Historical Perspective
• During the Civil War, Silas Weir Mitchell
observed a chronic pain syndrome in
soldiers who suffer...
• He described this syndrome using the
term causalgia (from the Greek kausis – “burning” and
algos – “pain”)
• Half a century later, a French
surgeon
named Rene Leriche
implicated the sympathetic
nervous system in causalgic
pain.
•...
• In the 1950’s, John Bonica (founder of the
IASP) introduced the phrase reflex
sympathetic dystrophy after noticing the
e...
• There have since been many confusing terms
used to describe the condition:
•
•
•
•
•
•
•
•
•
•
•
•

Acute atrophy of the...
• In 1993, the International Association for the
study of pain [IASP] introduced the term
Complex regional pain syndrome t...
CRPS
• Complex: Varied and dynamic clinical
presentation
• Regional: Non-dermatomal distribution of
symptoms
• Pain: Out o...
• The term “sympathetic” was avoided in the
revised definition because its contribution
is not constant across patients
• ...
Sympathetically
maintained pain

Sympathetically
independent pain

Nociceptor input
maintained by
interaction
btw Primary ...
• CRPS can be separated into two types
based on the presence or absence of a
nerve injury
• CRPS type I: A syndrome that d...
Epidemiology
• Prevalence: 20.57/100,000
• Female : Male ratio: 3-4:1
• 80-85% have experienced preceding trauma
(fracture...
P
athophysiology
Clinical presentation
• Characteristic triad of symptoms comprising
autonomic, sensory, and motor disturbances.
• Triad ca...
• Distal edema – 80%
• Skin temperature changes – 80%
• The affected area is initially warm, but over the course of the
di...
• Spontaneous pain:
• Often described as burning, aching, throbbing,
shooting, or deep pressure pain

•
•
•
•

Hyperpathia...
• Bony changes:
• Osteoporosis – periarticular distribution

• Joint stiffness
• Patients often have associated
psychological and psychiatric
disturbances
SPREADING SYMPTOMS

1.
•

A "continuity type" of spread where the symptoms
spread upward from the initial site, e.g. from ...
Stages of CRP
S

Based on severity and chronology
Diagnosis
• Based exclusively on the characteristic clinical
features of the condition
• IASP diagnostic criteria for Comp...
• A modified diagnostic criteria was proposed by the IASP
in 2007 to increase specificity (the ‘Budapest criteria’):
• Con...
• Differential diagnosis:
•
•
•
•
•
•
•
•

Unrecognized local pathology (fracture, sprain)
Traumatic vasospasm
Cellulitis
...
Diagnostic tests
• Three-phase bone scintigraphy:
• Significant uptake in the metacarpophalangeal or
metacarpal bones appe...
• Plain radiographs, x-ray bone
densitometry, and magnetic resonance
imaging have not been shown to be
sensitive or specif...
• Diagnostic tests used to assess for a
sympathetically maintained component:
• Sympathetic ganglia blockade
• Regional in...
Management of CRPS
• No scientifically validated cure exists
• Therapy is directed at managing the signs
and symptoms of t...
Individualize!

No protocol works for all patients
with CRPS. It is dependent on
current pain level, symptoms, and
toleran...
Medical Management
•

For constant pain associated with inflammation
–

•

For constant pain not caused by inflammation:
–...
Physical/Occupational therapy
• Early physical therapy is essential to avoid
atrophy and contractures of the affected limb...
Nonpharmacological Option
•

•

•
•

•

Pain
– Modalities (moist heat,
fluidotherapy, contrast baths)
Edema
– Elevation wi...
Psychological therapy
• An integral part of the multidisciplinary treatment
approach. Many patients with CRPS have a signi...
Mirror Box therapy
•
•
•
•
•
•

MIRROR VISUAL FEEDBACK:
This treatment is still experimental, but has helped in some cases...
Interventions
1.
2.
3.
4.

Sympathetic Blockade
Regional Block (Guanethidine)
Spinal cord stimulation
Morphine pump
Case report :
•
•

•

•

25-year-old female patient with persistent pain and sclerotic and
edematous skin lesions in the l...
EXAMINATION:
•Pale-coloured, oedematous and
indurated skin with a shiny surface
was observed over the patient’s left
dorsa...
laboratory test
•
•
•

•

Routine laboratory test results were
unremarkable.
Nerve conduction studies were
normal.
Radiogr...
TREATMENT
• Treatment with regular stellate ganglion blockade was
initiated.
• The therapy proved to be effective in relie...
Conclusion
• CRPS is a complicated chronic pain syndrome
with variable clinical presentation and
complicated diagnostic cr...
Thanks for your attention….
Dr. Sachin Joshi
Dr. Sachin Joshi
Dr. Sachin Joshi
Dr. Sachin Joshi
Dr. Sachin Joshi
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  • Fluidotherapy (with lowered temp of 98 degrees)
    Ice is not often tolerated well
    Desensitization (5-6 times per day as tolerated)
    paired with TENS to help with pain if not tolerated well
    Splinting in resting position at night can help the limb to rest and decrease potential contractures
    wrist in neutral, MCP flexion and IP extension
    Stress loading is the most recognized therapeutic treatment for CRPS
    Starts with scrubbing a table or rolling a ball for 3-5 min (3x/day) up to 10 min
    Follow with distraction (carrying weights (1lb-5lbs for up to 10 min)
    Joint protection and energy conservation
    assistive devices
    Patient Education
    educate about symptoms and symptom management
    encourage use as much as possible
    encourage with examples of progress to ensure they don’t dwell on limitations
  • Dr. Sachin Joshi

    1. 1. Historical Perspective • During the Civil War, Silas Weir Mitchell observed a chronic pain syndrome in soldiers who suffered traumatic nerve injuries • Their symptoms included constant burning pain and significant trophic changes
    2. 2. • He described this syndrome using the term causalgia (from the Greek kausis – “burning” and algos – “pain”)
    3. 3. • Half a century later, a French surgeon named Rene Leriche implicated the sympathetic nervous system in causalgic pain. • He treated these patients with surgical sympathectomy.
    4. 4. • In the 1950’s, John Bonica (founder of the IASP) introduced the phrase reflex sympathetic dystrophy after noticing the efficacy of temporary blockade of the sympathetic nervous system in these patients.
    5. 5. • There have since been many confusing terms used to describe the condition: • • • • • • • • • • • • Acute atrophy of the bone Algodystrophy Algoneurodystrophy Postinfarctional sclerodactyly Post-traumatic algodystrophy Post-traumatic dystrophy Post-traumatic sympathetic dystrophy Pseudodystrophy Reflex neurovascular dystrophy Shoulder hand syndrome Sudeck’s dystrophy Sympathalgia etc.
    6. 6. • In 1993, the International Association for the study of pain [IASP] introduced the term Complex regional pain syndrome to describe all pain states that previously would have been diagnosed as RSD or causalgia-like syndromes.
    7. 7. CRPS • Complex: Varied and dynamic clinical presentation • Regional: Non-dermatomal distribution of symptoms • Pain: Out of proportion to the inciting events • Syndrome: Constellation of symptoms and signs
    8. 8. • The term “sympathetic” was avoided in the revised definition because its contribution is not constant across patients • CRPS pain may be “sympathetically maintained pain” (SMP) or “sympathetically independent pain” (SIP)
    9. 9. Sympathetically maintained pain Sympathetically independent pain Nociceptor input maintained by interaction btw Primary afferents and sympathetic efferents through alpha adrenergic mechanism Maintaining nociceptor input comes from other causes such as peripheral nerve stimulation Eg: Neuroma
    10. 10. • CRPS can be separated into two types based on the presence or absence of a nerve injury • CRPS type I: A syndrome that develops after an initiating noxious event that may or may not be associated with a period of immobilization (without a nerve injury) • CRPS type II: Differs from CRPS type I by the presence of a known injury to a nerve or nerves
    11. 11. Epidemiology • Prevalence: 20.57/100,000 • Female : Male ratio: 3-4:1 • 80-85% have experienced preceding trauma (fractures, surgery) • 10% have experienced minor trauma • 5-10% occur spontaneously
    12. 12. P athophysiology
    13. 13. Clinical presentation • Characteristic triad of symptoms comprising autonomic, sensory, and motor disturbances. • Triad can differ amongst individuals. • Symptoms will generally change over time in a given individual
    14. 14. • Distal edema – 80% • Skin temperature changes – 80% • The affected area is initially warm, but over the course of the disease the skin temp decreases • Skin color changes • Initially red, becomes pale in chronic disease • Altered sweating • Increased sweating more common • Nail and hair changes • Increased growth in early disease
    15. 15. • Spontaneous pain: • Often described as burning, aching, throbbing, shooting, or deep pressure pain • • • • Hyperpathia: Hyperalgesia: Allodynia: Motor changes: • Weakness, distal tremors, dystonia, myoclonus • Not clear whether these are part of the clinical presentation of the disease or a result of protection/disuse of the painful limb
    16. 16. • Bony changes: • Osteoporosis – periarticular distribution • Joint stiffness
    17. 17. • Patients often have associated psychological and psychiatric disturbances
    18. 18. SPREADING SYMPTOMS 1. • A "continuity type" of spread where the symptoms spread upward from the initial site, e.g. from the hand to the shoulder. • A "mirror-image type" where the spread was to the opposite limb. • 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. • *Total body RSD
    19. 19. Stages of CRP S Based on severity and chronology
    20. 20. Diagnosis • Based exclusively on the characteristic clinical features of the condition • IASP diagnostic criteria for Complex Regional Pain Syndrome: • Presence of an initiating noxious event or cause of immobilization • Continuing pain, allodynia, or hyperalgesia, with pain disproportionate to any inciting event • Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain • Diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction
    21. 21. • A modified diagnostic criteria was proposed by the IASP in 2007 to increase specificity (the ‘Budapest criteria’): • Continuing pain that is disproportionate to any inciting event • Must report at least one symptom in three of the four following categories: – – – – Sensory: hyperalgesia, allodynia Vasomotor: temp. asymmetry, skin color changes or asymmetry Sudomotor/Edema: edema, sweating changes or asymmetry Motor/Trophic: decreased range of motion, weakness, tremor, dystonia, trophic changes • Must display at least one sign at the time of evaluation in two or more of the following categories: – – – – Sensory: hyperalgesia, allodynia Vasomotor: temp. asymmetry, skin color changes or asymmetry Sudomotor/Edema: edema, sweating changes or asymmetry Motor/Trophic: decreased range of motion, weakness, tremor, dystonia, trophic changes • No other diagnosis better explains the signs and symptoms
    22. 22. • Differential diagnosis: • • • • • • • • Unrecognized local pathology (fracture, sprain) Traumatic vasospasm Cellulitis Lymphedema Raynaud’s disease Thromboangiitis obliterans DVT Also, nerve entrapment syndromes and diabetic neuropathy
    23. 23. Diagnostic tests • Three-phase bone scintigraphy: • Significant uptake in the metacarpophalangeal or metacarpal bones appears to have high sensitivity and specificity for CRPS • The best timing for this study is in the subacute (up to 1 year) phase of the condition
    24. 24. • Plain radiographs, x-ray bone densitometry, and magnetic resonance imaging have not been shown to be sensitive or specific for CRPS
    25. 25. • Diagnostic tests used to assess for a sympathetically maintained component: • Sympathetic ganglia blockade • Regional intravenous blockade with Guanethidine • Phentolamine infusion test
    26. 26. Management of CRPS • No scientifically validated cure exists • Therapy is directed at managing the signs and symptoms of the disease • A multidisciplinary approach utilizing pharmacotherapy, physical therapy and psychological therapy is most appropriate
    27. 27. Individualize! No protocol works for all patients with CRPS. It is dependent on current pain level, symptoms, and tolerance
    28. 28. Medical Management • For constant pain associated with inflammation – • For constant pain not caused by inflammation: – • Oral opiods tried. For the treatment of sympathetically maintained pain (SMP) – • Anti-depressants (e.g. amitriptyline, doxepin, nortriptyline, trazodone, etc) For spontaneous (paroxysmal) jabs Anti-convulsants (e.g. carbamazepine, gabapentin may relieve constant pain as well) For widespread, severe RSD / CRPS pain, refractory to less aggressive therapies – • Agents acting on the central nervous system by an atypical mechanism (e.g. tramadol) For constant pain or spontaneous (paroxysmal) jabs and sleep disturbances; – • • • Nonsteroidal anti-inflammatory agents (e.g. aspirin, ibuprofen, naproxen, indomethacin, etc). Clonidine . For muscle cramps (spasms and dystonia) – – Klonopin (clonazepam) Baclofen
    29. 29. Physical/Occupational therapy • Early physical therapy is essential to avoid atrophy and contractures of the affected limb. • PT/OT have been shown to reduce pain and motor impairment, and improve function and coordination ability of the limb. • Requires that the patient take an active role in their care
    30. 30. Nonpharmacological Option • • • • • Pain – Modalities (moist heat, fluidotherapy, contrast baths) Edema – Elevation with AROM, manual edema mobilization, compression, massage Sensation – Desensitization Range of Motion – PROM, stretching, blocking, tendon gliding, PNF patterns Splinting – Resting position • • • Stress Loading – “load and carry” Joint Protection Patient Education – “To Improve, Move”
    31. 31. Psychological therapy • An integral part of the multidisciplinary treatment approach. Many patients with CRPS have a significant amount of psychological dysfunction, which is a reflection of the disease process itself as opposed to a cause thereof. • • • • • Pain coping skills Biofeedback Relaxation training Cognitive behavioral therapy Mirror Box therapy
    32. 32. Mirror Box therapy • • • • • • MIRROR VISUAL FEEDBACK: This treatment is still experimental, but has helped in some cases. A mirror is placed so that it reflects the opposite, unaffected limb, so that it looks as if the affected limb is normal. When the opposite limb is moved the person sees the affected limb move in the mirror. The affected limb can then also be felt to move. (This is called kinesthetic sensations). If this is repeated many times it may lead to normal movement of the affected limb and reduction in pain.
    33. 33. Interventions 1. 2. 3. 4. Sympathetic Blockade Regional Block (Guanethidine) Spinal cord stimulation Morphine pump
    34. 34. Case report : • • • • 25-year-old female patient with persistent pain and sclerotic and edematous skin lesions in the left hand. One year prior to her first visit, she had accidentally sprained her left wrist. The initial pain subsided quickly, but after a month, severe burning pain developed on her left thenar eminence with marked swelling of the distal forearm and the hand. pain gradually intensified and spread to the entire left hand, accompanying numbness, severe cold intolerance and muscle weakness. She underwent physical therapy for several months at an orthopedic clinic with no effect.
    35. 35. EXAMINATION: •Pale-coloured, oedematous and indurated skin with a shiny surface was observed over the patient’s left dorsal hand and fingers . •The lateral 3 digits showed mild flexion contracture. • The dorsal skin over the left fingers could not be pinched. Hair loss and hypohidrosis were also observed. •. Neurological examinations revealed hyperalgesia, paresthesia, dysesthesia and muscle weakness in the left forearm and the hand.
    36. 36. laboratory test • • • • Routine laboratory test results were unremarkable. Nerve conduction studies were normal. Radiographic examination showed marked decalcification of her left lateral 3 fingers . Thermography revealed a 2.6oC lower temperature in the left dorsal hand than in the right.., CRPS I was diagnosed.
    37. 37. TREATMENT • Treatment with regular stellate ganglion blockade was initiated. • The therapy proved to be effective in relieving pain and hyperalgesia and in ameliorating the range of motion,
    38. 38. Conclusion • CRPS is a complicated chronic pain syndrome with variable clinical presentation and complicated diagnostic criteria. • Diagnosis is made on a clinical basis and treatment is best managed with a multidisciplinary approach including: – medications, – interventional procedures, – physical therapy and psychological therapy
    39. 39. Thanks for your attention….

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