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Rsd ortho
1. S U B M I T T E D T O : D R . S H A B N A M P T
S U B M I T T E D B Y : M A N O J P U R O H I T
1 7 0 1 7 1 7 2 0 0 0 1
REFLEX SYMPATHETHIC
DYSTROPHY
2. COMPLEX REGIONAL PAIN SYNDROME
• Complex regional pain syndrome (CRPS) is a
chronic progressive disease characterized by severe
pain, swelling and changes in the skin.
• 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.
Hunter, Mackin, Callahan. Rehabilitation of the Hand and Upper Extremity,
5th Edn, Ch 104, Pg:1695
3. 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.
5. 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.
6. IASP Definition
(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"
7. 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.
8. Symptoms:
• 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,
• Restricted or painful movement.
9. STAGES OF PROGRESSION
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
10. 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.
11. 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
12. DIAGNOSIS
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.
13. 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.
14. 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.
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.
15. ASSESSMENT
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)
16. JOINT PAIN
0= no pain
1= mild pain with deep palpation
2= severe pain with deep palpation
3= severe pain with mild palpation
4= hyperesthesia
PAIN QUALIFIERS
• Aching
• Burning
• Cramping
• Heaviness/fatigue
• Numbness
• Sharp/stabbing
• Stiffness
• Swelling
• Throbbing
• Tingling/pins and needles
• Weakness
PAIN PROFILE
20. MANAGEMENT
• 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.
Pharmacological interventions:
21. Local anaesthetic blocks/injections
• Injection of lidocaine is often the first
step in treatment.
• Injections are repeated as needed.
• Results- short lasting.
• 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.
Spinal cord stimulators
22. • 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.
Drug pump
23. Sympathectomy
• Surgical, chemical, or radiofrequency
sympathectomy — interruption of the
affected portion of the sympathetic nervous
system — can be used as a last resort
