Saturday, November 15, 2008

CRPS RSD and ICE , Should it be used?

The normal course of physical therapy following an injury is to use ice to bring down inflammation. They usually recommend something along the lines of ice packs many times per day, for weeks at a time. In quite a few instances they will also use something called Hot/Cold Contrast Therapy. This is where they alternate applying heat and ice. 

For the typical pain patient recovering from the typical chronic pain injury these types of therapies can be very beneficial and have been used for many years. 

However, (you knew there was going to be a however didn't you?), CRPS is anything but typical. And the application of ice, even in small doses like the use of an ice pack, can have very negative consequences and if used continually for days and weeks the application of ice can actually increase the pain of the disease and accelerate the CRPS through the stages. 


How long have we known this?  Many years.

Does every physical therapy center out there know about this?  If not, they need to and should. The information has been out there, published in articles and medical journals, etc.  I will share some of that below so if you know of a Dr or therapist that is still using ice to treat CRPS/RSD patients you can share this with them so they can learn. 

Part of the problem comes in that the damage that gets done is not readily apparent. It isn't as if the ice application will make the patient scream out, like the "desensitization therapy" for instance. As a matter of fact in the very beginning it may actually "feel" good and in a weird way it sort of makes sense in your head to apply ice when your affected limb is full of burning pain!

So, let's look at why ice causes short and long term problems for CRPS patients and probable acceleration of the disease itself. 

There are two basic areas we will look at and I will try to break it down into layman's terms and also provide the links for those of you who would like more in-depth information on the subject.

1) Some of the symptoms of CRPS, such as pain, discoloration, and spasms, are due to a constriction of  the blood vessels. This causes a reduced blood flow to the extremities. many of you have seen the color show your feet/hands, legs/arms have put on where they turn dusky, purple, etc. and have felt the pain of the constriction as if your limb was being strangled, have felt the extreme coldness due to lack of blood flow, etc.  These are all partly due to constriction of the blood vessels. 

Now when you apply ice to that same affected limb you are constricting, shrinking, those blood vessels and reducing the flow of blood to your limb even further. 

2) The second and more important aspect to the application of ice is the damage done to the myelin sheath (fatty tissue insulating the large nerve fibers) . The best explanation I have seen written on it was done by Dr Hooshmand many years ago;



"As the ice freezes the large nerve fibers, causing freeze damage to the myelinated nerves, the patient develops sensory loss and pain due to permanent damage to the large sensory nerve fibers. This aggravates the RSD by adding sensory nerve pain of non-sympathetic origin to the initial thermal sensory pain of sympathetic origin.

As a result, Ice provides total anesthesia and relief of pain for several minute the same way as the hand becomes numb being exposed to snowballs in the winter. However, a few hours after the cessation of ice exposure, the pain recurs with vengeance due to reactive enlargement of blood vessels after the constriction of blood vessels due to exposure to ice.

This phenomenon causes excellent relief of pain with ice treatment followed by not only aggravation of pain, but damage to the nerve fibers adding sympathetic independent pain (SIP) to the original sympathetic mediated pain (SMP).

The end result is aggravation of the RSD and SIP resulting in failure of nerve blocks and then the patient is told, "You do not have RSD anymore because the nerve block did not help you and the phentolamine test proved that you do not have SMP or RSD".

In most RSD patients ice makes the condition worse and can cause denial of diagnosis and treatment for the patient."



The link to the complete article can be found by going to;



You can also read more about SIP (also called IMP or Independently Mediated Pain) and SMP by going to SMP OR IMP? WHAT IS THE DIFFERENCE


In the second ICE article it discusses this;

In stage I, the injured area shows hyperthermia (increased temperature) rather than hypothermia.This is because of a temporary shock to the sympathetic system not being able to preserve heat and to control any heat loss over the skin of the injured area. In a matter of a few weeks, the majority of such patients (over four-fifths of RSD patients) regain the function of the sympathetic system and develop cold skin over the skin surrounding the area of nerve damage. Such patients cannot tolerate ice. If anything, ice aggravates the disease and exaggerates the constriction of the blood vessels and hypothermia (coldness) of the extremity. Even in these patients, the small central area of nerve damage at the area of maximum brunt of the trauma, an area is left with total paralysis of the sympathetic function showing as a pin-point area of hyperthermia on thermography. In these patients which are the majority of RSD patients, ice application should be avoided by all means.

In one-fifth of the cases when hyperthermia persists for a few more weeks, the patient will continue to be intolerant of heat or ice.

In stages II and III, the extremity progressively develops more and more hypothermia due to persistence of the dysfunction of the sympathetic system.

Eventually, towards the end of stage III and beginning of stage IV, in some cases the hyperthermia has a tendency to recur. This phenomenon is in part due to the fact that the patient has had repeated sympathetic ganglion blocks. The repetitive, numerous sympathetic ganglion blocks cause what is called "virtual sympathectomy". This results in gradual hyperthermia of the extremity (warming of the extremity). Even though the extremity becomes warm due to the virtual permanent damage to the sympathetic system, the pain does not get any better. In these patients, again, heat should be avoided.

Regardless of which type of heat intolerance or cold intolerance the patient is dealing with, the so-called heat and cold challenge treatment does no good in RSD patients. It only confuses the diagnosis and treatment and it should be avoided.

In many patients, in stages II and III, in the same extremity, there are islands of sympathetic paralysis, (hyperthermia) and islands of marked hypothermia due to sympathetic nerve irritation. These are the cases that do not respond properly to sympathetic nerve blocks and are classified as SIP (sympathetically independent pain)."


What happens if there are repeated applications of ice and severe damage occurs? The patient can actually accelerate through the stages, so instead of being in stage one for six months where local blocks may give significant relief they are propelled forward into stage two or three where there is no relief at all from blocks. Not only is this discouraging to the patient and sometimes the Doctor, but in many cases the Doctor and/or deciding party (WC, Insurance Company, etc.) may say "If you aren't responding to blocks then you must not have CRPS/RSD".  Either not understanding the role that the application that the ice played, not knowing how severely damaging it could be, or not even having a clue that it was a factor at all. The patient is left without a correct diagnosis, many cases without an effective treatment, and now, has damaged nerves as well. 

Just one more reason (and there are quite a few) why blocks can work better with some people than others, better in some stages than others, and why we can never compare our pain to other patients pain. 

Hopefully, between what I have shared above and the links you will have a much better understanding of why the application of ice is not a good idea for CRPS patients and be able to share the information with your Drs and therapists. Besides the above links there are additional links on the website as well. 

Hope this helps!

Peace, Keith

American RSDHope


1 comment:

Coach Marla said...

Hi Keith,

I always love your articles, they are so full of such useful information!
Thank You!

I do have a question for you; Is there a connection to temporary paralysis and RSD without the nerve blocks being a factor?

The reason I ask is because I have been experiencing some paralysis that last a short period of time, my neurologist was thinking it was my SCS, possibly causing it....After many tests, we proved it wasn't that.
I do have MS as well, and know that is something that comes with it, but I am curious as to if anyone with just RSD has had that issue.

Thank You Keith for all you do for us!!

Much Appreciation & Many Blessings,
Coach Marla