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

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

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    Crps Crps Presentation Transcript

    • 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
    • Post traumatic osteodystrophy Shoulder hand syndrome reflex neurovascular dystrophy reflex sympathetic dystrophy complex regional pain syndrome
    • Post t.o,d/RSDS/CRPS MITCHEL.1864 certain vague/ ildefined/widesprea d painful conditions after/-trauma-- infection- thrombophlebitis. Leriche- 1916.sympathetic a.
    • 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
    • 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% unknown,10% colles fx,7-37% tibia shaft
    • RSDS/CRPS pathogenesis Holistic concept chronic sensory stimulus persistant vasomotor response motor response upregulated sensitivity of @- adrenergic receptores for catecholamines
    • Rsds/crps pathogenesis 1942 Sudeck th.. -exaggerated regional inflamatory response to: 1-injyry or 2-operation indium-111 anti.inflam.drug.
    • RSDS/CRPS pathogenesis Inter-nuncial pooling in lesion site (interconnecting pool) initiated series of reflexes spreads to central nervous system
    • 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…..
    • 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.sy neuropathies
    • 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 temperature(warm or cold) limited active ROM accentuation after limb use symptom area is distal to&more than injuried area
    • Rsds/crps symptoms&signs Pain swelling stiffness--->palmar faciitis discoloration vasomotor instability sudomotor effects temperature changes osteoporosis trophic skin changes
    • 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 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./
    • 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./
    • 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./
    • 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./
    • 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
    • Rsds/crps clinical types Minor causalgia minor traumatic dystrphy shoulder-hand syndrome major traumatic dystrophy major causalgia
    • 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./
    • Rsds/crps diagnosis Radionuclide imaging thermography Sympathetic blocks X-rays EMG, Nerve Conduction Studies, CAT scan and MRI studies no any lab. test
    • 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) abnormal sympathetic reflex
    • 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 spontaneously by functional use of affected limb.
    • Rsds/crps treatment
    • 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
    • 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:
    • 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
    • Rsd/crps treatment For constant pain associated with inflammation: Nonsteroidal anti-inflammatory agents (e.g. aspirin, ibuprofen, naproxen, indomethacin, etc).
    • Rsd/crps treatment For constant pain not caused by inflammation: Agents acting on the central nervous system by an atypical mechanism (e.g. tramadol)
    • Rsd/crps treatment For constant pain or spontaneous (paroxysmal) jabs and sleep disturbances; Anti-depressants (e.g. amitriptyline, doxepin, nortriptyline, trazodone, etc) Oral lidocaine
    • 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. narcotics with names such as Darvon, Vicodin, Loratab, Percocet, morphine, codeine, etc).
    • Rsds/crps treatment For the treatment of sympathetically maintained pain (SMP): Clonidine Patch,injection block,sympathectomy.
    • Rsds/crps treatment For muscle cramps (spasms and dystonia) which can be very difficult to treat: Klonopin (clonazepam) Baclofen
    • 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 stellate ganglion blocks continuous stellate blocks regional intravnous sym.block.guanethidine,reserpine sympathectomy
    • 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.
    • 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.
    • 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,trigger fing.epicond,lat&med.ant.metat arslgia,jumper knee,…... local neurogenic inflamation.
    • Rsds/crps legal issues Subjective data objective data 80% of RSD/CRPS cases have differences in temperature limbs portable infrared thermometer
    • 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.
    • Rsd/crps ‫پايان‬ ‫شما‬ ‫تحمل‬ ‫و‬ ‫دقت؛صبر‬ ‫از‬ ‫تشكر‬ ‫با‬ ‫گرانقدر‬ ‫وهمكاران‬ ‫اساتيد‬ ‫گنجي‬ ‫دكتر‬ 1382/2/22