Reflex Sympathetic Dystrophy (RSD), also known as Complex Regional Pain Syndrome (CRPS), is a chronic condition that causes persistent burning pain, swelling, and abnormal nerve activity in an affected limb, usually following an injury. It has two types: RSD (type I) occurs without major nerve damage and Causalgia (type II) occurs due to nerve injury. Symptoms include allodynia, hyperalgesia, changes in skin temperature and color. Diagnosis involves assessing sensory, vasomotor, sudomotor and motor symptoms. Treatment includes medications, surgery such as sympathectomy, and physiotherapy involving exercises, massage, and splinting to relieve pain and edema.
2. Introduction
Reflex sympathetic dystrophy (RSD) is a
chronic condition that causes persistent
burning pain , swelling and abnormal nerve
activity affected upper or lower limb followed
by any major or minor injury .
RSD is also known as complex regional pain
syndrome (CRPS)
Commonly occurs to proximal or contralateral
limb or also occur as mirror pain.
5. History
in 1864, MITCHELL introduced first concept of
CAUSALGIA .
Mitchell noticed that injuries to periphery
nerves may causes pain as well as changes in
color& temperature of skin within affected
area.
In 1990, JOHN BONICA first used the term RSD
PAUL SUDECK suggested symptoms &
assesment of RSD
6. • In 1994, IASP renamed the term reflex
sympathetic dystrophy and causalgia
COMPLEX REGIONAL PAIN SYNDOME (CRPS)
7. Epidemiology
According to IASP incidence of RSD or CRPS
occurs at any age. Number of cases reported
for RSD is more than causalgia.
In USA every 5th person in 10,000 has RSD and
1 in 10,000 has causalgia.
CRPS is three times more common in females
than males.
IAPS Diagnostic criteria of 2012 shows
decrease in cases by 50%
8. Complex regional pain
syndrome
In CRPS , there is complex interaction of
somatic psychological , behavioural factors &
the regional distribution of symptoms.
This abnormal activity occur because of any
minor or major injury.
CRPS has two types namely :-
REFLEX SYMPATHETIC DYSTROPHY (RSD) type I
CAUSALGIA (type II)
9. Etiology
CRPS occurs as a result of varying amount of
trauma or injury to tissues.
This can be major or minor injuries such as...
Blunt injuries
Inflammatory diseases
Degenerative joint diseases
Burns
Sprains
Fall from stairs
Stroke
mastectomy
10. Pathophysiology conti….
INJURY
Inflammatory &immune response
(B-cell activation, increase interleukins, substance P)
Result in noxious primary afferent traffic
Central sensitization, “wind up”
Increase abnormal alteration in sympathetic system.
11. Classification
IASP classify CRPS into RSD or type-I &
CAUSALGIA or type-II
CRPS (type-I)- condition triggered by an illness
or injury but you do not have a nerve injury in
affected area
CRPS(type-II)- condition is clearly linked to a
nerve injury in affected area.
12. Type-I (RSD)
IASP definition of CRPS type-I
“ It is syndrome that usually develops after an
initiating noxious event, is not limited to the
distribution of a single peripheral nerve. It is
associated at some point with evidence of edema,
changes in skin blood flow, abnormal sudomotor
activity in the region of the pain or allodynia ( pain
experienced from non-painful stimulus)or hyperalesia
(increase abnormal sensitivity to pain)”
13. Points to remember…RSD
Develops after an Noxious event
Not limited to single peripheral nerve and no
nerve injury at affected area.
Presence of allodynia & hyperalesia, changes
in skin color& temperature.
“ reflex nature is unclear, however the role of
sympathetic system is also not well
understood..so term CRPS used”
14. RSD often poorly
misunderstood by conditions
such as..
Pain and altered sensations
Motor disturbance and soft tissues changes
Vasomotor, autonomic changes
Psychological distrubances
15. Type-II CAUSALGIA
Causalgia derives from Greek word causos
which describes the burning pain sometimes
associated with neuropathy pain
Occur due to any major or minor trauma or
lesion followed by nerve injury
16. Causalgia
Syndrome develops after a nerve injury.
Spontaneous pain or allodynia &
hyperalesia
Evidence of pain, edema, skin changes
Abnormal sudomotor(sweat glands)
activity in the region of the pain since the
inciting event.
17. Stages of progression
There are three stages of progression of
condition namely…
First stages/acute/hyperaemic
Second/dystrophic/ischaemic
Third/atrophic
18. Acute or Hyperaemic
Acute stages lasts few weeks after injury.
Spontaneous pain which is aching and burning
in nature.
Affected area is red and warm than usuall
Presence of edema.
Hyperpathia – painful syndrome caused by
increase reaction to stimulus
19. Dystrophic or Ischaemic
Dystrophic stage is begin after 3 months of injury.
Vascular and dermatome region of injury.
Affected area is moist, cold
Skin is pale or cyanotic.
Increase joint stiffness.
Muscle wasting
Edema
Limiting ROM
20. Atrophic
Atrophic stage is end stage. Atrophic stages
begins 6 months after injury, when condition is
not treated properly.
Changes that occur in tissues and skin are
irreversible.
Sever pain in muscles, joints and tendons.
Abnormal growth of hairs and nails, nails are
brittle also.
Extreme weakness
Limiting ROM which results in ankylosis
23. Assesment and diagnosis
IASP criteria for RSD:-
Presence of an inciting noxious event or cause
of immobilization
Presence of allodynia , hyperalgesia
Presence of edema
Changes in skin.
24. Budapest criteria
Patient has pain which is disproportionate to
the inciting event.
Patient has at least one sign in two or more
categories i.e sensory, vasomotor, sudomotor,
motor.
25. Sensory
allodynia( light touch,
temperature, deep somatic
pressure) hyperalgesia from
pin prick. Hyperasthesia
Vasomotor Temperature assymetry, skin
and color changes
Sudomotor /edema Edema and sweating changes,
sweating assymetery
motor/trophic Decreased ROM, motor
dysfunction
28. Investigation conti..
Bone scans shows changes that occur in early
stages.
EMG &NCV are used to check the conductive
properties of nerve.
Thermograph – used to check the skin
temperature within affected area .
Stage 1 – increased temperature
Stage 2- normalized or warm temperature
Stage 3- decreased temperature.
30. Management
Prevention is best treatment in such cases.
However, medical and surgical interventions
reported to be benefit in RSD and CAUSALGIA
Treatment includes – pharmacological
intervention , surgical and physiotherapy
management.
32. Surgical
Destruction of the local sympathetic supply by
By sympathectomy
Lumbar sympatholysis
Interrpution of the affected portion of sympathetic nervous system
33. Physiotherpy
The goal is symptomatic treatment which
includes treatment for pain relief , edema ,
joint stiffness, allodynia & most important
patient education .
For pain relief- TENS, cryotherapy, vibrations.
For edema relief- elevation , massage,
compression bandages& active exercises.
For allodynia – contrast bath, massage,
vibration, active exercieses.
34.
35. For joint stiffness- active and passive
exercises, ultrasound, gentle stretching, cold,
heat fermentation, biofeedback activities,
splinting.