Posted by jeabt on 5/26/07 22:09
rekha,
I have been reading through all your posts and am so impressed with your past experiences! You are amazing! You refused to give up, even when bad became worse, and with persistence and determination you succeeded, and shared your success with all of us here. You can fight this, if anyone can. You have already been successful and you'll do it again. My hope and prayer for you is you'll recover quickly, and to top it off have children who will be a blessing to you from conception and throughout their lives.
I am a therapist and have worked with RSD and nerve injuries for a long time. Here are some things I have learned: You can have both a nerve injury and RSD. In fact the nerve injury can cause the RSD if the nerve is overly irritated and you happen to be prone to RSD. I explain it like this: The sympathetic nervous system reacts normally to an injury like a fracture or pinched nerve by causing pain, swelling, and fibrosis (ie stiffening, rebuilding of collagen) in order to protect the injury. That way we feel the pain, avoid moving, and give the injury time to heal. As the injury begins to heal, the pain begins to subside, the swelling subsides, and then we can slowly begin to move the injured part. This usually takes from 3-6 weeks. The next stage is regaining movement and strength, but often the extremity stays stiff for about 6 more months before feeling normal again.
Sometimes a nerve is injured, or some irritation like an external fixator or overstretching a stiff joint prolongs the pain. The more prolonged and intense the pain, the more likely the sympathetic reflex response becomes abnormal. I have even seen a patient who took narcotics (on his own) and tried to mobilize his stiff hand after a fracture and wound up with RSD. Even though he didn't feel the pain, the sympathetic nervous system responded to his aggressive mobilizing and overreacted by the reflexive vascular and sensory changes of burning, intense pain, swelling, and more stiffness. The biggest problem with RSD is the sympathetic reflex does not turn off as it normally should. It stays turned on causing more burning, pain, swelling, redness, fibrosis (stiffness), then muscle and bone atrophy. It can continue to increase in pain and spread if the sympathetic feedback loop is not blocked in some way.
Blocking the sympathetic feedback loop: First and most effective is an immediate referral to a pain specialist as soon as we begin to realize RSD may be happening. There are few docs out there who really understand RSD like a pain specialist. Second, try to calm irritated nerve pain. Nerve pain is very strange. Think of a toothache: the nerve becomes irritated by cold or sharp pressure and begins to fire a warning: pain, Pain, PAIN! The pain may not happen immediately, but builds up- like turning on the light with a dimmer switch. Calming it down takes protecting the nerve and providing it with 98.6 neutral warmth (not too hot, never cold) and rest(2-3 weeks usually). Anti-inflammatories help reduce the swelling of the nerve. Avoiding irritating activity (cold, sharp pressure, over-stretching) reduces the nerves hyperactivity.
Gentle stimulation after it begins to calm down actually helps it to calm down more and further desensitizes it. When treating a hand patient with RSD I use this principle to calm the nerve pain down by having them use the fluidotherapy, which is basically ground corn cob dust heated to 100-115 degrees and blowing like a dust storm around the extremity. My patients think it feels like sitting on a warm sandy beach and moving one's hand through the sand until it becomes desensitized (not numb, just calmed down, less painful). Some of my patients call it Floridatherapy for this reason. The literature states the gentle dust storm of particles on the nervous system actually reduces the firing of the C pain fibers, causing a desensitization effect. A fluidotherapy machine is expensive and can usually only be accessed by going to a therapist, but I wouldn't be suprised if moving gently through a warm sand box could have the same kind of effect if the right temperature.
Two other strategies we use are stress-loading and active movement, but again, these have to be done within pain-free limits as the nerve calms down. Lack of movement when tissue is healed actually makes things worse. The joints become stiffer, lacking in synovial fluid required for nourishment, oxygen, and health of the joint and vascular stimulation is diminished starving the all the tissues involved. Also, bone becomes weaker and more brittle as it needs weight bearing to grow and keep it strong. The movement should not be forced and never painful. Later on, after the pain is gone (0-2/10,) gentle low-load, no pain, prolonged stretch can be used to regain movement. Stress-loading is slowly putting gentle weight down on the extremity without pain. We use a scale and try to increase the weight a little each day: 1#, 2#, 3#, etc. until the limb is able to bear full weight without pain. Never do we force the limb into more painful weight bearing or range of motion. The stellate ganglion blocks help with this, as we can do more moving, weight bearing, and desensitization after the blocks since the reflexive loop is temporarily blocked. Finally, when the sympathetic reflex goes into remission and pain is less than 1-2/10 we can carry on the rehabilitation, anywhere from a month to half a year later. I think it really depends on how quickly the pain doc is seen once RSD is recognized.
Unfortunately, I have not found the answer to the post RSD stiffness and contractures that become so rigid and hard after fibrosis of the extremity. I have tried a lot of different types of splints ( I work with hands) but they take so long to produce tissue change with the prolonged stress on them.
Regarding likelihood of developing RSD: It seems that some are more prone to it than others. One doc I worked with used to test his patients with a stress test (using cold/hot) before he would do elective surgery on the hand. If they were positive for a hyperactive sympathetic response, he would avoid the surgery.
Recently I had a patient recovering from RSD have surgery on her hand to relieve the contractures by having them mobilized while under anesthesia and a stellate ganglion block. She did not have a recurrence of her RSD which amazed me. But, I have to say, her contractures did not seem much improved after all she went through, and the doc wound up breaking one of her fingers! She was happy with the little improvements though and that is what is important. I am still wondering what can be used to soften and release the thickened fibrotic tissue which looks so similar to the changes in connective tissue with scloeroderma (a type of arthritis, thickening of the collagen, stiffness, shiney skin, swelling, etc.) I was wondering about relaxin, a hormone which I read was being used with fibromyalgia patients. Don't know if anyone has done any research...
Rekha, after reading your history, it seems that your former pf, and foot problems may have initiated the RSD, especially after the stretching and icing. You may have had nerve problems even then. With the RSD came the fibrotic changes (thickening and hardening of connective tissue in your foot and leg) may have made you more prone to further pf and tts. Overstretching can definitely irritate already sensitive nerves which may have been further at risk of impingment by swelling and fibrosis from the previous RSD, yet to begin another round of RSD, especially in those who have been prone to it in the past. Once you win this second battle from RSD and have no more pain which I know you will: Stay away from overstretching and ice! Use natural, pain-free stretches like slow careful walking, wear those supportive shoes, never squat, don't run uphill or on hard pavement, and get some really comfy gel inserts that make it feel like you are walking on a cloud.
One other note: I also had pf in both my feet, and I really hated stretching that tissue. In fact, I quit doing it because it hurt and seemed to make things worse. As a therapist I don't believe in making pain worse. Instead I found some really good supportive shoes (they were new balance 1122s) and soft, comfortable gel inserts which kept my feet warm and happy, and quit the activities which made the pf worse. (I found I would set it off by squatting, overstretching the plantar fascia when I would put stuff away or when I was doing yard work.) I used a step stool to sit low on instead of squatting and overstretching my feet. It worked, and took about 2 months to completely resolve after I made these changes. My husband, a PT, uses these principles all the time now when treating pf and has much better results.
Well, this is long, but hope it helps! jeabt
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