utility of sympathetic skin response (SSR) in evaluating the sympathetic function and to follow up the effects of sympathetic blockade in reflex sympathetic dystrophy (RSD). Thirty patients having RSD with upper extremity involvement were randomly divided into two groups. Besides medical therapy and exercise, physical therapy agents were applied to both the groups. In addition to this treatment protocol, stellar ganglion blockade was done by diadynamic current in Group II. The normal sides of the patients were used for the control group. SSRs were measured in all the patients before and after the therapy. The amplitude was found to be increased and the latency was found to be decreased in the affected side in both the groups before the therapy. After the therapy, the amplitude was decreased and latency was increased in both the groups. But, the differences in amplitude (P=0.001) and latency (P=0.002) before and after the therapy were significantly higher in Group II. (Before the treatment, SSRs were significantly different between the normal and the affected sides in both the groups. The observed change in SSRs after the treatment was higher in Group II.) It was concluded that, SSR can be a useful and noninvasive method in diagnosing the sympathetic dysfunction in RSD and can be used for evaluating the response to sympathetic blockade and other treatment modalities.     

Management of reflex sympathetic dystrophy.

Reflex sympathetic dystrophy (RSD) is currently defined as CRPS type I (complex regional pain syndrome). Due to the lack of comprehensive understanding of underlying pathophysiological mechanisms, a wide variety of therapeutic approaches are proposed, all of them being of unpredictable and variable efficacy. This is also due to the lack of controlled studies and randomized therapeutic trials. Most of the so-called "efficient" treatments are in fact based on anecdotal case reports and/or uncontrolled studies with small number of cases. Sympathetic blocks and active physiotherapy are, for many authors, the cornerstones of the efficient management. The role of prevention must be strongly emphasized, focusing, if RSD occurs following surgery, on the importance of pre- and postoperative efficient analgesia.     

Recurrent and migratory reflex sympathetic dystrophy syndrome

Summary A case of recurrent reflex sympathetic dystrophy syndrome (RSDS), involving consecutively three extremities in an otherwise healthy adult is described. In a period of four years follow-up she presented three RSDS episodes occurring without precipitating events and involving consecutively both lower legs and the left hand. The RSDS resolved without sequelae after treatment with physiotherapy and diclofenac in an early phase. RSDS is an often unrecognized entity which appears mostly confined to a single limb. Recurrent forms have also been described, sometimes with a migratory pattern. Involvement of upper and lower limbs in the same patient is thought to be infrequent.     

Concept and limits of the reflex sympathetic dystrophy

Clinical Rheumatology - Reflex sympathetic dystrophy (RSD) is a clinical syndrome defined in the English literature by pain, dystrophic tissue changes and local disturbance of autonomic function in...     

Bisphosphonate therapy of reflex sympathetic dystrophy syndrome

OBJECTIVE—The reflex sympathetic dystrophy syndrome (RSDS) is a painful limb disorder, for which a consistently effective treatment has not yet been identified. The disease is associated with increased bone resorption and patchy osteoporosis, which might benefit from treatment with bisphosphonates, powerful inhibitors of bone resorption.
METHODS—Twenty patients with RSDS of foot and hand, were randomly assigned to blind administration of either alendronate intravenously (Istituto Gentili, Pisa, Italy) 7.5 mg dissolved in 250 ml saline solution or placebo saline infusions daily for three days. Two weeks later all patients had an identical treatment course with open labelled alendronate (7.5 mg/day for three days), independent from the results of the first blind treatment.
RESULTS—In the patients treated with blind alendronate the diminution in spontaneous pain, tenderness, and swelling (circumference of the affected limb) and the improvement in motion were significantly different from baseline (p<0.001), from those observed within the first two weeks in the control group (p<0.01), and from week 2 to week 4 (p<0.01). In the patients given blind placebo infusions no relevant symptomatic changes were observed after the first two weeks of follow up, but they responded to the open alendronate therapy given afterwards. In 12 patients with RSDS of the hand the ultradistal bone mineral content (BMC) of the affected arm was considerably lower than that of the controlateral arm (mean (SD)) (426(82) mg/cm versus 688(49)). Six weeks after the beginning of the trial BMC rose by 77(12) mg/cm (p<0.001) in the affected arm, but it did not change in the controlateral.
CONCLUSIONS—These results indicate that bisphosphonates should be considered for the treatment of RSDS, producing consistent and rapid remission of the disease.

     

Munchausen''s syndrome simulating reflex sympathetic dystrophy.

A 15 year old girl who had pain, oedema of her left hand, and fever of four months' duration is described. Marked demineralisation of her hand was shown by radiography, and increased articular uptake by technetium-99m bone scan. All these changes were indistinguishable from reflex sympathetic dystrophy. After two admissions to hospital and multiple explorations we discovered that she had induced her symptoms herself and a diagnosis of Munchausen's syndrome was made. As far as we know this presentation has not been previously reported and might help to explain the physiopathology of some signs of reflex sympathetic dystrophy.     

Metastatic malignancy associated with reflex sympathetic dystrophy

A patient who presented with reflex sympathetic dystrophy of the foot is described. Biopsy confirmed metastases of the small bones which at postmortem proved to be from carcinoma of the lung.     

Reflex sympathetic dystrophy syndrome of the lower limbs in renal transplant patients treated with cyclosporin A

In a 36-month period, 240 patients at our institution received kidney transplants from cadaver donors. Cyclosporin A (CsA) was used as the initial immunosuppressive therapy. Seven patients (5 men and 2 women) developed severe pain, periarticular soft tissue swelling with no effusion, and vasomotor changes in affected areas. Although articular mobility was conserved, most of the patients had great difficulty in walking. A patchy osteoporotic pattern was seen radiographically and increased uptake of 99mtechnetium with a periarticular distribution in the clinically affected areas were found. All of these symptoms and radiographic and scintigraphic signs are compatible with definite reflex sympathetic dystrophy syndrome (RSDS). Articular symptoms began within 3 months after kidney transplantation in all patients; all but 1 patient had plasma CsA levels greater than 200 ng/ml at that time. When the dosage of CsA was reduced, there was concomitant improvement in the RSDS, which appeared when the plasma CsA levels declined to less than 200 ng/ml. The mean duration of the clinical symptoms of RSDS was 8 months. We believe RSDS should be added to the list of complications that may appear in kidney transplant patients who receive CsA treatment.     

Hypofixation on bone scintigraphy in reflex sympathetic dystrophy syndrome

Summary We report an adult case of reflex sympathetic dystrophy. In contrast to the usual findings in adults, three phase bone scintigraphy showed decreased bloodflow and bloodpool with hypofixation on delayed steady state bone scan of the affected lower limb. In spite of various therapeutic attempts severe dystrophy developed.     

Contralateral thalamic perfusion in patients with reflex sympathetic dystrophy syndrome

Iodine-123-labelled iodoamphetamine single-photon emission computed tomography of patients with reflex sympathetic dystrophy syndrome showed substantial variation in thalamic perfusion of the side contralateral to the painful limb. The variations are related to time from the onset of symptoms, which suggests that the thalamus undergoes adaptive changes in the course of this neurological disorder.     

The effect of gabapentin in earlier stage of reflex sympathetic dystrophy

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.     

Painful congestion of the lower limbs and recurrent fever

We describe a 45-year-old patient with massive pain and congestion in the lower limbs. In addition, he daily presented fever up to 39.5°C (103.1°F) without any infectious focus for 8 days. A formerly unknown vena cava atresia with severe bilateral deep vein thrombosis and concomitant heterozygous prothrombin (factor II) gene mutation (G20210A) was diagnosed during the hospital stay. Because of the severe clinical findings and hereditary thrombophilia, we recommended a lifelong anticoagulant therapy and elastic stockings. Furthermore, different diagnosis and treatment strategies are discussed in case of concomitant prothrombin gene mutation.