NeuroRehabilitation ELSEVIER
NeuroRehabilitation 9 (1997) 213-219
Vocational rehabilitation considerations for people with reflex sympathetic dystrophy T.S. Smitha,*, M.e. Genoff b b The
a Intracorp, Arnaudville, LA, USA Louisiana Hand Center, Alexandria, LA, USA
Abstract Reflex sympathetic dystrophy (RSD) is identified by the existence of pain, trophic changes, vasomotor instability, limited range of motion and swelling of an extremity. RSD is difficult to treat and prognosis is often poor. Although widely noted in the medical literature, the vocational rehabilitation literature has failed to address the potential role of vocational rehabilitation professionals in the social and economic employment outcome for people with RSD. Vocational rehabilitation professionals are defined as those performing vocational assessments, assessing transferable skills, determining adaptive skills, certifying residual work-related capacities, conducting vocational interest testing, coordinating efforts with pre-injury employers to assist in work reentry efforts, or performing other activities to assist in the placement or retraining of individuals with RSD. The sources used for this article include a review of the literature and observations of the authors. A vocational rehabilitation primer is provided. The following topics are addressed: the anatomical and physiological basis of RSD, treatment protocols, difficulties in accurately diagnosing RSD, influence of litigation, job placement considerations and vocational planning. As the vocational rehabilitation counsellor faces a greater number of people either diagnosed with RSD, or exhibiting RSD symptoms, he/she will be challenged to: (1) increase one's knowledge base about the etiology and treatment of RSD; (2) coordinate personal efforts with other professionals; and (3) provide personal counselling to address lifestyle and motivational factors. © 1997 Elsevier Science Ireland Ltd.
Keywords: Reflex sympathetic dystrophy; Vocational rehabilitation; Return-to-work
* Corresponding author. 455 Carmen Dr. Arnaudville
LA 70512, USA, Tel.: + 1 318 6626381, fax: + 1 318 6626392.
1053-8135/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PH S1053-8135(97)00032-2
214
T.S. Smith, M.e. Genoff / NeuroRehabilitation 9 (1997) 213-219
1. Introduction
Reflex sympathetic dystrophy (RSD) is the exaggerated response of an injured extremity. Symptoms may include prolonged pain, disuse of the affected extremity and delayed functional recovery [1]. The diagnosis of RSD has been known for over a century, but has only recently become the focus of attention in the medical literature. The medical literature has outlined treatment processes, problems diagnosing the dystrophy, innovative classification systems and case studies outlining the specific location of RSD in anatomical structures, but this same body of literature fails to address the role of the vocational rehabilitation counsellor and vocational rehabilitation processes in affecting return-to-work success rates. Likewise, notation of RSD in the vocational rehabilitation literature does not exist. Due to increased interest in the medical field towards RSD, RSD will playa greater role in the vocational rehabilitation counsellor's caseload as career windows for people with RSD must be opened and career paths must be envisioned. This article contains a discussion of medical factors, treatment plans and rehabilitation planning provisions for people with RSD. 2. Anatomy and physiology Prior to a discussion concerning specific aspects of RSD, it will be important for the reader to understand the anatomy and physiology of RSD. The sympathetic nervous system is responsible for the regulation of body temperature, blood pressure, heart rate and other factors that maintain homeostasis. When an affected part becomes inactive, the sympathetic nervous system reduces blood circulation to the skin, resulting in the unnecessary release of heat through the affected extremity [2]. Pain makes one reluctant to use an injured extremity. Pain and other chemical factors will decrease blood flow by constricting arteries to injured areas, thus limiting hemorrhage. Pain, through actions of the sympathetic nervous system, increases heart rate and the force of contraction to maintain blood pressure in cases of
blood loss. What differentiates acute and protective pain from chronic pain is the intensity and the duration of the response. Persistence of the normal physiological responses to pain beyond the period of cellular repair is the basis of RSD [3].
RSD is a multi-symptom, multi-system syndrome usually affecting one or more extremities, but it may affect any part of the body. The literature has noted RSD in greater than one extremity [4,5], including the lumbar spine [6], facial region [7], and lower extremity [8]. While not noted in the literature, as the sympathetic nervous system has branches throughout the body, the whole body has potential for RSD signs and symptoms. 3. Symptoms, signs and stages of RSD The pain of RSD is typically burning in quality and constant. It is often worse at night. Any activity involving the affected extremity can exacerbate the pain. Swelling, change of colour, temperature change and sweating of the extremity is also often described. Examination of the patient will often verify the objective complaints of swelling and colour changes. The affected extremity may feel warmer or colder than the other. The skin may be more or less sensitive to light touch than usual. If the condition has been present for some time there will be stiffness of joints to passive range of motion, atrophy of fat and muscle and decreased hair growth [9]. The following outlines a time reference and physical characteristics associated with RSD across three stages. It was developed in concurrence with references in the literature [10,11] and observations of the authors. Stage I (1-3 months) Localized pain and edema. Hypersensitivity. Muscle spasm. Stiffness and limited mobility. Variable colour, temperature and moisture of skin. 6. Hyperhidrosis.
1. 2. 3. 4. 5.
T.S. Smith, M.e. Genaff / NeuroRehabilitation 9 (1997) 213-219
Stage II (3-6 months) 1. Pain and edema become even more severe and diffuse. 2. Hair becomes scant, nails become brittle, cracked and heavily grooved. 3. Spotty osteoporosis may become severe and diffuse. 4. Increased joint thickness. 5. Muscle wasting. Stage III (greater than 6 months) 1. Changes become irreversible. 2. Pain becomes intractable and may involve the entire limb 3. Interphalangeal and other joints of the foot or hand have become extremely weak; have limited motion and may finally become fused. 4. Contraction of flexor tendons occurs and occasionally dislocated joints.
215
Table 1 Some conditions whose symptoms mimic those of RSD Pain of neurogenic origin CeIVical radiculopathy Peripheral neuropathy Entrapment neuropathies, i.e. carpal tunnel syndrome Post·herpetic neuralgia Thoracic outlet syndrome Pain of musculoskeletal origin Facet joint syndrome Rotator cuff tears Myofascial pain syndrome Fibrositis Arthritis Pain of vascular origin Scleroderma Raynaud's syndrome Peripheral artery disease Malingering or factitious illness This information outlines several of the misdiagnoses associated with RSD. Data is derived from personal experiences of the second author.
4. Diagnostic tests Improvement of symptoms or signs with an adequate sympathetic block is the most definitive test for RSD [9]. X-ray findings of osteoporosis, at first next to joints and later generalized, present evidence of RSD [3]. If present, these processes help to confirm the diagnosis. As with most diagnostic tests, three phase bone scans have been shown to have both false positive and false negative results. Thermography has been reported to be helpful in the diagnosis of RSD [9], but there is no agreement in the literature regarding exactly what is a positive test [2]. There are many additional tests, such as laser Doppler flowmetry and stress testing which are not available to the general clinician [3,9]. Admittedly, RSD may 'fool' the orthopedist, physical therapist, or treating physician and become misdiagnosed. Table 10utlines some conditions that mimic those of RSD. 5. Treatment of RSD The most important determinant of treatment is early diagnosis [1,2,9]. The mainstay of medical
treatment for RSD has been procedures and agents that block the sympathetic nelVOUS system [12]. The most common of these are ganglion blocks with local anesthetics and intravenous regional blocks, although the literature has indicated a failure rate of around 25% [13]. Therapeutic modalities such as contrast baths, range of motion exercises, stress loading, biofeedback training and transcutaneous nelVe stimulation have also been shown to be effective by themselves in mild cases and should be used as an adjunct to blocks in others (based on impressions by the second author). Antidepressant medications such as amitriptyline (elaviO can provide help with lack of sleep and the depression that is usually found with chronic pain. Other oral medications such as sympatholytic drugs (clonidine), alpha blockers (phenoxybenzamine) and calcium channel blockers (nifedipine) have also been tried with some success (based on impressions by the second author). Spinal cord stimulators have been used with some success, but should be considered only as a last resort [3,9,14].
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Patient lifestyle patterns will affect their response to RSD and its treatment, including tobacco use, alcohol use and immobilization [2]. While the rehabilitation professional cannot change existing long-term lifestyle patterns, counselling and intervention may change future lifestyle patterns. The rehabilitation professional and others must take an active role in the recovery process by educating the person with RSD about the influence lifestyle patterns may have upon their outcome. 6. Vocational rehabilitation principles
The vocational rehabilitation professional can play a major role for the client, physician, allied health professional and other rehabilitation personnel. For the sake of this article, the vocational rehabilitation professional is defined as an individual with the responsibility, either assumed or assigned, of prompting return-to-work processes. The processes may include vocational assessment, determination of transferable skills, adaptive skills appraisal, assessment of residual work-related capacities, vocational interest testing, coordination of efforts with pre-injury employers to assist in work reentry efforts, or other activities to assist in the placement or retraining of individuals with RSD to return to work activities. The person may be deemed 'vocational rehabilitation counsellor', 'vocational rehabilitation consultant', or 'vocational rehabilitation specialist'. The vocational rehabilitation counsellor may be employed in either the private or public sector. The rehabilitation professional can assist the client understand their condition and facilitate treatment planning and implementation. This may be accomplished by speaking to the patient in everyday language and by using terms feasible for the patient. Special efforts must be taken to not interpret medical information, but rather to disseminate diagnosis and treatment information. The vocational counsellor may become a secondary resource beyond the treating physician. Physicians and allied health professionals will require consultation concerning return-to-work strategies and prospective vocational directions. Basic information regarding the physical charac-
teristics of the pre-injury position and willingness of the pre-injury employer to render a position are important information points for other rehabilitation personnel. The vocational hierarchy should be outlined and actions appropriate to meet specific goals should be specified (see Table 2 for an outline of the vocational hierarchy). Information obtained through vocational testing should also be disseminated to other parties. The patient should be the focus point for the vocational rehabilitation initiatives. Other rehabilitation specialists will need basic information about RSD and can aid in the establishment of long-term and short-term goals to afford vocational independence. The goals may translate into actual activities to afford returnto-work options. For example, the vocational rehabilitation counsellor may consult with the recreational therapist to coordinate recreational tasks with work-related tasks. Likewise, work hardening activities with a physical therapist could simulate work activities. Essentially, a team approach will be needed to afford a client with RSD quality medical and rehabilitation services. The vocational counsellor can be such a team member. The following concepts and issues should guide the rehabilitation professional as efforts are taken to develop physical rehabilitation and vocational paths for the client with RSD. 6.1. Lack of immediate diagnosis
The majority of people with RSD will not receive an immediate diagnosis [2,9]. The RSD may have been previously diagnosed as carpal tunnel syndrome [14], rotator cuff tear [2], or arthritis [2]. Table 2 Vocational rehabilitation hiearchy Return-to-work with same employer in same position Return-to-work with same employer in modified position Return-to-work with alternate employer in a related position On the job training (less than 90 days) On the job training (greater than 90 days) Retraining Self-employment
T.S. Smith, M.e. Genoff I NeuroRehabilitation 9 (1997) 213-219
Table 1 outlines several of the misdiagnosis paths. While several of the return-to-work strategies for people with other RSD-associated disorders can accommodate or parallel the vocational needs of the client with RSD, some strategies may be inappropriate. Does an identified job address temperature and pressure changes? Does an identified job account for possible degeneration? Will other resource team members be utilized if the diagnosis is predetermined? The answers to these questions must be addressed and appropriate mechanisms to afford solutions must be developed.
6.2. RSD is an ongoing disorder While the symptoms of RSD may be addressed, RSD cannot be 'cured.' The rehabilitation professional must not wait for the magical day when an affected extremity will no longer be disabled. Strategies must be taken to address current residual abilities and projections must be made to evaluate future abilities. Will the client be able to perform the identified job in two years? Will additional medical assistance be needed in two years? Will retraining be needed in two years? Based on the vocational goals, long term planning must be coordinated with the patient and other rehabilitation professionals.
6.3. Degeneration is a normal part of aging The body is constantly losing and regenerating cells. People are constantly growing older. As people grow older, their bodies lose endurance, strength and mobility. People with RSD will parallel the rest of the population. People will lose endurance, strength and mobility as time passes. The rehabilitation professional must assess, along with other health professionals, whether degeneration is a factor of the RSD, or rather a factor of the normal aging process.
6.4. Several people will be involved in rehabilitation efforts The range of people that may become involved in total rehabilitation efforts include orthopedic
217
physicians, neurologists, neurosurgeons, occupational therapists, physical therapists, vocational rehabilitation counsellors, recreational therapists, pain management physicians and persons with RSD. Legal counsel for both plaintiff and defence may avail themselves to become a member of the rehabilitation team. A determination should be made as to the purpose and need for such participation. Coordination between these people will be extremely difficult as various professionals have multiple levels of expertise across several rehabilitation fields. The various professionals may also have different treatments goals and criteria for 'successful rehabilitation'. The goal of the vocational rehabilitation professional is for the person with RSD to return to work. By becoming involved in early identification and treatment efforts, the rehabilitation professional will be able to establish independent vocational goals in concurrence with other treatment plans. Griepp and Thomas [11] outline the need for nurses to become familiar with RSD so they may assist in patient detection and direct the resolution of problems peculiar to people with RSD. Additional literature references are needed to define professional roles and responsibilities in the wake of RSD.
6.5. Vocational planning While the medical literature notes employment outcomes for those diagnosed with RSD, a gap exists in the literature with regard to past role, existing role, or future role of vocational rehabilitation counsellors in the assessment of residual skills, planning of career goals, or general assistance in the retraining process. This lack of notation in the medical literature may be due to failure to report such rehabilitation intervention, or failure to recognize the potential impact of vocationally-specific treatment processes to affect return-to-work success rates. Vocational counsellors must become involved from the initial diagnosis stages to final job placement procedures. To afford career independence, vocational counsellors must first become familiar with basic RSD diagnosis criteria, treatment strategies and medical management. Once involved in the re-
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habilitation processes, the consultant must recognize that changes in medical condition must accommodate the job placement processes. RSD may initially be misdiagnosed. The person with RSD may have periods of exacerbation and job exploration efforts must recognize these periods of exacerbation. The consultant must become knowledgeable of pain concepts and the sociocultural dynamics involved with pain management practises as well as how these concepts relate to the job-specific environment and tasks. The vocational consultant must be cautious about the influence of litigation on motivation. The consultant may realize that the person with RSD may not be motivated to become rehabilitated until a settlement offer is rendered. Also, legal counsel may inappropriately 'diagnose' the motivation of a person with RSD. Bases for opinions should be based on scientific, quantifiable information, rather than hearsay. On the other hand, the person with RSD may have become wary of the workers compensation process and consider the vocational consultant another professional wanting to inappropriately reduce compensation benefits. The person with RSD may question the role of the rehabilitation consultant as provider. The role of the vocational professional must be defined not only to other medical service providers, but also to the individual with RSD. 6.6. Job placement considerations The medical literature has presented two studies with vocational outcome as a research question of consideration. In the first study, Inhofe and Garcia-Moral [1] conducted a long-term outcome study for 10 patients diagnosed with RSD. The patients were treated non-operatively and a I-year follow-up was documented. Of those who were employed prior to diagnosis, 67% reported a job change or unemployment directly related to the disease. Of the seven patients who held jobs prior to the diagnosis, six were contacted. One patient held the same job, three patients had different jobs and two were unemployed. Of the five patients who had a different job or were unemployed, four reported that the change was
directly related to the RSD. This study indicates and reinforces the idea that RSD diagnosis reflect job change. As RSD reflects job change, the rehabilitation consultant must account for both physical requirements and environmental conditions in the existing job if an employer is interested in making modification, or in other employment if vocational exploration is needed. Another worthwhile study outlined the vocational outcome of 125 people with RSD of the upper extremity [15]. Twenty-six (35%) claimed that they remained disabled following treatment and 23 (30%) held the same job. This account did not include 28 housewives (36.3%) who were able to do all the housework. This indicates greater than 65% of the people returned to substantial work activities. These studies leave more questions to be answered. The literature reveals a variety of success rates. Additional research is needed to account for more vocational outcome prospectives. Perhaps future medical research will include vocational consultants to establish research designs which address vocational outcomes for people with RSD. 7. Discussion RDS is a complex disorder. While the etiology of RSD is easy to understand, the diagnosis and treament of RSD is less clear. Furthermore, the vocational rehabilitation potential for persons with RSD is based on speculation, rather than based on empirical procedures. Rehabilitation efforts must be coordinated through many professionals. The clients must become an active component in the medical and vocational recovery process. As a vocational rehabilitation professional faces a greater number of patients either diagnosed with RSD, or exhibiting RSD symptoms, the vocational rehabilitation professional will be challenged to coordinate efforts with other professionals, provide counselling to address lifestyle and motivational factors and increase one's knowledge base about the etiology and treatment of RSD. By conducting and successfully completing these actions, the rehabilitation professional will afford quality rehabilitation services for the person diagnosed with RSD. The person
T.S. Smith, M.C Geno!! / NeuroRehabilitation 9 (1997) 213-219
with RSD may return to work and obtain vocational independence.
[3] [4]
Acknowledgements [5]
T.S. Smith is a Rehabilitation Consultant for Intracorp. The range of his clients involves a significant percentage of those diagnosed with RSD. He works closely with the second author and others to provide vocational rehabilitation services. He has a Master of Arts degree in Rehabilitation Counselling from the University of Alabama. He is a Certified Rehabilitation Counsellor and a Licensed Rehabilitation Counsellor in the State of Louisiana. M.C. Genoff is the founder and chief hand surgery consultant for The Louisiana Hand Center in Alexandria, Louisiana. He is board certified in orthopedic surgery with a fellowship in surgery of the hand. His practice involves a significant percentage of work-related injuries. He works closely with the first author and others to provide patients with the maximum possible functional recovery from their injuries. Special thanks to Glen Mercer for his consultation concerning this document. Also, special appreciation is given to Rachel Smith for her patience during development of this paper.
[6] [7] [8] [9] [10] [11] [12]
[13]
[14]
References Inhofe PO, Garcia-Moral CA. Reflex sympathetic dystrophy: a review of the literature and a long-term case study. Orthop Rev 1994;34:665-671. [2] Hooshmand H. Chronic pain: reflex sympathetic dystrophy prevention and management. Boca Raton, FL: CRC Press, 1993. [1]
[15]
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Lister G. The hand: diagnosis and indications. Edinburgh: Churchill Livingstone Press, 1994. Schiffenbauer J, Fagien M. Reflex sympathetic dystrophy involving mUltiple extremities. J Rheumatol 1993;2(XJ):I64-169. Teasell RW, Potter P, Moulin D. Reflex sympathetic dystrophy involving three limbs: a case study. Arch Phys Med Rehabil 1994;75:1008-1010. Sachs BL, Zindrick MR, Beasley RD. Reflex sympathetic dystrophy after opertive procedures on the lumbar spine. J Bone Jt Surg 1993;75:721-725. Jaeger B, Singer E, Kroening R. Reflex sympathetic dystrophy of the face: report of two cases and a review of the literature. Arch Neurol 1986;43:693-695. Seale KS. Reflex sympathetic dystrophy of the lower extremity. Clin Orthop Relat Res 1989;243:80-85. Green DP, Hotchkiss RN. Operative hand surgery, 3rd ed. New York: Churchill Livingston, 1993. Wattay EG. Reflex sympathetic dystrophy syndrome. Clin Man 1993;9(1):28-29. Griepp ME, Thomas AF. Reflex sympathetic dystrophy syndrome: a nursing challenge. Orthop Nurs 1987;6(3):32-35. Hooshmand H. RSD puzzles: (puzzle no. 30): (Available from Neurological Associates, 903 East Causeway Boulevard, Vero Beach, FL 32963): Neurological Associates, 1995a. Hooshmand H. RSD Puzzles: (puzzle no. 13): (Available from Neurological Associates, 903 East Causeway Boulevard, Vero Beach, FL 32963): Neurological Associates, 1995b. Hooshmand H. RSD Puzzles: (puzzle no. 23): (Available from Neurological Associates, 903 East Causeway Boulevard, Vero Beach, FL 32963): Neurological Associates, 1995c. Subbbarao J, Stillwell GK. Reflex sympathetic dystrophy of the upper extremity: analysis of total outcome of management of 125 cases. Arch Phys Med Rehabil 1981 ;62:549--554.
NeuroRehabilitation 9 (1997) 213-219
Vocational rehabilitation considerations for people with reflex sympathetic dystrophy T.S. Smitha,*, M.e. Genoff b b The
a Intracorp, Arnaudville, LA, USA Louisiana Hand Center, Alexandria, LA, USA
Abstract Reflex sympathetic dystrophy (RSD) is identified by the existence of pain, trophic changes, vasomotor instability, limited range of motion and swelling of an extremity. RSD is difficult to treat and prognosis is often poor. Although widely noted in the medical literature, the vocational rehabilitation literature has failed to address the potential role of vocational rehabilitation professionals in the social and economic employment outcome for people with RSD. Vocational rehabilitation professionals are defined as those performing vocational assessments, assessing transferable skills, determining adaptive skills, certifying residual work-related capacities, conducting vocational interest testing, coordinating efforts with pre-injury employers to assist in work reentry efforts, or performing other activities to assist in the placement or retraining of individuals with RSD. The sources used for this article include a review of the literature and observations of the authors. A vocational rehabilitation primer is provided. The following topics are addressed: the anatomical and physiological basis of RSD, treatment protocols, difficulties in accurately diagnosing RSD, influence of litigation, job placement considerations and vocational planning. As the vocational rehabilitation counsellor faces a greater number of people either diagnosed with RSD, or exhibiting RSD symptoms, he/she will be challenged to: (1) increase one's knowledge base about the etiology and treatment of RSD; (2) coordinate personal efforts with other professionals; and (3) provide personal counselling to address lifestyle and motivational factors. © 1997 Elsevier Science Ireland Ltd.
Keywords: Reflex sympathetic dystrophy; Vocational rehabilitation; Return-to-work
* Corresponding author. 455 Carmen Dr. Arnaudville
LA 70512, USA, Tel.: + 1 318 6626381, fax: + 1 318 6626392.
1053-8135/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PH S1053-8135(97)00032-2
214
T.S. Smith, M.e. Genoff / NeuroRehabilitation 9 (1997) 213-219
1. Introduction
Reflex sympathetic dystrophy (RSD) is the exaggerated response of an injured extremity. Symptoms may include prolonged pain, disuse of the affected extremity and delayed functional recovery [1]. The diagnosis of RSD has been known for over a century, but has only recently become the focus of attention in the medical literature. The medical literature has outlined treatment processes, problems diagnosing the dystrophy, innovative classification systems and case studies outlining the specific location of RSD in anatomical structures, but this same body of literature fails to address the role of the vocational rehabilitation counsellor and vocational rehabilitation processes in affecting return-to-work success rates. Likewise, notation of RSD in the vocational rehabilitation literature does not exist. Due to increased interest in the medical field towards RSD, RSD will playa greater role in the vocational rehabilitation counsellor's caseload as career windows for people with RSD must be opened and career paths must be envisioned. This article contains a discussion of medical factors, treatment plans and rehabilitation planning provisions for people with RSD. 2. Anatomy and physiology Prior to a discussion concerning specific aspects of RSD, it will be important for the reader to understand the anatomy and physiology of RSD. The sympathetic nervous system is responsible for the regulation of body temperature, blood pressure, heart rate and other factors that maintain homeostasis. When an affected part becomes inactive, the sympathetic nervous system reduces blood circulation to the skin, resulting in the unnecessary release of heat through the affected extremity [2]. Pain makes one reluctant to use an injured extremity. Pain and other chemical factors will decrease blood flow by constricting arteries to injured areas, thus limiting hemorrhage. Pain, through actions of the sympathetic nervous system, increases heart rate and the force of contraction to maintain blood pressure in cases of
blood loss. What differentiates acute and protective pain from chronic pain is the intensity and the duration of the response. Persistence of the normal physiological responses to pain beyond the period of cellular repair is the basis of RSD [3].
RSD is a multi-symptom, multi-system syndrome usually affecting one or more extremities, but it may affect any part of the body. The literature has noted RSD in greater than one extremity [4,5], including the lumbar spine [6], facial region [7], and lower extremity [8]. While not noted in the literature, as the sympathetic nervous system has branches throughout the body, the whole body has potential for RSD signs and symptoms. 3. Symptoms, signs and stages of RSD The pain of RSD is typically burning in quality and constant. It is often worse at night. Any activity involving the affected extremity can exacerbate the pain. Swelling, change of colour, temperature change and sweating of the extremity is also often described. Examination of the patient will often verify the objective complaints of swelling and colour changes. The affected extremity may feel warmer or colder than the other. The skin may be more or less sensitive to light touch than usual. If the condition has been present for some time there will be stiffness of joints to passive range of motion, atrophy of fat and muscle and decreased hair growth [9]. The following outlines a time reference and physical characteristics associated with RSD across three stages. It was developed in concurrence with references in the literature [10,11] and observations of the authors. Stage I (1-3 months) Localized pain and edema. Hypersensitivity. Muscle spasm. Stiffness and limited mobility. Variable colour, temperature and moisture of skin. 6. Hyperhidrosis.
1. 2. 3. 4. 5.
T.S. Smith, M.e. Genaff / NeuroRehabilitation 9 (1997) 213-219
Stage II (3-6 months) 1. Pain and edema become even more severe and diffuse. 2. Hair becomes scant, nails become brittle, cracked and heavily grooved. 3. Spotty osteoporosis may become severe and diffuse. 4. Increased joint thickness. 5. Muscle wasting. Stage III (greater than 6 months) 1. Changes become irreversible. 2. Pain becomes intractable and may involve the entire limb 3. Interphalangeal and other joints of the foot or hand have become extremely weak; have limited motion and may finally become fused. 4. Contraction of flexor tendons occurs and occasionally dislocated joints.
215
Table 1 Some conditions whose symptoms mimic those of RSD Pain of neurogenic origin CeIVical radiculopathy Peripheral neuropathy Entrapment neuropathies, i.e. carpal tunnel syndrome Post·herpetic neuralgia Thoracic outlet syndrome Pain of musculoskeletal origin Facet joint syndrome Rotator cuff tears Myofascial pain syndrome Fibrositis Arthritis Pain of vascular origin Scleroderma Raynaud's syndrome Peripheral artery disease Malingering or factitious illness This information outlines several of the misdiagnoses associated with RSD. Data is derived from personal experiences of the second author.
4. Diagnostic tests Improvement of symptoms or signs with an adequate sympathetic block is the most definitive test for RSD [9]. X-ray findings of osteoporosis, at first next to joints and later generalized, present evidence of RSD [3]. If present, these processes help to confirm the diagnosis. As with most diagnostic tests, three phase bone scans have been shown to have both false positive and false negative results. Thermography has been reported to be helpful in the diagnosis of RSD [9], but there is no agreement in the literature regarding exactly what is a positive test [2]. There are many additional tests, such as laser Doppler flowmetry and stress testing which are not available to the general clinician [3,9]. Admittedly, RSD may 'fool' the orthopedist, physical therapist, or treating physician and become misdiagnosed. Table 10utlines some conditions that mimic those of RSD. 5. Treatment of RSD The most important determinant of treatment is early diagnosis [1,2,9]. The mainstay of medical
treatment for RSD has been procedures and agents that block the sympathetic nelVOUS system [12]. The most common of these are ganglion blocks with local anesthetics and intravenous regional blocks, although the literature has indicated a failure rate of around 25% [13]. Therapeutic modalities such as contrast baths, range of motion exercises, stress loading, biofeedback training and transcutaneous nelVe stimulation have also been shown to be effective by themselves in mild cases and should be used as an adjunct to blocks in others (based on impressions by the second author). Antidepressant medications such as amitriptyline (elaviO can provide help with lack of sleep and the depression that is usually found with chronic pain. Other oral medications such as sympatholytic drugs (clonidine), alpha blockers (phenoxybenzamine) and calcium channel blockers (nifedipine) have also been tried with some success (based on impressions by the second author). Spinal cord stimulators have been used with some success, but should be considered only as a last resort [3,9,14].
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M.e. Genoff / NeuroRehabilitation 9 (1997) 213-219
Patient lifestyle patterns will affect their response to RSD and its treatment, including tobacco use, alcohol use and immobilization [2]. While the rehabilitation professional cannot change existing long-term lifestyle patterns, counselling and intervention may change future lifestyle patterns. The rehabilitation professional and others must take an active role in the recovery process by educating the person with RSD about the influence lifestyle patterns may have upon their outcome. 6. Vocational rehabilitation principles
The vocational rehabilitation professional can play a major role for the client, physician, allied health professional and other rehabilitation personnel. For the sake of this article, the vocational rehabilitation professional is defined as an individual with the responsibility, either assumed or assigned, of prompting return-to-work processes. The processes may include vocational assessment, determination of transferable skills, adaptive skills appraisal, assessment of residual work-related capacities, vocational interest testing, coordination of efforts with pre-injury employers to assist in work reentry efforts, or other activities to assist in the placement or retraining of individuals with RSD to return to work activities. The person may be deemed 'vocational rehabilitation counsellor', 'vocational rehabilitation consultant', or 'vocational rehabilitation specialist'. The vocational rehabilitation counsellor may be employed in either the private or public sector. The rehabilitation professional can assist the client understand their condition and facilitate treatment planning and implementation. This may be accomplished by speaking to the patient in everyday language and by using terms feasible for the patient. Special efforts must be taken to not interpret medical information, but rather to disseminate diagnosis and treatment information. The vocational counsellor may become a secondary resource beyond the treating physician. Physicians and allied health professionals will require consultation concerning return-to-work strategies and prospective vocational directions. Basic information regarding the physical charac-
teristics of the pre-injury position and willingness of the pre-injury employer to render a position are important information points for other rehabilitation personnel. The vocational hierarchy should be outlined and actions appropriate to meet specific goals should be specified (see Table 2 for an outline of the vocational hierarchy). Information obtained through vocational testing should also be disseminated to other parties. The patient should be the focus point for the vocational rehabilitation initiatives. Other rehabilitation specialists will need basic information about RSD and can aid in the establishment of long-term and short-term goals to afford vocational independence. The goals may translate into actual activities to afford returnto-work options. For example, the vocational rehabilitation counsellor may consult with the recreational therapist to coordinate recreational tasks with work-related tasks. Likewise, work hardening activities with a physical therapist could simulate work activities. Essentially, a team approach will be needed to afford a client with RSD quality medical and rehabilitation services. The vocational counsellor can be such a team member. The following concepts and issues should guide the rehabilitation professional as efforts are taken to develop physical rehabilitation and vocational paths for the client with RSD. 6.1. Lack of immediate diagnosis
The majority of people with RSD will not receive an immediate diagnosis [2,9]. The RSD may have been previously diagnosed as carpal tunnel syndrome [14], rotator cuff tear [2], or arthritis [2]. Table 2 Vocational rehabilitation hiearchy Return-to-work with same employer in same position Return-to-work with same employer in modified position Return-to-work with alternate employer in a related position On the job training (less than 90 days) On the job training (greater than 90 days) Retraining Self-employment
T.S. Smith, M.e. Genoff I NeuroRehabilitation 9 (1997) 213-219
Table 1 outlines several of the misdiagnosis paths. While several of the return-to-work strategies for people with other RSD-associated disorders can accommodate or parallel the vocational needs of the client with RSD, some strategies may be inappropriate. Does an identified job address temperature and pressure changes? Does an identified job account for possible degeneration? Will other resource team members be utilized if the diagnosis is predetermined? The answers to these questions must be addressed and appropriate mechanisms to afford solutions must be developed.
6.2. RSD is an ongoing disorder While the symptoms of RSD may be addressed, RSD cannot be 'cured.' The rehabilitation professional must not wait for the magical day when an affected extremity will no longer be disabled. Strategies must be taken to address current residual abilities and projections must be made to evaluate future abilities. Will the client be able to perform the identified job in two years? Will additional medical assistance be needed in two years? Will retraining be needed in two years? Based on the vocational goals, long term planning must be coordinated with the patient and other rehabilitation professionals.
6.3. Degeneration is a normal part of aging The body is constantly losing and regenerating cells. People are constantly growing older. As people grow older, their bodies lose endurance, strength and mobility. People with RSD will parallel the rest of the population. People will lose endurance, strength and mobility as time passes. The rehabilitation professional must assess, along with other health professionals, whether degeneration is a factor of the RSD, or rather a factor of the normal aging process.
6.4. Several people will be involved in rehabilitation efforts The range of people that may become involved in total rehabilitation efforts include orthopedic
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physicians, neurologists, neurosurgeons, occupational therapists, physical therapists, vocational rehabilitation counsellors, recreational therapists, pain management physicians and persons with RSD. Legal counsel for both plaintiff and defence may avail themselves to become a member of the rehabilitation team. A determination should be made as to the purpose and need for such participation. Coordination between these people will be extremely difficult as various professionals have multiple levels of expertise across several rehabilitation fields. The various professionals may also have different treatments goals and criteria for 'successful rehabilitation'. The goal of the vocational rehabilitation professional is for the person with RSD to return to work. By becoming involved in early identification and treatment efforts, the rehabilitation professional will be able to establish independent vocational goals in concurrence with other treatment plans. Griepp and Thomas [11] outline the need for nurses to become familiar with RSD so they may assist in patient detection and direct the resolution of problems peculiar to people with RSD. Additional literature references are needed to define professional roles and responsibilities in the wake of RSD.
6.5. Vocational planning While the medical literature notes employment outcomes for those diagnosed with RSD, a gap exists in the literature with regard to past role, existing role, or future role of vocational rehabilitation counsellors in the assessment of residual skills, planning of career goals, or general assistance in the retraining process. This lack of notation in the medical literature may be due to failure to report such rehabilitation intervention, or failure to recognize the potential impact of vocationally-specific treatment processes to affect return-to-work success rates. Vocational counsellors must become involved from the initial diagnosis stages to final job placement procedures. To afford career independence, vocational counsellors must first become familiar with basic RSD diagnosis criteria, treatment strategies and medical management. Once involved in the re-
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habilitation processes, the consultant must recognize that changes in medical condition must accommodate the job placement processes. RSD may initially be misdiagnosed. The person with RSD may have periods of exacerbation and job exploration efforts must recognize these periods of exacerbation. The consultant must become knowledgeable of pain concepts and the sociocultural dynamics involved with pain management practises as well as how these concepts relate to the job-specific environment and tasks. The vocational consultant must be cautious about the influence of litigation on motivation. The consultant may realize that the person with RSD may not be motivated to become rehabilitated until a settlement offer is rendered. Also, legal counsel may inappropriately 'diagnose' the motivation of a person with RSD. Bases for opinions should be based on scientific, quantifiable information, rather than hearsay. On the other hand, the person with RSD may have become wary of the workers compensation process and consider the vocational consultant another professional wanting to inappropriately reduce compensation benefits. The person with RSD may question the role of the rehabilitation consultant as provider. The role of the vocational professional must be defined not only to other medical service providers, but also to the individual with RSD. 6.6. Job placement considerations The medical literature has presented two studies with vocational outcome as a research question of consideration. In the first study, Inhofe and Garcia-Moral [1] conducted a long-term outcome study for 10 patients diagnosed with RSD. The patients were treated non-operatively and a I-year follow-up was documented. Of those who were employed prior to diagnosis, 67% reported a job change or unemployment directly related to the disease. Of the seven patients who held jobs prior to the diagnosis, six were contacted. One patient held the same job, three patients had different jobs and two were unemployed. Of the five patients who had a different job or were unemployed, four reported that the change was
directly related to the RSD. This study indicates and reinforces the idea that RSD diagnosis reflect job change. As RSD reflects job change, the rehabilitation consultant must account for both physical requirements and environmental conditions in the existing job if an employer is interested in making modification, or in other employment if vocational exploration is needed. Another worthwhile study outlined the vocational outcome of 125 people with RSD of the upper extremity [15]. Twenty-six (35%) claimed that they remained disabled following treatment and 23 (30%) held the same job. This account did not include 28 housewives (36.3%) who were able to do all the housework. This indicates greater than 65% of the people returned to substantial work activities. These studies leave more questions to be answered. The literature reveals a variety of success rates. Additional research is needed to account for more vocational outcome prospectives. Perhaps future medical research will include vocational consultants to establish research designs which address vocational outcomes for people with RSD. 7. Discussion RDS is a complex disorder. While the etiology of RSD is easy to understand, the diagnosis and treament of RSD is less clear. Furthermore, the vocational rehabilitation potential for persons with RSD is based on speculation, rather than based on empirical procedures. Rehabilitation efforts must be coordinated through many professionals. The clients must become an active component in the medical and vocational recovery process. As a vocational rehabilitation professional faces a greater number of patients either diagnosed with RSD, or exhibiting RSD symptoms, the vocational rehabilitation professional will be challenged to coordinate efforts with other professionals, provide counselling to address lifestyle and motivational factors and increase one's knowledge base about the etiology and treatment of RSD. By conducting and successfully completing these actions, the rehabilitation professional will afford quality rehabilitation services for the person diagnosed with RSD. The person
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with RSD may return to work and obtain vocational independence.
[3] [4]
Acknowledgements [5]
T.S. Smith is a Rehabilitation Consultant for Intracorp. The range of his clients involves a significant percentage of those diagnosed with RSD. He works closely with the second author and others to provide vocational rehabilitation services. He has a Master of Arts degree in Rehabilitation Counselling from the University of Alabama. He is a Certified Rehabilitation Counsellor and a Licensed Rehabilitation Counsellor in the State of Louisiana. M.C. Genoff is the founder and chief hand surgery consultant for The Louisiana Hand Center in Alexandria, Louisiana. He is board certified in orthopedic surgery with a fellowship in surgery of the hand. His practice involves a significant percentage of work-related injuries. He works closely with the first author and others to provide patients with the maximum possible functional recovery from their injuries. Special thanks to Glen Mercer for his consultation concerning this document. Also, special appreciation is given to Rachel Smith for her patience during development of this paper.
[6] [7] [8] [9] [10] [11] [12]
[13]
[14]
References Inhofe PO, Garcia-Moral CA. Reflex sympathetic dystrophy: a review of the literature and a long-term case study. Orthop Rev 1994;34:665-671. [2] Hooshmand H. Chronic pain: reflex sympathetic dystrophy prevention and management. Boca Raton, FL: CRC Press, 1993. [1]
[15]
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Lister G. The hand: diagnosis and indications. Edinburgh: Churchill Livingstone Press, 1994. Schiffenbauer J, Fagien M. Reflex sympathetic dystrophy involving mUltiple extremities. J Rheumatol 1993;2(XJ):I64-169. Teasell RW, Potter P, Moulin D. Reflex sympathetic dystrophy involving three limbs: a case study. Arch Phys Med Rehabil 1994;75:1008-1010. Sachs BL, Zindrick MR, Beasley RD. Reflex sympathetic dystrophy after opertive procedures on the lumbar spine. J Bone Jt Surg 1993;75:721-725. Jaeger B, Singer E, Kroening R. Reflex sympathetic dystrophy of the face: report of two cases and a review of the literature. Arch Neurol 1986;43:693-695. Seale KS. Reflex sympathetic dystrophy of the lower extremity. Clin Orthop Relat Res 1989;243:80-85. Green DP, Hotchkiss RN. Operative hand surgery, 3rd ed. New York: Churchill Livingston, 1993. Wattay EG. Reflex sympathetic dystrophy syndrome. Clin Man 1993;9(1):28-29. Griepp ME, Thomas AF. Reflex sympathetic dystrophy syndrome: a nursing challenge. Orthop Nurs 1987;6(3):32-35. Hooshmand H. RSD puzzles: (puzzle no. 30): (Available from Neurological Associates, 903 East Causeway Boulevard, Vero Beach, FL 32963): Neurological Associates, 1995a. Hooshmand H. RSD Puzzles: (puzzle no. 13): (Available from Neurological Associates, 903 East Causeway Boulevard, Vero Beach, FL 32963): Neurological Associates, 1995b. Hooshmand H. RSD Puzzles: (puzzle no. 23): (Available from Neurological Associates, 903 East Causeway Boulevard, Vero Beach, FL 32963): Neurological Associates, 1995c. Subbbarao J, Stillwell GK. Reflex sympathetic dystrophy of the upper extremity: analysis of total outcome of management of 125 cases. Arch Phys Med Rehabil 1981 ;62:549--554.
