Post traumatic
osteodystrophy
Causalgia
acute bony atrophy
sudeck,s atrophy
post traumatic
osteoporosis
traumatic angiospa...
Post traumatic
osteodystrophy
Shoulder hand
syndrome
reflex neurovascular
dystrophy
reflex
sympathetic
dystrophy
complex
r...
Post t.o,d/RSDS/CRPS
MITCHEL.1864
certain vague/
ildefined/widesprea
d painful conditions
after/-trauma--
infection-
throm...
RSDS/CRPS
reported associated conditions:
(etiology)
Post traumatic
cerebro vascular
disorders
djd of cervical spine
disca...
RSDS/CRPS
rep.ass.cond,cont
Neoplasm:
-brain
-lung
-ovary
-breast
-pancreas
-bladder
-other
RSDS/CRPS
prospective std,n=829
Trauma,65% fx
operation,19%
other enhancing
fact(im,iv inject) 4%
inflamatory
process,2%
u...
RSDS/CRPS
pathogenesis
Holistic concept
chronic sensory
stimulus
persistant vasomotor
response
motor response
upregulated
...
Rsds/crps
pathogenesis
1942 Sudeck th..
-exaggerated
regional
inflamatory
response to:
1-injyry or
2-operation
indium-111
...
RSDS/CRPS
pathogenesis
Inter-nuncial
pooling in lesion
site
(interconnecting
pool)
initiated series
of reflexes
spreads to...
Rsds/crps
pathogenesis
Reduced
concentration of
_norepinephrine
_neuropeptide-y
increased numbers
of@1-adrenorecept
ors in...
Rsds/crps
pathogenesis
Psycosocial fact
emotional instab
depresion
anexiety
life events,style
BUT NO
DECISIVE
REASONS
Rsds/crps
diff,diag
Phlebothrombosis
arterial insufficiency
infection
inflammatory condition
compartment sy
carp.tars.tun....
Rsds/crps
diff,diag.
Rsds/crps
diff,diag.
Rsds/crps
diff,diag.
Rsds/crps
signs&symptoms
Unexplained diffuse pain
difference in skin color(red or blue)
diffuse edema
difference in skin t...
Rsds/crps
symptoms&signs
Pain
swelling
stiffness--->palmar faciitis
discoloration
vasomotor instability
sudomotor effects
...
Rsds/crps
spreading symptoms patterns
continuity
type
mirror-image
type
independent
type
Rsds/crps
staging
Stage I-(1st 3
months)
stage II-(3 to 9
months)
stage III-(9
months to 2 or
more years)
Rsds/crps
stage I
1.Onset of severe, pain limited to the site of injury
2.Increased sensitivity of skin to touch and light...
Rsds/crps
stage II
1.Pain becomes even more severe and more diffuse
2.Swelling tends to spread and it may change from a so...
Rsds/crps
stage III
1.Marked wasting of tissue (atrophic)
eventually become
irreversible
2.For many patients the pain beco...
Rsds/crps
incidence
1. The exact prevalence of RSDS is unknown; however,
data from several studies suggest it is more freq...
Rsds/crps
demographic features in children
(1) Children and adolescents have lower
extremity involvement 6 times more ofte...
Rsds/crps
clinical types
Minor causalgia
minor traumatic
dystrphy
shoulder-hand
syndrome
major traumatic
dystrophy
major c...
Rsds/crps
diagnosis-clinical***
Cardinal signs:1-PAIN.2-
SWELLING-3-STIFFNESS.4
-DISCOLORATION
secondary signs:1-osseous
d...
Rsds/crps
diagnosis
Radionuclide imaging
thermography
Sympathetic blocks
X-rays
EMG, Nerve Conduction
Studies, CAT scan an...
Rsds/crps
X-ray findings
Patchy
osteoporosis
small bones
hands,feet
forearm,tibia
distal
metaphysis
Rsds/crps
etiology
Persistent painful
lesion(trauma or
disease)
diathesis(predispositi
on,suceptility,inherent
trait)
abno...
Rsds/crps
Rsds/crps
Rsds/crps
treatment
PREVENTION
promtly
effective
treatment
should be
started
pain-free
exercise
program
Rsds/crps
treatment
Prompt immobilization of injuried part
may obviate further treatment.
Many patients recover spontaneou...
Rsds/crps
treatment
Rsds/crps
treatment
Educate About Therapeutic Goals
Encourage Normal Use of the Limb (Physical
Therapy)
Minimize Pain
Dete...
Rsd/crps
treatment
1. Establish a written treatment protocol.
2. Psychosocial modalities must be considered in all patient...
Rsd/crps
treatment
Sequential Drug Trials:
Constant pain
Pain causing sleep problems
Inflammatory pain or pain due to rece...
Rsd/crps
treatment
For constant pain associated with
inflammation:
Nonsteroidal anti-inflammatory agents (e.g.
aspirin,
ib...
Rsd/crps
treatment
For constant pain not caused by
inflammation:
Agents acting on the central nervous
system by an
atypica...
Rsd/crps
treatment
For constant pain or spontaneous
(paroxysmal) jabs and sleep
disturbances;
Anti-depressants (e.g. amitr...
Rsd/crps
treatment
For spontaneous (paroxysmal)
jabs:
Anti-convulsants (e.g.
carbamazepine)
Rsd/crps
treatment
For widespread, severe RSD/CRPS
pain, refractory to less
aggressive therapies:
Oral opioid. (e.g. narco...
Rsds/crps
treatment
For the treatment of sympathetically
maintained pain (SMP):
Clonidine Patch,injection
block,sympathect...
Rsds/crps
treatment
For muscle cramps (spasms and
dystonia) which can be very
difficult to treat:
Klonopin (clonazepam)
Ba...
Rsds/crps
treatment
For localized pain related to
nerve injury:
Injection,surgical procedures
Rsd/crps
treatment,nerve-block
Sympatholytic drugs.benzamine,prazosin
somatic nerve blocks
periodic perineural blocks
stel...
Rsd/crps
treatment
Adjunctive T.
trigger points ablation
trans cutaneus n.stimulation(TENS)
oral steroids
calcitonin
diath...
Rsd/crps
treatment
Free radical scavenger T.
manitol 10% 1000cc/24h,,via
cent.ven,cath.7d
Dimethyl sulfoxide 50% 5t/daily,...
Rsd/crps
treatment
vasodilation
verapamil
ketanserin
pentoxifilin
Rsd/crps
treatment
Painful trigger points
#50% trigger p. is present.
Cts,tendinitis,bic.T.scap.tendini
tis,neuroma,trigge...
Rsds/crps
legal issues
Subjective data
objective data
80% of
RSD/CRPS cases
have differences
in temperature
limbs
portable...
Rsd/crps
summary
Inclusive term
5-clinical types
3-etiologic factors
4-cardinal signs&symptoms
5-secondary symptoms
confir...
Rsd/crps
‫پايان‬
‫شما‬ ‫تحمل‬ ‫و‬ ‫دقت؛صبر‬ ‫از‬ ‫تشكر‬ ‫با‬
‫گرانقدر‬ ‫وهمكاران‬ ‫اساتيد‬
‫گنجي‬ ‫دكتر‬
1382/2/22
Crps
Crps
Upcoming SlideShare
Loading in...5
×

Crps

1,323

Published on

Complex Regional Pain Syndrome , Reflex Sympathetic Dystrophy Syndrome (RSDS)

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,323
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
36
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Crps

  1. 1. Post traumatic osteodystrophy Causalgia acute bony atrophy sudeck,s atrophy post traumatic osteoporosis traumatic angiospasm algodystrophy reflex dystrophy of limbs minor causalgia post infarction sclerodactyly
  2. 2. Post traumatic osteodystrophy Shoulder hand syndrome reflex neurovascular dystrophy reflex sympathetic dystrophy complex regional pain syndrome
  3. 3. Post t.o,d/RSDS/CRPS MITCHEL.1864 certain vague/ ildefined/widesprea d painful conditions after/-trauma-- infection- thrombophlebitis. Leriche- 1916.sympathetic a.
  4. 4. RSDS/CRPS reported associated conditions: (etiology) Post traumatic cerebro vascular disorders djd of cervical spine discal herniation polymyelgia rh. Myocardial infarction post surgical post infection calcific tendinitis vasculitis neoplasm
  5. 5. RSDS/CRPS rep.ass.cond,cont Neoplasm: -brain -lung -ovary -breast -pancreas -bladder -other
  6. 6. RSDS/CRPS prospective std,n=829 Trauma,65% fx operation,19% other enhancing fact(im,iv inject) 4% inflamatory process,2% unknown,10% colles fx,7-37% tibia shaft
  7. 7. RSDS/CRPS pathogenesis Holistic concept chronic sensory stimulus persistant vasomotor response motor response upregulated sensitivity of @- adrenergic receptores for catecholamines
  8. 8. Rsds/crps pathogenesis 1942 Sudeck th.. -exaggerated regional inflamatory response to: 1-injyry or 2-operation indium-111 anti.inflam.drug.
  9. 9. RSDS/CRPS pathogenesis Inter-nuncial pooling in lesion site (interconnecting pool) initiated series of reflexes spreads to central nervous system
  10. 10. Rsds/crps pathogenesis Reduced concentration of _norepinephrine _neuropeptide-y increased numbers of@1-adrenorecept ors in the skin 2 double-blind studies,sym block/placebo…..
  11. 11. Rsds/crps pathogenesis Psycosocial fact emotional instab depresion anexiety life events,style BUT NO DECISIVE REASONS
  12. 12. Rsds/crps diff,diag Phlebothrombosis arterial insufficiency infection inflammatory condition compartment sy carp.tars.tun.sy neuropathies
  13. 13. Rsds/crps diff,diag.
  14. 14. Rsds/crps diff,diag.
  15. 15. Rsds/crps diff,diag.
  16. 16. Rsds/crps signs&symptoms Unexplained diffuse pain difference in skin color(red or blue) diffuse edema difference in skin temperature(warm or cold) limited active ROM accentuation after limb use symptom area is distal to&more than injuried area
  17. 17. Rsds/crps symptoms&signs Pain swelling stiffness--->palmar faciitis discoloration vasomotor instability sudomotor effects temperature changes osteoporosis trophic skin changes
  18. 18. Rsds/crps spreading symptoms patterns continuity type mirror-image type independent type
  19. 19. Rsds/crps staging Stage I-(1st 3 months) stage II-(3 to 9 months) stage III-(9 months to 2 or more years)
  20. 20. Rsds/crps stage I 1.Onset of severe, pain limited to the site of injury 2.Increased sensitivity of skin to touch and light pressure(parasthesia) 3.Localized swelling 4.Muscle cramps 5.Stiffness and limited mobility 6.At onset, skin is usually warm, red and dry and then it may change to a blue (cyanotic) in appearance and become cold and sweaty. 7.Increased sweating (hyperhydrosis). 8.In mild cases this stage lasts a few weeks, then subsides spontaneously or responds rapidly to treatment./
  21. 21. Rsds/crps stage II 1.Pain becomes even more severe and more diffuse 2.Swelling tends to spread and it may change from a soft to hard (brawny) type 3.Hair may become coarse then scant, nails may grow faster then grow slower and become brittle, cracked and heavily grooved 4.Spotty wasting of bone (osteoporosis) occurs early but may become severe and diffuse 5.Muscle wasting begin./
  22. 22. Rsds/crps stage III 1.Marked wasting of tissue (atrophic) eventually become irreversible 2.For many patients the pain becomes intractable and may involve the entire limb. A small percentage of patients have developed generalized RSD affecting the entire body./
  23. 23. Rsds/crps incidence 1. The exact prevalence of RSDS is unknown; however, data from several studies suggest it is more frequent than commonly believed. 2. Both sexes are affected, but the incidence of the syndrome is higher in women. 3. The RSD/CRPS Databank shows the average age to be in the mid thirties. There is increasing evidence that the incidence of RSD/CRPS in adolescents and young adults is on the rise./
  24. 24. Rsds/crps demographic features in children (1) Children and adolescents have lower extremity involvement 6 times more often than upper extremity involvement. (2) Girls are affected roughly 5 times as often as boys. (3) RSD/CRPS1 is rare below age 8; the incidence increases markedly just before puberty. (4) Female dancers, gymnasts and competitive athletes comprise a high percentage of the patients
  25. 25. Rsds/crps clinical types Minor causalgia minor traumatic dystrphy shoulder-hand syndrome major traumatic dystrophy major causalgia
  26. 26. Rsds/crps diagnosis-clinical*** Cardinal signs:1-PAIN.2- SWELLING-3-STIFFNESS.4 -DISCOLORATION secondary signs:1-osseous demineralization 2- sudomotor changes.3- temperature changes.4- trophic changes.5-vasomotor instability.6-palmar faciitis./
  27. 27. Rsds/crps diagnosis Radionuclide imaging thermography Sympathetic blocks X-rays EMG, Nerve Conduction Studies, CAT scan and MRI studies no any lab. test
  28. 28. Rsds/crps X-ray findings Patchy osteoporosis small bones hands,feet forearm,tibia distal metaphysis
  29. 29. Rsds/crps etiology Persistent painful lesion(trauma or disease) diathesis(predispositi on,suceptility,inherent trait) abnormal sympathetic reflex
  30. 30. Rsds/crps
  31. 31. Rsds/crps
  32. 32. Rsds/crps treatment PREVENTION promtly effective treatment should be started pain-free exercise program
  33. 33. Rsds/crps treatment Prompt immobilization of injuried part may obviate further treatment. Many patients recover spontaneously by functional use of affected limb.
  34. 34. Rsds/crps treatment
  35. 35. Rsds/crps treatment Educate About Therapeutic Goals Encourage Normal Use of the Limb (Physical Therapy) Minimize Pain Determine the Contribution of the Sympathetic Nervous System to the Patient’s Pain
  36. 36. Rsd/crps treatment 1. Establish a written treatment protocol. 2. Psychosocial modalities must be considered in all patients with RSD/CRPS. 3. Sequential Drug Trials: 4. Physical and Occupational Therapy: 5. Sympathetic Blocks: 6. Sympathectomy: 7. Placebo 8. Spinal Cord Stimulation (SCS) : 9. Morphine Pump: 10. How to Determine the Effectiveness of Treatments:
  37. 37. Rsd/crps treatment Sequential Drug Trials: Constant pain Pain causing sleep problems Inflammatory pain or pain due to recent tissue injury Spontaneous jabs (paroxysmal dysesthesias and lancinating pain) Sympathetically maintained pain (SMP) Muscle cramps
  38. 38. Rsd/crps treatment For constant pain associated with inflammation: Nonsteroidal anti-inflammatory agents (e.g. aspirin, ibuprofen, naproxen, indomethacin, etc).
  39. 39. Rsd/crps treatment For constant pain not caused by inflammation: Agents acting on the central nervous system by an atypical mechanism (e.g. tramadol)
  40. 40. Rsd/crps treatment For constant pain or spontaneous (paroxysmal) jabs and sleep disturbances; Anti-depressants (e.g. amitriptyline, doxepin, nortriptyline, trazodone, etc) Oral lidocaine
  41. 41. Rsd/crps treatment For spontaneous (paroxysmal) jabs: Anti-convulsants (e.g. carbamazepine)
  42. 42. Rsd/crps treatment For widespread, severe RSD/CRPS pain, refractory to less aggressive therapies: Oral opioid. (e.g. narcotics with names such as Darvon, Vicodin, Loratab, Percocet, morphine, codeine, etc).
  43. 43. Rsds/crps treatment For the treatment of sympathetically maintained pain (SMP): Clonidine Patch,injection block,sympathectomy.
  44. 44. Rsds/crps treatment For muscle cramps (spasms and dystonia) which can be very difficult to treat: Klonopin (clonazepam) Baclofen
  45. 45. Rsds/crps treatment For localized pain related to nerve injury: Injection,surgical procedures
  46. 46. Rsd/crps treatment,nerve-block Sympatholytic drugs.benzamine,prazosin somatic nerve blocks periodic perineural blocks stellate ganglion blocks continuous stellate blocks regional intravnous sym.block.guanethidine,reserpine sympathectomy
  47. 47. Rsd/crps treatment Adjunctive T. trigger points ablation trans cutaneus n.stimulation(TENS) oral steroids calcitonin diathesis t. hand, therapy:exercise,heat,glove,TENS, splinting,functional activity. Surgical reconstruction.
  48. 48. Rsd/crps treatment Free radical scavenger T. manitol 10% 1000cc/24h,,via cent.ven,cath.7d Dimethyl sulfoxide 50% 5t/daily,2- 3mon. (cream) N-acetyle cisteine.3t/600mg/d/oral.
  49. 49. Rsd/crps treatment vasodilation verapamil ketanserin pentoxifilin
  50. 50. Rsd/crps treatment Painful trigger points #50% trigger p. is present. Cts,tendinitis,bic.T.scap.tendini tis,neuroma,trigger fing.epicond,lat&med.ant.metat arslgia,jumper knee,…... local neurogenic inflamation.
  51. 51. Rsds/crps legal issues Subjective data objective data 80% of RSD/CRPS cases have differences in temperature limbs portable infrared thermometer
  52. 52. Rsd/crps summary Inclusive term 5-clinical types 3-etiologic factors 4-cardinal signs&symptoms 5-secondary symptoms confirmed diag.sympathic influnce; traumatic;CTS exercise/splinting,prog. Reconstructive surg.
  53. 53. Rsd/crps ‫پايان‬ ‫شما‬ ‫تحمل‬ ‫و‬ ‫دقت؛صبر‬ ‫از‬ ‫تشكر‬ ‫با‬ ‫گرانقدر‬ ‫وهمكاران‬ ‫اساتيد‬ ‫گنجي‬ ‫دكتر‬ 1382/2/22
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×