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  1. 1. The syndromes appearing under this include •Sudeck's atrophy, •Sympathetic dystrophy, •algodystophy, •shoulder-hand syndrome, •causalgia.
  2. 2. 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
  3. 3. 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.
  4. 4. 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
  5. 5. 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
  6. 6. •CRPSCRPS Type 1-no specific nerve injury Type 2 –nerve injury +
  7. 7. 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..
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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.
  12. 12. 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
  13. 13. 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
  14. 14. 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)
  15. 15. 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)
  16. 16. 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.