2. The syndromes appearing under
this include
•Sudeck's atrophy,
•Sympathetic dystrophy,
•algodystophy,
•shoulder-hand syndrome,
•causalgia.

3. What do they have inWhat do they have in
common?common?
• Vasomotor instability
• Trophic skin changes
• Regional osteoporosis
• Pain, OUT OF PROPORTION to the
inciting cause.
• Functional impairment

4. Definition?Definition?
• “CRPS is a multi-symptom, multi-
system, syndrome usually affecting
one or more extremities, but may
affect virtually any part of the
body.”-International Research Foundation
For RSD/CRPS.

5. Historically the signs & symptoms wereHistorically the signs & symptoms were
first recognized by Weir Mitchellfirst recognized by Weir Mitchell
during American Civil War in 1864during American Civil War in 1864

6. EtiologyEtiology
A number of precipitating factors have
been associated with RSD / CRPS including:
•Trauma (often minor) like fractures
•Ischemic heart disease and myocardial
infarction
•Spinal cord disorders
•Cerebral lesions
•Infections
•Surgery
•However, in some patients a definite
precipitating event can not be identified

7. •CRPSCRPS
Type 1-no specific
nerve injury
Type 2 –nerve
injury +

8. PathophysiologyPathophysiology
•Argued over since it was first described a
hundred years ago.
•It was usually regarded as type of sympathetic
overactivity ,hence the earlier name-Reflex
Sympathetic Dystrophy.
•Now recognised that multiple mechanisms are
involved,,, abnormal cytokine
release,neurogenic inflammation,sympathetic
mediated enhancement of pain responses and
cortical reactions to noxious stimuli..

11. Clinical featuresClinical features
.
Highly variable & difficult to characterize
Sensory Disturbances:
•Pain that is disproportionate to precipitating cause-
hallmark
•Allodynia , hyperalgesia , hyperaesthesia
•Aggravating factors active/passive movement ,
environmental/local temperature changes , dependent
limb position & emotional excitement

12. Sympathetic dysfunction:
•Skin colour -acutely red,warm,dry / chronic-bluish,
mottled,cold &moist
•Swelling
•Abnormal sweating
•Cold intolerence
Motor abnormalities:
•Weakness of affected limbs-disuse & muscle wasting
•Long standing cases-hyperfunctionaction
tremor,myoclonus,hyperreflexia,muscle spasm,voluntary
guarding,dysonia,apraxia

13. Trophic changes:
•Thinning of skin,
• Atrophy of s/c fat
• Brittle nails,
•Tendon atrophy
•The classic finding of periarticular
osteoporosis- Sudeck’s atrophy
•c/c joint stiffness  Fixed contractures
Psychological issues:
•Fear , Anxiety , Anger , Suffering
•Depression , Failure to Cope

16. SPREADING SYMPTOMS
a.An "independent type" where symptoms
spread to a separate, distant region of the
body. This type of spread may be
spontaneous or related to a second
trauma.
b.Total body RSD
c.A "continuity type" of spread where the
symptoms spread upward from the initial
site, e.g. from the hand to the shoulder.
d.A "mirror-image type" where the spread
was to the opposite limb.

17. diagnosis?diagnosis?
Primarily on clinical grounds & then confirmed with objective
tests
Blood studies
WBC count,ESR,C-reactive peptide Inflammatory processes
RF,ANA titres  ruling out
Radiography
Soft tissue swelling & osteoporosis
Bone scanning
Triple phase bone scan after i.v radionuclide tracer
MRI
Rule out & narrow the DD or to find out cause
Vasomotor & Sudomotor measurements
Thermography ,sweat outputs-QSART , blood flow , edema
volume

18. Paravertebral Sympathetic Ganglion
Blockade
Most effective & “GOLD STANDARD” in diagnosis of
SMP
Phentolamine Testing
Non-specific alpha antagonist
Safe,simple,less adverse effects
Most practical when more than one limb is affected
Regional intravenous sympathetic
blockade
Common agent--Guanithidine

19. ManagementManagement
Patient education & information
Physical therapy-mainstay of treatment,,,counselling,gain
confidence, motivation,
desensitization&mobilization,strengthening of muscles
Symptomatic relief
For constant pain associated with
inflammation:Nonsteroidal anti-inflammatory agents (e.g.
aspirin, ibuprofen, naproxen, indomethacin, etc).
•Corticosteroids(e.g. methyl prednisolone)
•Calcium channel blockers-pain reduction especially during cold
weather,relaxes smooth muscles ( eg; nifedipine)
For constant pain not caused by inflammation:
• Agents acting on the central nervous system by an atypical
mechanism (e.g. tramadol)

20. For constant pain and sleep disturbances:
o Anti-depressants (e.g. amitriptyline, doxepin,
nortriptyline, trazodone, etc)
For muscle cramps (spasms and dystonia):
o Klonopin (clonazepam)
o Baclofen
Protectives to bone:
o Calcitonin.bisphosphonates,vitamin C
Psychotheray:
o To prevent depression,anxiety & sleep
deprivation
Sympatholysis:
o Topical clonidine-alpha receptor agonist that
inhibit presynaptic release of
norepinephrine,reduces localise
dhyperalgesia
o Oral sympatholysis-alpha blockers
(eg:prazosin,terazoin)

21. SurgicalSurgical
Paravetebral Sympathetic chain ganglion
Blockade:
•Stellate ganglion blockade-upper
•Lumbar ganglion blockade-lower
Surgical sympathectomy:
•Open / Percutaneous chemical ablation /
radiofrequency / Enodscopic.
Regional Block: (Guanethidine)
Spinal cord stimulation:
•Transcutaneous electrical nerve stimulation for pain
management.