to the editor: I am writing in response to the recent editorial on reflex sympathetic dystrophy.1
Many of the references cited were written by Dr. Ochoa or his colleagues and do not, in my estimation, represent the opinion of the medical majority.
It is Dr. Ochoa's belief that the concept of reflex sympathetic dystrophy, for the most part, doesn't exist. He makes reference to “many patients with reflex sympathetic dystrophy, those who neither have organic neurologic damage nor malinger, harbor a primary psychiatric disorder in the realm of what used to be called ‘psychosomatic disease . . . ’ ” I recently attended a conference in Orlando, Fla., where more than 200 patients with reflex sympathetic dystrophy were present to learn about possible advances on the horizon for the treatment of this incurable and disabling problem. Perhaps Dr. Ochoa should be present at the next such meeting and address this group himself.
Dr. Ochoa fails to recognize the established work of many experts in the treatment of reflex sympathetic dystrophy. He also seems to feel that the use of sympathetic blockade is either useless or farcical and seems to castigate physicians who perform diagnostic tests and ridicule patients who do not have clear-cut neurologic symptoms. He should recognize that this disorder is one that does not allow for clear-cut findings to exist, which is why the diagnosis is so difficult and the treatment virtually impossible in certain instances.
Dr. Ochoa states that the disorder is neither reflex nor sympathetic nor dystrophy; perhaps that is why the experts in this field have changed the name of the disorder to “complex regional pain syndrome.”
in reply: In response to Dr. Getson's letter regarding my editorial on reflex sympathetic dystrophy, I would like to offer the following comments:
After extensive literature review, I continue to question the validity of reflex sympathetic dystrophy as a pathophysiologically meaningful diagnostic entity. To further support my views, I urge readers to review the enclosed references.1–6
The clinical entity labeled with the descriptive term “reflex sympathetic dystrophy” is heterogenous. A variety of organically and psychologically based disorders can yield the same symptom complex. Moreover, the concept of “sympathetically maintained pain” is disabled by current awareness that what had been thought of as a gold standard test—the sympathetic block—amounts to a placebo artifact.
This issue is more than a mere theoretic debate; my concern lies in the possibility of misdiagnosis and its attendant complications. If a label of “reflex sympathetic dystrophy” in any way denies or postpones a proper diagnosis or subjects a patient to unnecessary treatment, we have done our patient a great disservice.
As long as a lack of definitive evidence remains, it will be impossible to decide the bottom line; the debate continues and, indeed, remains necessary. As long as theoretic assumptions are the basis for empiric treatments that may fail or result in harm, our patients are at risk for needless suffering. Consider my proposal then, that for the time being we view reflex sympathetic dystrophy as a nonspecific symptom complex rather than a discrete pathophysiologic disease entity.