Reflex Sympathetic Dystrophy (CRPS I) is a chronic pain condition characterized by severe pain, swelling, and skin changes, often affecting a limb. It has no nerve damage. Early multimodal treatment including medications, nerve blocks, and physical therapy can help improve symptoms. Physical therapy focuses on reducing pain and edema, improving range of motion, and addressing vasomotor instability. As the condition progresses, symptoms may become more severe and irreversible changes can occur.

1. Sayantika
Dhar
Reflex Sympathetic Dystrophy
(CRPS I)

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Dhar
Definition:
• Complex regional pain syndrome (CRPS) is a chronic
progressive disease characterized by severe pain,
swelling and changes in the skin. [1]
• It often affects an arm or a leg and may spread to
another part of the body.
• Though treatment is often unsatisfactory, early
multimodal therapy can cause dramatic
improvement or remission of the syndrome in some
patients.
[1] Hunter, Mackin, Callahan. Rehabilitation of the Hand and Upper Extremity,
5th Edn, Ch 104, Pg:1695

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Dhar
Classification:
The International Association for the Study of Pain has
proposed dividing CRPS into two types based on the
presence of nerve lesion following the injury.
• Type I, formerly known as reflex sympathetic
dystrophy (RSD), does not have demonstrable nerve
lesions.
• Type II, formerly known as causalgia, has evidence of
obvious nerve damage.

4. Sayantika
Dhar
Synonyms for CRPS:
• Algodystrophy
• Mimocausalgia
• Peripheral trophoneurosis
• Posttraumatic sympathetic dystrophy
• Reflex neurovascular dystrophy
• Shoulder-hand syndrome
• Sudeck’s atrophy
• Sympathetic neurovascular dystrophy

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Dhar
CRPS I: Reflex Sympathetic Dystrophy
• RSD is a somewhat generic term used to
describe post traumatic pain accompanied by
inappropriate autonomic activity and impaired
extremity function.

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IASP Definition
Dhar
(International Association for the Study of Pain)
"CRPS Type I is a syndrome that usually develops
after an initiating noxious event, is not limited to
the distribution of a single peripheral nerve, and is
apparently disproportioned to the inciting event. 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 or
hyperalgesia"

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Dhar
Susceptibility
• CRPS can strike at any age, but the mean age at
diagnosis is 42.
• CRPS has been diagnosed in children as young as 2
years old.
• It affects both men and women; however, CRPS is 3
times more frequent in females than males.
• Investigators estimate that 2-5 percent of those with
peripheral nerve injury, and 13-70 percent of those
with hemiplegia will suffer from CRPS.

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Symptoms:
Dhar
• The most common symptoms overall are burning
and electrical sensations, described to be like
"shooting pain".
• muscle spasms
• local swelling, abnormally increased sweating
• changes in skin temperature (usually hot but
sometimes cold)
• Changes in color (bright red or a reddish violet)
• softening and thinning of bones
• joint tenderness or stiffness,
• and/or restricted or painful movement.

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Dhar
Stages of Progression:

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Dhar
Stage 1
• Stage one is characterized by severe, burning
pain at the site of the injury.
• Muscle spasm
• joint stiffness
• restricted mobility
• rapid hair and nail growth, and
• vasospasm

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Dhar
Stage 2
• Stage two is characterized by more intense pain.
• Swelling spreads
• hair growth diminishes
• nails become cracked, brittle, grooved, and
spotty
• osteoporosis becomes severe and diffuse
• joints thicken
• muscles atrophy.

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Dhar
Stage 3
• Stage three is characterized by irreversible
changes in the skin and bones
• Pain-unyielding, may involve the entire limb
• marked muscle atrophy
• severely limited mobility of the affected area
• flexor tendon contractures
• marked bone softening and thinning

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Dhar
Diagnosis:

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Dhar
The International Association for the Study of Pain
(IASP) lists the diagnostic criteria for RSD as follows:
1. The presence of an initiating noxious event or a
cause of immobilization
2. Continuing pain, allodynia (perception of pain
from a nonpainful stimulus), or hyperalgesia (an
exaggerated sense of pain)
3. Evidence at some time of edema, changes in
skin blood flow
4. The diagnosis is excluded by the existence of
any condition that would otherwise account for
the degree of pain and dysfunction.

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Dhar
Thermography
• Use of infrared radiation to view or locate
over heated parts of the limb.
• Not a reliable tool for diagnosis
• Results affected by smoking, drinking coffee,
recent physical activity, topical lotions and
creams, etc.

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Dhar

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Dhar

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Dhar
Yoichi Koike, Hirotaka Sano. Changes with time in skin
temperature of the shoulders in healthy controls and a
patient with shoulder-hand syndrome. Upsala Journal of
Medical Sciences. 2010; 115: 260–265
“A thermography is unable to capture temperature changes over
time. In contrast, a Thermocron is an effective measuring
device to monitor temperature changes over time.
Thermocron is a more effective way to detect shoulder skin
temperature abnormalities in a patient with shoulder-hand
syndrome.

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Dhar
Sweat testing
• A powder that changes color when exposed to
sweat can be applied to the limbs
• However, this method does not allow for
quantification of sweating.

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Dhar
Radiography
• Patchy osteoporosis- detected through X-ray
imagery- as early as two weeks after onset.
• A bone scan of the affected limb may detect
these changes even sooner.
• Bone densitometry can also be used to detect
changes in bone mineral density.

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Dhar

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Dhar
Electrodiagnostic testing
• EMG should not be done for the diagnosis of
CRPS I or II.
• It is extremely painful for patients suffering
from CRPS and may even be considered
unethical and cruel.

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Dhar
Assessment:

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Dhar
• Presenting signs and symptoms:
– Pain, including spontaneous burning pain,
allodynia, hyperalgia.
– Sensory hyperasthesia
– Tissue abnormality, including vasomotor
instability, edema, skin color changes,
subcutaneous bone and joint changes.
– Motor changes, including decreased ROM and
weakness and movement disorders (tremor,
dystonia and neglect)

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Dhar
Hand & Orthopedic Rehabilitation services
Pain profile
PAIN QUALIFIERS JOINT PAIN
 Aching 0= no pain
 Burning
1= mild pain with deep palpation
 Cramping
 Heaviness/fatigue 2= severe pain with deep palpation
 Numbness 3= severe pain with mild palpation
 Sharp/stabbing
4= hyperesthesia
 Stiffness
 Swelling
 Throbbing
 Tingling/pins and needles
 Weakness
 Other ______________

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Dhar
• VAS; 10 cms line.
• Body chart:

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Dhar
Sensory evaluation
• Cutaneous Pressure Sensation
Pathology Fingertip (mg) Thumb (mg) Palm (mg)
Normal 2.36-2.83 2.36-2.83 2.44-2.83
Diminished Light 3.22-3.61 3.22-3.61 3.22-3.84
touch
Diminished 3.84-4.31 3.84-4.31 4.07-4.56
Protective sensation
Loss of Protective 4.56-6.65 4.56-6.65 4.74-6.65
sensation

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Dhar
Differential Diagnosis:

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Dhar
Michael Stanton-Hicks. Complex regional pain
syndrome. Anesthesiology Clin N Am 21 (2003) 733–
744.
The distinction between CRPS I and II is the
evidence of a definable nerve lesion. The signs
and symptoms for both conditions, however,
are clinically indistinguishable.

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Dhar
MANAGEMENT

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Dhar
Pharmacological interventions:
Physicians use a variety of drugs to treat RSD
• antidepressants
• anti-inflammatory such as corticosteroids
• COX-inhibitors such as piroxicam,
• vasodilators
• GABA analogs such gabapentin and pregabalin,
• alpha- or beta-adrenergic-blocking compounds,
and the entire pharmacy of opioids.

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Dhar
Invasive techniques:
Local anaesthetic blocks/injections
• Injection of lidocaine is often the first step in
treatment.
• Injections are repeated as needed.
• Results- short lasting.

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Dhar
Spinal cord stimulators
• Neurostimulation (spinal cord stimulator) may
also be surgically implanted to reduce the pain
by directly stimulating the spinal cord.
• These devices place electrodes either in the
epidural space or directly over nerves located
outside the central nervous system.

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Dhar

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Dhar
Drug pump
• Implantable drug pumps may also be used to
deliver pain medication directly to the
cerebrospinal fluid which allows
powerful opioids to be used in a much smaller
dose than when taken orally.

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Dhar

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Dhar
Sympathectomy
• Surgical, chemical, or radiofrequency
sympathectomy — interruption of the
affected portion of the sympathetic nervous
system — can be used as a last resort

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Dhar
Physiotherapy Management:
• Goal: ‘symptomatic treatment’

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Dhar
Pain
• TENS
• Thermal agents
• Cryotherapy
• Vibration
• Splinting-dynamic
• CPM

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Dhar
Edema
• Elevation
• Soft tissue manipulations
• Active exercises
• Compression- continuous

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Dhar
Allodynia
• Vibration
• Massage
• Progressive weight bearing
• Contrast bath
• Desensitization
– Peripheral to central
– Fine texture to coarse texture

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Dhar
Dystonia and joint stiffness
• Biofeedback and activities
• Active exercises
• Splinting
– Dynamic: pain and motion
– Static: prevention, assist weak muscles
– Static progressive: joint stiffness, tissue contracture
• CPM
• Modalities
– Superficial heat with gentle stretch
– Ultrasound with gentle stretch

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Dhar
Vasomotor instability
• Low-impact aerobic activities
• Thermal biofeedback
Vasoconstriction Vasodilation
Thermal agents Cryotherapy
Massage TENS
Ultrasound Neural mobilization
TENS(burst) Patient education- alcohol
Patient education-
caffiene/nicotine intake

44. Sayantika
Dhar
Volker et al. Interaction of Hyperalgesia and Sensory Loss in Complex
Regional Pain Syndrome Type I. July 2008, Volume 3, Issue 7, e2742.
www.plosone.org.
They proposed three pathomechanisms of CRPS I, which follow a distinct
time course:
• Thermal hyperalgesia, observed in acute CRPS, indicates an ongoing
aseptic peripheral inflammation.
• Thermal hypoaesthesia, as detected in acute and chronic CRPS, signals a
degeneration of A-delta and C-fibres, which further deteriorates in
chronic CRPS.
• Paradoxical Heat Sensation(PHS) in acute CRPS I indicates that both
inflammation and degeneration are present, whilst in chronic CRPS I, the
pathomechanism of degeneration dominates, signalled by the absence of
PHS.
Conclusion:
Acute CRPS I :- Heat and Cold Pain thresholds reduced but Warm and
Cold Detection thresholds were normal
Chronic CRPS I :- Thermal hyperalgesia declined. But Warm and Cold
Detection thresholds deteriorated.

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Dhar
Thacker, M., Gifford, L., 2002. A review of physiotherapy
management of complex regional pain syndrome. Topical
Issues in Pain, Vol. 3. CNS Press, Falmouth, pp. 119–141.
Use of electrotherapy may cause more
symptoms in patients with mechanical
allodynia through stimulation of large
myelinated A fibers

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Dhar
Chang-Zern Hong. Specific sequential Myofascial Trigger Point therapy in
the treatment of a patient with Myofascial Pain syndrome with reflex
Sympathetic dystrophy. ACO. Vol 9, No.1, March 2000.
 MTrP for- wrist and finger extensors and anterior deltoid were
commenced.
 MTTrP can be used along with:
o Intermittent cold (sprays or ice massage)
o Stretching and post isometric relaxation
o Deep pressure soft tissue massage
o Thermotherapy
o Trigger point injections with local anaesthetic solution or dry needling
on trigger points.

47. Sayantika
Dhar
THANK YOU