REFLEX SYMPATHETIC DYSTROPHY
WHAT IT IS AND WHAT IT ISN'T
Michael Wescott, an economist who structures settlements, is seeing a nationwide explosion of reflex sympathetic dystrophy (RSD) cases. He believes RSD is the latest wave in fraud cases. While RSD is a genuine, often devastating, disorder; many claimant's are incorrectly diagnosed.
Exactly what is RSD? It is a pathological condition of the local sympathetic nervous system that may involve the hand alone, or extend from the hand to the shoulder. Occasionally, RSD affects the foot and leg. Symptoms include the following: disproportionate burning pain in light of the injury; bluish skin discoloration (cyanosis), redness or skin; temperature changes; cracked and grooved finger or toe nails; smooth and shiny skin; increased hair growth in the painful extremities; joint swelling or stiffness; edema of the extremity; osteoporosis or abnormal uptake on the bone scan. The pain endures long after the injury is presumed healed.
In early stages of RSD, expect vasoconstriction, disproportionate pain, excessive sweating and mild tenderness to the touch. In advanced stages expect color changes, swelling, tremor and spasticity. The pain of RSD is usually accompanied by flexion deformity of the elbow, hand or joints; tremor; and abnormal muscle rigidity with spasm. The extremity may take on a claw like appearance.
RSD can be caused by blunt trauma (even trivial trauma), inflammatory disorders, immobility associated with heart attacks and strokes, cervical osteoarthritis or other degenerative joint diseases, frost bite, burns, and drugs. In 35% of the cases the causes are unknown.
There are many diagnostic tests which can rule RSD in or out. Some of those tests are as follows:
- tests for sympathetic function such as sweat tests, skin plethysmography, skin galvanic resistance;
- tests of skin blood flow; thermography; x-rays and bone scanning which is helpful in the second & third stages;
- tests of limb volume (placing extremities in a tank of water and measuring the displacement); measurements of capillary blood velocity show an increase in skin and regional blood flow in early RSD and a reduction in flow in the more advanced stages. Between stages the flow is similar to normal skin blood flow.
Ironically, it is thermography, one of the most ineffective tests for orthopedic injuries, which is most determinative with RSD. In the textbook, Chronic Pain: Reflex Sympathetic Dystrophy,(p. 109) the authors state that diagnosing RSD without thermography is like diagnosing a heart attack without an EKG. It is the most sensitive test for RSD since it addresses itself purely to temperature differences. To appropriately manage a case, a thermogram should be performed within three months of the trauma.
Early diagnosis is the single most important factor in determining the outcome of treatment. There should be at least one degree difference in temperature between the affected and unaffected extremity for an accurate diagnosis of RSD. The danger of using thermography is the number of false positives in patients with old injuries to their sympathetic nerve to the skin with no clinical pain being present.
How do claims adjustors investigate and appropriately manage RSD claims? When claimants appear to medical appointment and depositions with immobile extremities yet there is no atrophy or swelling, surveillance is necessary. Ask the doctors to rule out alternate causation such as malignancy, arthritis, inflammatory disorders or infection. Where medical reports during the first three months of treatment document disproportionate pain, excessive sweating and mild tenderness to the touch; ask the doctor if a thermogram is indicated to rule out RSD. Ensure that claimants with RSD diagnoses are treated by doctors familiar with diagnosing and treating this disorder. Do not apply the big green poultice!
This page was last updated May 7, 2008