Geertzen, Joannes Henricus Bernardus

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   University of GroningenReflex sympathetic dystrophyGeertzen, Joannes Henricus BernardusIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:1998Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Geertzen, J. H. B. (1998). Reflex sympathetic dystrophy: a study in the perspective of rehabilitationmedicine. s.n.CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 13-02-2023summary - 133SUMMARYReflex Sympathetic Dystrophy: A study in the perspective of rehabilitation medicine.This thesis describes patients with reflex sympathetic dystrophy (RSD) of the upper extremity.RSD is a chronic and disabling disease. The clinical picture of RSD is characterized by acombination of the triad autonomic, motor and sensory changes. At our Department of Rehabili-tation, with special interest in hand injuries, RSD is a syndrome which is frequently seen.Knowledge about and insight in this syndrome is needed to treat and inform patients well.Because there was and is a lot of discussion whether RSD is a somatic or psychosomaticsyndrome, we performed two studies concerning this question. We also analyzed at the medicaltreaÍnent in the early stage of RSD because in the beginning of our study, a new treatrnent wasproposed. We performed a randomized clinical trial whether the new treatment with hydroxylradical scavengers, would be better than our usual treatÍnent with Ismelin blocks. Little isknown about interacting aspects in the development of RSD therefore we additionally analyzedin the same trial these possible interacting aspects such as psychological dysfunction and sociallife events. Vy'e performed a long-term follow-up study in order to arralyze functional outcomeafter RSD. Functional outcome encloses irnpairments, disability, vocational outcome, generalhealth status, and handicap. It is supposed by the World Health Organization that there is asequence between disease, impairment, disability, and handicap; therefore, we analyzed therelationship between disease-impairment-disability, and handicap in RSD patients.These studies were followed by two studies to investigate the sources of variation in measure-ments in medical examinations in RSD patients. Finally two patients are described with a poorend-result: an amputation of the affected upper extremity. The aims of this thesis are discussedin chapter 1.Chapter 2 describes the results of a randomized clinical trial concerning early treatment andpsychological aspects of a series of 26 patients who had RSD of the hand and in which treat-ment was started within three months after the diagnosis. Ismelin blocks were a very often usedtherapy in RSD in the eighties but a probable better therapy in the first stage of the RSD,proposed by RIA Goris was also investigated. Thirteen patients were treated with RegionalIntravenous Ismelin blocks and 13 with a hydroxyl radical scavenger, dimethylsulfoxide(DMSO). After nine weeks the increase of range of motion and the decrease of pain wassignificantly better in the group treated with DMSO as compared to the group treated with RISblocks. With DMSO, the patient can treat him- or herself and the costs are lower than thetreatment with Ismelin. This chapter also reviews briefly the psychological aspects associatedwith RSD and describes the psychological aspects of a group of 24 RSD patients compared witha control group of 42 patients who underwent elective hand surgery. The female RSD patients134 - rcflex sympathetic dystrophywere more depressed and emotional unstable. Eighty percent of all RSD patients had a recentliÍ-e event; the control group 207á. Based on the results, it was concluded that there is a multi-causal relation to getting RSD. Depression, emotional disturbances, anxiety and/or social liÍèevents, together with a trauma, can increase the risk of RSD.The objective of the study described in chapter 3 was to determine to what extent stressful lifeevents and psychological dysfunction play a role in the pathogenesis of RSD. This was acomparative study between the RSD group and the control group, described in chapter 2.Stressful iÍè events and psychological dysÍïnction evaluation were performed by a life eventrating list and the Symptom Checklisr9O (SCL-90). The RSD group consisted of 24 patientswith a history of upper extremity RSD, less than 3 months. The control group consisted of 42hand pathology patients waiting for elective hand surgery. Eighty percent of the RSD patientshad a recent liÍè event; the control group 20o/n. Male RSD patients were more anxious thanmale controls. Female RSD patients were more depressed, inadequate and were emotionally lessstable than fèmale controls. In rnultivariate analysis no significant differences were Íbundbetween the groups with respect o gender, age and age-gender interactions. Of the SCL-90dimensions only insornnia correlaied with the experienced stressÍul ife events. It is concludedthat stressful ifè events are conrmon in the RSD group, indicating that there is a multi-condi-tional model of RSD. Thc experience of a stressful l i fe event besides trauma or surgery is a riskÍactor in such a n.rult i-conditional model.The objective of the long term Íbllow-up study described in chapter 4a was to identify impair-ments resulting fiom RSD of the upper extremity and to analyze the relationship betweenirnpairn.rent and disability in RSD patients. The study group consisted of a reÍ'erred sample of ó5RSD patients with clinical signs of the upper extremity. RSD appeared aÍïer fractures of thewrist or hand in 29 patients (44.6%) or after a carpal tunnel release in 9 patients (13.8%). Themean interval between the diagnosis RSD and the fbllow-up was 5.5 years (sd :0.16: range =3-9 yeals). The n.rain outcome measurements were the impairments measured by standardphysical examination. Activity of Daily Lifè (ADL) and pain were assessed using a VisualAnalogue Scale (VAS). Pain was assessed direct beÍbre and after the physical examination andthe pain perceived in the week beÍbre exarnination was assessed. Significant diflèrences inimpairments were found betrveen the affected and the non-afÍècted side (p<0.05). According tothe AMA guides the impairments Íbund. should not result in disabil it ies. Significant correlationswere fbund between VAS-ADL and VAS-Pain in the last week prior to evaluation (r : 0.65)and between VAS-ADL and Íuil f ist grip strength (r : -0.55). Pain was the most disablingÍactor. It was tbund that an early diagnosis and early treatment, did not lead to less impairmentsor disabil it ies as was suÍrcested in l i terature.Thegenevepatlhealquer? 5 \) ) r- -  Ípaincont( r r L  IbetutnterTherelat:Sixtyoutc(the h(GAiphysiof thtlnentithumlIADIpatierÍbunct! an,handiChatrresull(sDrobseland aaccoÍinteríof vaents had a recentt there is a multi-nd/or social life)xtent stressful lifeThis was an chapter 2.I by a life eventd of 24 patientsp consisted of 42lhe RSD patientse anxious than)re emotionally lesswere foundlf the SCL-90i. It is concludedis a multi-condi-or surgery is a risk.o identify impair-hip betweenèrred sample of 65ractures of thents (13.8%).  The= 0.16; range :5y standarding a Visualexamination andfferences in)5). According toficant correlationsion (r : 0.65):st disablingless impairmentssummary - 135The objective of the long term follow-up study described in chapter 4b was to identify thegeneral health status, long-term vocational outcome and psychosocial aspects such as social lifeevents (SLE), around the inciting event of RSD and to identify the psychological history of 65patients, 5.5 years (sd : 0.76; range : 3-9 years) after RSD of the upper extremity. Generalhealth status and long term vocational outcome were assessed by means of a general healthquestionnaire (RAND-36) and a structured interview, respectively. SLE, (life change unit >35), was present in 32 patients (49%). A psychological (or psychiatric) history was present in22patients (34%).In total, 60% of the patients had a SLE and/or a psychological history. Thepain scores of the RAND-36 of the RSD patients were significantly higher than a RANDcontrol group. In total 17 patients (26%)had to change profession due to RSD. Nearly 30% ofthe patients had to stop their work for more than one year. The results show a high co-incidencebetween RSD and interacting psychosocial disorders and this co-incidence may play a role inintensifying and prolonging the symptomatology of RSD.The objective of the long-term follow-up study described in chapter 5 is to determine therelationship between impairments, disability, and handicap in upper extremity RSD patients.Sixty five patients, five and half year after RSD of the upper extremity were studied. The mainoutcome measures were: range of motion, moving two point discrimination, muscle strength ofthe hand and pain. Disability was assessed with the Groningen Activity Restriction Scale(GARS) and handicap was assessed with 3 subscales, social functioning, role limitations due tophysical problems and role limitations due to emotional problems, of the RAND-36. After RSDof the upper extremity, 61.5% of the patients is limited to some extent in ADL and/or Instru-mental Activities of Daily Life (IADL). Pain and restrictions in forward flexion of the shoulder,thumb opposition and grip strength are the most important impairments limiting ADL andIADL. Patients with limitations in ADL and IADL are significantly more handicapped thanpatients without limitations. Pain is the most important factor contributing to handicap. Wefound a weak to moderate relationship between impairments and disability and between disabili-ty and handicap in RSD patients. Pain is the most important factor leading to disability andhandicap.Chapter 6a concerns a study which identifies different sources of variation in measurementresults of upper extremity range of rnotion and estimates the smallest detectable difference(SDD) between measurerlents. Twenty-nine RSD patients were measured repeatedly. Twoobservers each measured in two sessions the range of motion, using a two armed goniometerand an inclinometer. The measurement results were analyzed using an analysis of varianceaccording to the generalizability theory. The results indicate that observer and patient-observerinteractions are important sources of variation. The random error was the most important sourceof variation. The SDD was smallest for elbow flexion non-affected side, 7.1o and largest forI-136 - reflex synipathotic dystrophyshoulder external rotation affected side, 28.7". Clinically our results indicate that range ofmotion measurement in RSD patients are subject to considerable variation and indicate thatresults of medical examinations in order to assess disability on the basis of range of motionmeasurements are also subiect to considerable variation.In chapter 6b the same patients, as described in chapter 6a, were assessed. In this study thethree different grip strengths are measured in 29 upper extremity RSD patients. Again we usedthe generalizability theory to assess the extent of the disagreement or differences (errors of themeasurements) within or between observers and interactions between observer-session andrepetition of the measurements. The aims of our study were to identify the different sources ofvariation in grip strength and to analyze the smallest detectable differences (SDD) and todetermine the reliability of upper extremity grip strength tests in RSD patients. The mostimportant sources of variation of measurement errors were observer, patient-observer interac-tions and patient-session-observer interaction and the random error. We found that the generali-zability theory is a good tool fbr estimating the sources of measurement error. Clinical examina-tions fbr muscle strength measurements as a part of a total clinical examination for example adisability payment or worker's compensation in case of RSD patients should be done in morethan one session and with more than one reoetition.In chapters 7a and 7b two case reports are described. In both clinical notes the end-result forthe RSD patient was poor, namely an amputation of the upper extremity. These clinical notesare added to this thesis to indicate that there is a difference between outcome on group level andon the individual level and to indicate that in some cases the diasnosis RSD is difficult andremains questionable, as well as the treatment.In chapter 8, the general discussion, the results of the different studies are discussed. It isconcluded that RSD tends to become a chronic pain syndrome, in which psychosocial factorsplay a role. Further it is concluded that DMSO is a good treatment in the early stage of RSD.In "chronic" RSD, pain and loss of fïll fist grip strength are the most evident impairments.RSD is a disabling disease in which pain is the most disabling factor. At last it is found that inmedical examinations, the interaction patient-observer, is responsible for a considerable varia-tion in measuring impairments such as range of motion or grip strength.Symtklinisen selGronimet Sgoedde vriverricnieu*"randzuurslGuantsympíSRD,on-tdalwerdarbeidGezortenslode onrVervcmeh.1lslechtDe d<In hode vrbuwrot diin deonde:ten ndeldten.

Reflex sympathetic dystrophy:a study in the perspective of rehabilitation medicine

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Reflex sympathetic dystrophy:a study in the perspective of rehabilitation medicine

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