Neurological Associates

Pain Management Center

Vero Beach, Florida

 

 

H. Hooshmand, M.D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY


BOARD CERTIFIED IN ELECTROMYOGRAPHY

BOARD CERTIFIED IN AMERICAN BOARD OF ELECTRODIAGNOSTIC MEDICINE


INTRACTABLE NEUROLOGY

( Epilepsy, Pain, MS) 

An International Referral Center dedicated to Treatment, Education and Research

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ON-LINE

RSD SURVEY FORM

 

International Reflex Sympathetic Dystrophy FoundationŠ

Dear Friends:

I would like to thank you in advance for taking the time to fill out this very important survey regarding Reflex Sympathetic Dystrophy (RSD) (CRPS). This survey will help us find some answers to the very puzzling problem we call RSD (CRPS). All information that is collected from this survey will be placed into a data bank. This may take sometime to finish, but I do hope within the next few years I will be able to send you the results of this ongoing survey study. All returned information will be confidential.

I would like to thank you for your time and help with this very important project.

Sincerely,
Eric M. Phillips
President
International RSD Foundation
P.O. Box 1145
Lakeville, Massachusetts 02347-1145 USA
If you have any questions or comments about this survey, please feel free to contact me at 508-946-9888. You can also fax or e-mail me your questions or comments to the following:
Fax: 508-946-3338
EricmP9512@AOL.com
Utopia33@Prodigy.net

*Please Note: If you have a problem filling out this survey form please go to the link for the "Printable RSD Survey", and you will be able to print out this same RSD Survey.  After you print it out, please fill out the form and return it to me by snail mail to the address above. Thank you. :-)
 

 
This survey is designed to help us get a better understanding of how RSD (CRPS) affects each individual and what treatments help and which  do not help in the management of Reflex Sympathetic Dystrophy.

 

 

Name (Optional):

E-Mail Address :

Age :

Sex:  M F

 

 

1. How did you develop RSD?
Animal Bite
Cause unknown?
Flare up of an old injury
Electrical Injury
Injury
Minor Trauma
Surgery
Venipuncture (I.V. or I.M. injection / needle injury)
(Please tell us how you developed your RSD)

 

2. When did you develop symptoms of RSD?
After Electrical Injury
After Heart Attack
After Injury
After Stroke
After Surgery
After Venipuncture (I.V. or I.M. injection / needle injury)
 
3. Where do you have your RSD?
Face
Internal Organs
Left Lower Extremity
Left Upper Extremity
Right Lower Extremity
Right Upper Extremity
Total Body (All four extremities)
 

4. How long have you suffered from RSD?                                                                                                  

Days: Weeks: Months:    Years:

 

5. What method was used to help diagnose your RSD?
 
Blood Test
Bone Scan
Clinical Diagnosis  
Cold Stress Test
CT Scan  
Doppler   
EMG
MRI
Phentolamine (Regitine) Test
QSART Test
Sympathetic Nerve Block
Thermal Stress Test
Thermography ( Infrared Thermal Imaging)
X-Rays
Others (Please describe)
 
6. How long after injury or surgery were you diagnosed as having RSD?                                                 
Days: Weeks: Months:    Years:    
 
7. Please check any of the following symptoms that you have had along with your RSD.
 
Abdominal Pain 
Atrophy
Back Pain
Bruising
Cardiac Disturbance
Depression
Dizziness
Discoloration of Skin
Dystonia
Facial Pain
Falling Spell
Hearing Disturbance
Headaches
Heartburn
High Grade Fever
Hot Flashes
Hyperpathia
Hypertension
Immune System Disturbance
Internal Organ Disturbance
Limited Mobility
Loss Of Sex Desire (Libido)
Low Blood Pressure
Low Grade Fever
Memory Disturbance
Menstrual Irregularity
Migraine Headaches
Mood Swings
Movement Disorder
Muscle Contractions of the Fingers or Toes
Muscle Spasm
Osteoporosis
Pelvic Pain
Rapid Hair Growth
Rapid Hair Loss
Rapid Nail Growth   
Rapid Nail Loss
Rash
Severe Fatigue
Shoulder Hand Syndrome
Skin Lesion's (Skin Ulcers)
Sleep Disturbance
Stomach Ulcers
Sweating
Swelling (Edema)
Tremor
Vasoconstriction
Visual Disturbance
Weight Gain
Weight Loss
 Others
 

8. Please check any of the following treatments listed below, that you have tried. Please select one of the following answers if these treatments increased or decreased your RSD symptoms and if these treatments were a success or failure in your quest for pain relief. If not sure select "Undecided".
 

Acupuncture 

Amputation         

Application of Heat

Application of Ice       

Arthroscopy

Bio-Feed Back    

Carpal Tunnel Surgery       

Chemical Sympathectomy  

Chiropractor  

Cingulotomy      

Cordotomy  

Cryosurgery

Disc Surgery

Exploration 

Fusion Surgery    

Homeopathy

Hydrotherapy     

Hypnosis Therapy

Infusion Pump      

I.V. Mannitol   

Ketamine Treatment

Knee Surgery  

Laser Surgery

Magnet Therapy  

Micro Surgery  

Nerve Graft

Neurectomy

Occupational Therapy (O.T.)

Phentolamine Test

Physical Therapy (P.T.)

Psychotherapy

Radiofrequency Treatment

Removal of Neuroma

Rhizotomy

Rib Resection

Rotator Cuff Surgery

Spinal Cord Stimulator

Sympathectomy (Surgical)

Sympathetic Nerve Block

Tarsal Tunnel Surgery

Tendon Release

TENS Unit Treatment

Ulnar Nerve Release

Ultrasound

Others (Please describe)

 

9. Please check any of the following medications listed below, that you have taken to help treat your RSD. Please select one of the following answers if these medications increased or decreased your RSD symptoms and if these medications were a success or failure in your treatment of RSD. If not sure select "Undecided".      PLEASE NOTE * (GENERIC NAME)
Ativan (Lorazepam*)     
Baclofen (Lioresol*)      
Buprenorphine (Buprenex*)  
Butorfranol (Stadol*)     
Calan or Isoptin (Verapamil*)    
Catapres (Clonidine) (Oral or Patch*)  
Dalmane (Flurazepam*)
Demerol (Meperidine*)       
Desyrel (Trazodone*)          
Dibenzyline (Phenoxybenzamine*)   
Dilantin (Phenytoin*)      
Dilaulid (Hydro Morphone)  
Elavil (Amitriptyline*)       
Flexeril (Cyclobenzaprine*)
Halcion (Triazolam*)     
Haldol (Haloperidol*)  
Hytrin (Terazocin *)     
Inderal (Propranolol *)
Klonopin (Clonazepam*)  
Lodine (Etodolac*)
Lidoderm (Lidocaine Patch 5%*)
Lortab
Methadone    
Mexitil (Mexiletine*)
Minipress (Prazosin*)        
Morphine
MS Contin (Morphine Sulfate)
Naprosyn (Naproxen*)
Neurontin ( Gabapentin*)
Noropramin(Desipramine*)
Nubain
Pamelor (Nortriptyline*)
Paxil (Paroxetine*)
Percocet
Percodan
Procardia (Nifedipine*)
Prozac(Fluoxetine Hydrochloride*)
Relafen (Nabumetone*)
Restoril (Temazepam*)
Soma (Carisoprodol*)
Talacen
Tegretol (Carbamazepine*)   
Tofranil (Imipramine*)
Tranxene (Clorazepate Dipotassium*)
Ultracet (Tramadol HCI*)
Ultram (Tramadol Hydrochloride*)   
Valium (Diazepam*)
Vicodin
Xanax (Alprazolam*)
Zanaflex
Zoloft (Sertraline Hydrochloride
Zonalon Cream
Zostrix (Capsaicin*)
Others (Please describe)
 

10. Please list below the names and amount of the medications that you are currently taking.

 

11. If you are currently taking Methadone for your RSD, have you had any of the following side effects? (If you are not taking Methadone please skip to question 17).
 
Bronchopneumonia
Cardiac Dysrhythmia
Confusion Dizziness
High Toxicity Level
Narcolepsy (Tendency To Fall Asleep)
Pulmonary Edema
Respiratory Depression (Breathing Problems)
Sleep Apnea (Temporary Cessation Of Breathing During Sleep)
 
12. While taking Methadone have you had any blood testing done to check the toxicity levels of the Methadone in your system?                                     Y N
 
13. Please tell us what other medications you are currently taking along with Methadone. (Please describe)
 
14. How long have you been taking Methadone?                                                                                       
Days: Weeks: Months:Years:
 
15. How many milligrams of Methadone do you take each day?
 
16. Has Methadone increased or decreased your RSD pain?                                                                                             Increased Decreased   
 
17. Prior to taking Methadone did you ever take Morphine or M.S. Contin?                                                                                                                            Y N
 
18. Since you developed RSD have your sleep patterns changed?      Y N    If , so do you sleep more or less now since you developed RSD?
      
It may be necessary to hold your Ctrl key down while clicking with your mouse to select multiple options.
    
19. How many hours a night do you sleep?
 
20. How is your ability to concentrate on things that you feel are important to you?   Good Moderate Poor
 
 

21. Do you ever have a feeling of a electrical jolt in your affected extremity?                                                                                                                             Y N

 

22. Have you had problems with your balance since developing RSD?                                                                                                                               Y N

 

23. Have you ever been told by any doctor that your RSD is in your head and that you are crazy?                                                                                                                            Y N

 

24. Has your RSD spread since the time of onset?                                   Y N

 

25. If your RSD has spread from the time of onset, please tell us how long that it took for your RSD to spread.   Days:Weeks:Months:Years:

 

26. Did your RSD spread after surgery?                                                     Y N

 

27. Did your RSD spread after ice application?                                         Y N

 

28. If your RSD did spread from surgery, please describe below what type of surgery you had.

 

29. Did your RSD spread after application of cast?                                  Y N

 

30. At the time of onset was the skin temperature in your affected extremity hot or cold?

 

31. Have you developed any type of deformity or contractures in your affected extremity?                                                                                                        Y N

 

32. If you have developed any type of deformity or contractures, please tell us how long it took for the deformity or contractures to start after the onset of your RSD.                                                                          

Days:Weeks:Months:Years:

 

33. Please check any of the following places where you have your deformity or contractures.

Left Fingers
Left Hand
Left Wrist
Left Arm
Left Elbow
Left Shoulder
Left Toes
Left Foot
Left Ankle
Left Leg
Left Knee
Left Hip
Right Fingers
Right Hand
Right Wrist
Right Arm
Right Elbow     
Right Shoulder
Right Toes
Right Foot
Right Ankle
Right Leg
Right Knee
Right Hip
 
34. Have you had any amputations of your affected RSD extremities or digits?                                                                                                                             Y N
 
35. If an amputation was performed, please tell us below what extremity or digit was amputated.
 
36. If an amputation was performed, please tell us below if it increased or decreased your RSD pain.
 
37. On average, how many points (zero to 10) pain improvement did you have after amputation?
 
38. Since the time you were diagnosed with RSD, have you ever been diagnosed with any of the following disorders:

Arthritis
Bursitis
Carpal Tunnel Syndrome
Chronic Fatigue Syndrome (CFS)
Cervical Spondylosis
Clonus
Diabetes
Dystonia
Fibromyalgia Syndrome (FMS)
Frozen Shoulder Syndrome
Lupus
Migraine Headaches
Multiple Sclerosis (MS)
Myofacial Pain Syndrome
Phantom Limb Pain (PLP)
Scleroderma
Spinal Disc Disease
Tarsal Tunnel Syndrome
Tendonitis
Thoracic Outlet Syndrome (TOS)
TMJ
Trigeminal Neuralgia
Ulnar Nerve Entrapment
Others
 
 

39. Please check any of the following, if they increase your RSD pain.
 

Alcohol

Chocolate

Cold

Emotions

Foods

Heat

Humidity

Stress

Others

 

40. Are there others in your family who also suffer from RSD?              Y N
If so, please tell us how many family members also suffer from RSD.

 

41. If you have had a Spinal Cord Stimulator implanted, please tell us if the SCS has increased or decreased your RSD pain.

 

42. How many Spinal Cord Stimulators have you had implanted?

 

43. Have you had any of the following complications with your Spinal Cord Stimulator:
 
Attacks of Falling
Attacks of Paralysis
Infections
Increased Pain
Jerking Movement of Extremities
Movement Disorder
Movement of Electrodes and Lead Wires
Spread of RSD
Stimulator Not Working
Tremor
Weakness of Extremities
Others
 
44. On average, how many points (zero to 10) pain improvement did you have with the (SCS) Spinal Cord Stimulator?

 

45. If you have had an Infusion or Morphine Pump implanted, please tell us below if the pump has increased or decreased your RSD pain.

 

46. Have you had any of the following complications with your Infusion Pump.
 

Increased pain

Infection

Headaches

Leakage       

Pump not working

Scar formation around the pump

Spread of RSD

Swelling of extremities

Vomiting or Intolerance of pump

Others

 

47. Do you take pain medication by mouth in addition to morphine in the pump? Y N  (Please describe)

 

48. On average, how many points (zero to 10) pain improvement did you have with the pump? 

 

49. How long did your SCS or Infusion pump work before you started to have complications?   Days:Weeks:Months:Years:

 

50. Have you had a Surgical or Chemical Sympathectomy?                   Y N

 

51. If a Surgical or Chemical Sympathectomy was performed did it increase or decrease your RSD pain.

 

52. Have you had any of the following complications after having the Surgical or Chemical Sympathectomy performed?

Horner's syndrome

Increased pain

Infection Spread of RSD

Others

 

53. How long did your Surgical or Chemical Sympathectomy give you pain relief before you started to have complications?   Days: Weeks: Months: Years:

 

54. On average, how many points (zero to 10) pain improvement did you have after Surgical or Chemical Sympathectomy?

 

55. Please check any of the following types of Nerve Blocks that were used to treat your RSD.
 

Axillary Nerve Block

Bier Block

Brachial Plexus Block

Epidural Block

Lower Lumbar Sympathetic Nerve Block

Paravertebral Nerve Block

Stellate Ganglion Nerve Block

Others

 

56. How many Nerve Blocks have you had since you started your treatment for RSD.

 

57. Please tell us if your pain increased or decreases after having any of the above mentioned nerve blocks.

It may be necessary to hold your Ctrl key down while clicking with your mouse to select multiple options.

 

58. How many hours, days, weeks, or months did you have relief after having any of the following types of nerve blocks:

Axillary Nerve Block:                                                                                                                                         

Hours:Days:Weeks:Months:


Bier Block:                                                                                                                                                             Hours:Days:Weeks:Months:


Brachial Plexus Block:                                                                                                                                     

 Hours:Days:Weeks:Months:


Epidural Block:                                                                                                                                                    

Hours:Days:Weeks:Months:


Lower Lumbar Block:                                                                                                                                        

 Hours:Days:Weeks:Months:


Paravertebral:                                                                                                                                                        

Hours:Days:Weeks:Months:


Stellate Ganglion Block:                                                                                                                                    

Hours:Days:Weeks:Months:

 

59. How is your activity level after having a Nerve Block?
Excellent Good Moderate Poor

 

60. Have you had any complications from having a Nerve Block?
(Please describe)

 

61. If your RSD developed from a Venipuncture, please check one of the following procedures that caused your RSD.(If this question does not pertain to you please skip to question 62)

Blood Donation

Blood Sampling

Flu Shot

Hepatitis B Injection

Intramuscular Injection

I.V. Injection ( Intravenous line)

I.V. Injection (Intravenous of medication)

Needle Injury

Tetanus Shot

Others

 

 

62. When did you experience pain from your venipuncture injury?

After Venipuncture

During Venipuncture

After Intramuscular Injection

During Intramuscular Injection

Days

Weeks

Months

Years

 

 

63. Have you had any of the following complication from your venipuncture injury?


Bruising

Skin Lesions

Skin Rashes

Swelling

Trophic Ulcers

Others

 

 

64. Do you ever have any of the following symptoms on your skin in the RSD affected extremity?
 

Bruising

Discoloration

Skin Lesions

Skin Rashes

Skin Ulcers

Others

 

65. Do you ever have sudden attacks of falling?                                       Y N

 

66. If you do have sudden attacks of falling, please tell us how often.

 

67. Please tell us below what your occupation was at the time of onset.

 

68. Are you still able to work?                                                                 Y      N

 

69. How many doctors did you see before you were diagnosed with RSD?

 

70. If your RSD was caused by surgery , how long after surgery were you diagnosed as having RSD?   Days: Weeks: Months: Years:

 

71. What type of doctor diagnosed your RSD?

 

72. Has your RSD ever gone into remission?                                            Y N

 

 

73. If your RSD has gone into remission, please tell us at what stage of RSD you were in at the time of remission.

Stage I Dysfunction (Burning pain)


Stage II Dystrophy (Skin and nail changes and edema)


Stage III Atrophy (Disuse)


Stage IV (Disturbance of immune system. Lack of response to treatment)

 

74. If your RSD did go into remission, please tell us how long you were
in remission.   Days: Weeks: Months: Years:

 

75. Please tell us below, what treatment or method helped your RSD go into remission.

 

76. Has your RSD gone into remission more than once since your onset of RSD?                                                                                                                             Y N

 

77. What helps you more heat or cold or both?

 

78. Was your RSD aggravated after the application of ice?                     Y N

 

79. Was your RSD aggravated after the application of a cast?                Y N

 

 

80. Do you suffer from any of the following disorders other than RSD:

Bell's Palsy                     

Cerebral Palsy (CP)          

Diamond Gardner Syndrome (Bruising)              

Ehrler Danlos Syndrome  

Epilepsy

Fabry's Disease

Herpes Zoster (Shingles)

Lupus

Lyme Disease

Menier's Disease

Multiple Sclerosis (MS)

Muscular Dystrophy (MD)

Parkinson

Trigeminal Neuralgia (Tic Douloureux)

Other

 

 

81. If your RSD developed from an Electrical Injury, please check one of the following injuries that caused your RSD.

Electrical Burn

Electrical Shock

High Voltage (600-1,000 volts or higher / A.C.= Alternating Current)

Lightning Strike( D.C.= Direct Current)

Low Voltage (110 to 240 volts / A.C.= Alternating Current)

 

82. Was your electrical injury an industrial or household injury? (Please briefly describe below what happen during your electrical injury.)

 

83. How long after your electrical injury were you diagnosed as having RSD?
Hours: Days: Weeks: Months: Years:

 

84. Was your RSD caused by a chemical burn?                                        Y N

 

85. If your RSD was caused by a chemical burn, please briefly describe what type of chemical caused the burn.

 

86. How long after your chemical burn were you diagnosed as having RSD?                         Hours: Days: Weeks:  Months: Years:

 

87. Was your RSD caused by an infection?                                              Y N

 

88. Please describe what type of infection caused your RSD.

 

89. How long after developing your infection were you diagnosed as having RSD?
Hours: Days: Weeks: Months: Years:

 

90. Have you developed any herniated disc since you developed your RSD?                                                                                                                           Y N

 

 

91. Please check any of the following assistive devices that you use.
 

Braces

Cane

Crutches

Electric Scooter

Walker

Wheelchair

 

92. How long have you been using these assistive devices?
Days: Weeks: Months: Years:

 

93. Has there been any one doctor or pain clinic that has had any success in treating your RSD?                                                                                       Y N

 

94. If your RSD was successfully treated, please list below the name and address of your doctor or the pain clinic that treated you.

 

95. Would you recommend your doctor or the pain clinic that you go to for treatment to other RSD patients?                                                                                                          Y N