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Reflex Sympathetic Dystrophy
Three Stages of RSD

Reflex Sympathetic Dystrophy comes in three stages: I'll talk about each stage in more detail below, but this chart should give you a quick overview of the symptoms and characteristics of each stage.

Stage
  Stage I: Acute Stage II: Dystrophic Stage III: Acute
Pain Type Very strong burning and neuralgia Very strong burning and throbbing Moderate to strong burning and throbbing
Temperature Increased temperature of affected area Decreased temperature of affected area Decreased temperature of affected area
Function Some impairment of movement Restriction of function and movement within the affected area Severe restriction of function and movement
Autonomic
Dysfunction		 Increased blood flow in the region Decreased Decreased
Dysthesia +++ ++ +
Discoloration Erythematous Mottled and dusky Cyanotic
Sudomotor
Dysfunction		 Minimal dysfunction Moderate dysfunction Severe dysfunction
Edema Noticable edema Increased Edema Moderate
Trophic
Changes		 No changes Strong changes Very servere
Osteoporosis No signs of osteoporosis Some osteoporosis and softening of the bones noticeable Osteoporosis more advanced

Phase I: Acute

When started: This phase starts with the injury or up to several weeks later.
Characteristics: Starts at the time of the injury or up to a few months later.
(2) Characterized by constant pain, usually burning in nature, of moderate severity and localized to the area of injury.
(2) Pain is aggravated by movement
(2) Pain is associated with hyperpathia (delayed over-reaction and aftersensation to a stimulus, particularly of a repetitive nature).
(2) Allodynia (pain caused by a normally non-noxious stimulus, particularly if repetitive or prolonged.
(2)Hyperesthesia (increased sensistivity) and hypesthesia (decreased sensitivity) may also be present.
(2) Localized edema
(2) Muscle spasm
(2) Tenderness
(2) Skin is usually warm, red and dry because of vasodilation, although signs of vasoconstriciton sometimes predominate late in this stage.
(2) toward the end of this phase, the skin becomes smooth and taut, with decrease or loss of normal wrinkles and creases.
(2) Radiographs taken at this stage show slight, if any, osteoporosis.
(2) In mild cases the first stage lasts only a few weeks, but in sever cases this stage may last as long as 6 months. During this stage the syndrome is treated with sympathetic blockade to good effect.

Stage II: Dystrophic

 Persistence of pain and disability with increasing dystrophy*
(2) If stage I (acute) is untreated (or treated incorrectly), it can progress to the second stage, which is sometimes referred to as dystrophic.
(2) Stage 2 is characterized by spreading of the edema, increasing stiffness of the joints and atrophy of the muscles.
(2) Pain remains the major symptom and is usually spontaneous and burning.
(2) Pain may radiate proximally from the site of the injury and may involve the whole extremity.
(2) Hyperpathia and allodynia are usually more pronounced than in the first stage.
(2) Skin is moist, cyanotic and cold.
(2) The hair is coarse and the nails show ridges and are brittle.
(2)Signs of atrophy become more prominent, and some literature says that radiographs usually reveal patchy osteoporosis.
(2) During this stage sympathetic blocks may still be effective in reversing or at least limiting the process, although the response to blockade may be short-lived and less pronounced.
(2) A larger series of blocks or prolonged sympathetic blockade may be necessary to afford permanent relief. (Not all people who have RSD get relief from blocks.)

Stage III: Atrophic

Skin and subcutaneous tissue atrophy and contractures.
Cold skin temperatures in the affected limb
Osteoporosis (Lancet study of 829 patients showed that 70% of them did not show osteoporosis, and in that article on taxonomy osteoporosis was removed from the symptoms list when the name of RSD was changed to Complex Regional Pain Syndrome)
(2) Characterized by marked trophic changes that eventually become irreversible (according to much of the literature).
(2)Pain is less prominent feature.
Skin becomes smooth, glossy and tight.
Skin temperature is lowered.
Skin appears pale or cyanotic in color.
Although the hair is long at the beginning of this stage, by the end of this stage, the hair has usually fallen out.
The subcutaneous tissues are atrophic, as are the muscles, particularly the interossei.

There is extreme weakness and limitation of motion at virtually all of the involved joints, which finally become ankylosed. Contractions of the flexor tendons often occur at this stage. Osteoporosis is more advanced, and the pain continues, aggravated by weight bearing, movement and frequently by exposure to cold. At the point many of the trophic changes produced by the syndrome become irreversible, and although interruption of sympathetic pathways by blocks may still provide temporary relief, repetitive sympathetic blocks alone are no longer effective in terminating the process permanently. An aggressive approach including physical therapy, psychologic counseling, and sympathetic and somatic nerve blockade is needed to reverse the process as much as possible. No longer is the pathophysiology confined to an aberrant sympathetic reflex arc. Other nerve fiber types are now involved, including A-beta (mechanoreceptors) and A-delta (sharp pain) fibers. At this point the process may not respond to neural blockade, either chemical or surgical, performed at any point in the chemical or surgical, performed at any point in the neuraxis because the self-sustaining mechanism may have moved to higher central nervous system centers, out of reach of these measures.

RSD manifests itself in three stages of severity. Not all of the literature agrees on the various aspects of each stage, but that is par for the course with RSD. This document attempts to codify the various definitions of the stages in one place. As more information becomes available, this document will be update. Note that with RSD, not all symptoms are present in all people. The main constant is the pain, and most people with RSD do have the severe burning pain.

Much of the current literature and discussion of taxonomy has ruled out osteoporosis as a symptom that identifies someone as having RSD. Too many patients who met all the other criteria did not have noticeable bone thinning.

1
2, Pain Medicine: A Comprehensive Review. P. Prithvi Raj, ed. Mosby, 1996.
3, Schwartzman, RJ. Reflex Sympathetic Dystrophy in Current Opinion in Neurology and Neurosurgery, 1993, 6:531-536.

It is interesting to note that many journal articles quote the same texts from 1947 and the 1950s. While there has been some research on RSD, very little of it has been through double-blind studies and under controlled circumstances. Much of the literature that lists itself as review of cases is really a review of one to 12 patients and how they reacted to a specific course of treatment and a review of other individual cases that have been written up in the medical journals to meet the criteria of "publish or perish." Still another way that people look at RSD is to retroactively review many many cases in an attempt to catch patterns and codify the findings.

This page was last updated on December 2, 1996.

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