HBOT and RSD

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Treatment of Sympathetic Reflex Dystrophy

(SRD) with Hyperbaric Oxygen Therapy (HBO)

 

 

Background

Sympathetic Reflex Dystrophy ( " Sudeck-Atrophy " , " Algodystrophy " ) is

a commonly serious complication after trauma or operation of

extremities. Incidence ranges from 1 to 35 % and does not correlate

with the extends of the trauma or operative intervention (Mathes

1984, Richter & Brackertz 1989). The underlying pathogenesis of the

disease is mainly unknown. The theory, already mentioned by Sudeck,

of an overreaction inflammatory response is still the favourite.

With this reaction micro vascular changes occur, followed by an

increased permeability for large proteins, disturbed metabolism of

high energy phosphates, and a reduced oxygen consumption in the

affected extremity. Treatment is limited to symptomatic measures

(Kozin 1985, Küntscher 1998, Matthes 1984, Ott 1974, Veldman 1993).

A total restitution can only be achieved in very small minority of

the patients.

Possible mechanisms of HBO Therapy in SRD are (Knighton et al. 1981,

1983, Silver 1984)

Enhancement of microcirculation,

Reduction of oedema,

Improvement of local metabolism and recalcification,

Reduction of the inflammatory response.

Purpose of the Study

To investigate in a prospective study, if the course of the disease

of patients with a manifest SRD can be positively influenced by

adjunctive HBO Therapy.

Selection of Patients

Inclusion criteria

Patients with a manifest SRD in Stage I will be included in the

study, when they fulfil the following criteria of the Nijmegen

Classification (Veldmann et al 1993):

1. 4 out of 5:

Unexplained diffuse pain

Difference in skin colour compared to the opposite extremity

Diffuse oedema

Difference in skin temperature compared to the opposite

Decreased range of movement

2. Start or increase of the symptoms when extremity is used

3. Manifestation of the symptoms expanding the area of the primary

injury or operation and distally thereof

Stage I is equally to the acute („hot " ) phase of the first 2-3 month.

Exclusion criteria

Arterial occlusive disease (pulse less)

Raynaud Disease

Thrombophlebitis

Autoimmune or rheumatic disease

Generalised osteoporosis

Methods

Therapy arms

Therapy arms are differed by:

A Standard treatment (Antiphlogistics, Elevation, Physiotherapy,

Plexus catheter with Guanethidin blockade)

B Standard treatment plus HBO Therapy (3 x 30 min, 2,4 bar, 20 days

1x daily.)

Randomisation

Randomisation of the patients will be achieved by telephone.

Evaluation Criteria

Examination of the patients includes:

Swelling (circumference of wrist, middle hand with volumetry),

Mobility (fist closure, finger stretching, hand span, wrist),

Sensibility (Semmes-Weinstein),

Power measurement at fist closure (computer aided in alternate

grip),

Pain medication consume,

Subjective pain sensation by visual analogue scale,

Temperature and Colour with comparison of opposite site,

DASH (main criterion),

Bone density measurement with identifiable decalcification in

conventional radiographs.

Examinations are carried out in defined time intervals:

Time interval (weeks)

  Pre-operative 2 4 8 12

Swelling X X X X X

Mobility X X X X X

Sensibility X X X X X

Power X X X X X

Temperature X X X X X

Colour X X X X X

Pain sensation X X X X X

DASH X   X   X

Bone density (x)       (x)

Patient amount

In each study arm 20 patients are proposed.

Ethics

Participation in the study requires written informed consent of the

patients, especially on the risks and benefits of HBO Therapy.

Statistics

The main criterion will be tested statistically, while the other

criteria will be described by data analysis. Definitive estimation

of the necessary amount of patients is not possible, as no data are

available to estimate the possible improvement.

Study Group

Priv.-Doz. Dr. H. Menke, Dr. S. Kluge, Dr. M. Küntscher, Prof. Dr.

G. Germann

Department of Burns, Plastic- and Handsurgery, BG-Unfallklinik

Ludwigshafen, Clinic for Plastic- and Handsurgery of the University

of Heidelberg -

Dr. Müller, HBO-Zentrum Rhein-Neckar am Diakonie-Krankenhaus

Mannheim Speyerer Strasse.

The hospital in Ludwigshafen has numerous patients and excellent

experience in the treatment of SRD, therefore adequate treatment

with Ergo- and Physiotherapy etc. is also provided. The Hyperbaric

Centre in Mannheim is specialised for the treatment with hyperbaric

oxygen therapy, a long experience in this field is granted.

Literature (selected)

Field J, Monc C, Atkins RM (1993) J Hand Surg Br Jun 18 (3): 339

Knighton DR, Hunt TK, Schenestuhl H et al (1983) Science 221: 1283

Knighton DR, Silver IA, Hunt TK (1981) Surgery 90: 262

Kozin F (1985) In: McCarthy DJ (ed) „Arthritis and allied

conditions " , Lea & Feabinger, Philadelphia, 1322-1355

Küntscher MV Promotionsschrift Heidelberg 1998

Mathes H (1984) Hefte zur Unfallheilkunde 164: 547

Ott VR (1974) Fortbildk Rheumatol 3: 166

Richter D, Brackertz D (1989) Z Rheumatol 48: 72

Silver IA (1984) In: Soft and Hard Tissue Repair. Hunt TK,

Heppenstall RB, Pines E (Eds) New York: Praeger (1984), 50-66

Veldman PH, Reynen HM, Arntz IE, Goris RJ (1993) Lancet 342 (8878):

1012

Study protocol NOT finalised !!!

Send comments or expressions of interest to:

Dr. med. HJ Müller

HBO-Zentrum Rhein-Neckar

Diakoniekrankenhaus Mannheim

Speyerer Strasse 91-93

D-68163 Mannheim/Germany

Phone: +49-621-8102-390

e-mail: dr.mueller@hbo-mannheim