| Neurological AssociatesH. Hooshmand, M. D., P.A.RSD Puzzle #102Ice Versus
Heat In our study of ice versus heat tolerance, 87% of the patients could
not tolerate cold. and 13% could not tolerate heat. The infrared thermal
imaging showed that the ones who could not tolerate heat (13 %) had advanced
stages of sympathetic nerve paralysis rather than nerve irritation (death
of the sympathetic nerve fibers rather than hyperactive nerve fibers).
The area of permanent sympathetic nerve damage in late stage acted like
a leaky radiator, causing leakage of heat through the skin which resulted
in warm extremity and secondary intolerance to external heat. Meaning
that due to permanent damage to the sympathetic nerve fibers( after repeated
ganglion nerve blocks or sympathectomy) the sympathetic nerves could not
contain and preserve the heat originating from the deep structures of
muscle, bone, etc... This minority of 13% of the patients did not have
the hyperactive cold vasoconstriction of the skin seen in earlier stages
of RSD. These heat intolerant patients would be classified as erythromelalgia,
rather than the 87% RSD patients who have hyperactive sympathetic function
with cold extremity and intolerance of cold exposure. On the other hand
repetitive application of ice freezes and coagulates the myelin (fatty
tissue insulating large nerve fibers) exactly like ice freezes and solidifies
melted butter. 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.
One last comment: this study was on advanced cases of RSD. In early stages
of RSD, without exposure to ice, there is far lower percentage of RSD
patients who from the beginning suffer from permanent damage to large
areas of sympathetic nerve fibers with intolerance of heat and secondary
erythromelalgia. It becomes obvious that heat-cold challenge physical
therapy is nonsensical because it end result is one temperature extreme
neutralizing the other and ice challenge further damaging nerve fibers.
Please stay away from any ice exposure, even if you can not tolerate heat.
H.Hooshmand, MD. 561-231-1300 FAX: 561-231-1499 903 East Causeway Blvd., P.O. Box 7147 Vero Beach, Florida 32961 |