COMPLEX REGIONAL PAIN SYNDROME, SUDEK'S OSTEODYSTOPHY, PHYSICAL MEDICINE AND REHABILITATION, MIRROR THERAPY

2. • A female of aged 55yrs came to OPD with pain
at right wrist for last 4 months for the first
time. She had a history of trauma to right
wrist following which she was undergone
immobilisation by casting for 6 weeks.
• She developed gradual onset of pain which
was out of proportion and restricted
movement of wrist and fingers over last 2
months following cast removal.

3. • Non diabetic, normotensive and euthyroid
• No h/o any surgery,
• No h/o evening rise of temperature,
prolonged cough or weight loss.

4. • Conscious, well oriented.
• Bp-110/70 mmof Hg, PR- 64bpm, regular, good
volume, no delay (Radial pulse).
• Inspection- pale skin, mild swelling around right
wrist, no atrophy no scarmark.
• Palpation- coldness over right hand and wrist,
AROM is restricted at wrist and hand, tenderness
on light touch at distal radioulnar joint.
• Right wrist was more sweaty than the opposite.
Rest of joint in U/L and L/L AROM full without any
tenderness or any deformity.
• Motor and sensory examination couldn’t be
performed as the pain was out of proportion.

7. COMPLEX REGIONAL PAIN SYNDROME
• CRPS Type 1 -Formerly known as RSD (1946),
Sudeck dystrophy (1900)
• CRPS Type 2 – Formerly known as causalgia

8. IASP-1994

9. IASP CRITERIA
• CRPS Type 1- The presence of an initiating noxious
event or a cause of immobilization
• CRPS Type 2- can be defined as a burning pain,
allodynia and hyperpathia occurring in a region of
the limb after partial injury of a nerve or one of its
major branches innervating that region

10. PATHOPHYSIOLOGY(Hypothesis)
• Aberrant inflammatory mechanisms
• Central and peripheral sensitisation
• Altered cutaneous innervation
• Altered sympathetic nervous system function
• Circulating catecholamines
• Vasomotor dysfunction
• Maladaptive neuroplasticity
• Genetic factors- HLA-B62 and HLA-DQ8
• Psychological factors

11. Budapest criteria 2003
• Continuing pain, which is disproportionate to
any inciting event
• Must report at least one symptom in three of
the four following categories.
• Must display at least one sign at time of
evaluation in two or more of the following
categories.
• There is no other diagnosis that better
explains the signs and symptoms

12. CATEGORIES
Sensory
Vasomotor
Sudomotor/ Edema
Motor/Trophic

13. SYMPTOMS
Sensory: hyperesthesia and/or allodynia
Vasomotor: temperature asymmetry and/or skin
color changes and/or skin color asymmetry
Sudomotor/ Edema: edema and/or sweating
changes and/or sweating asymmetry
Motor/Trophic: decreased range of motion
and/or motor dysfunction (weakness, tremor,
dystonia) and/or trophic changes (hair, nail, skin)

14. SIGNS
Sensory: hyperalgesia (to pinprick) and/or
allodynia
Vasomotor:temperature asymmetry (>1°C)
and/or skin color changes and/or asymmetry
Sudomotor/Edema: edema and/or sweating
changes and/or sweating asymmetry
Motor/Trophic: decreased range of motion
and/or motor dysfunction (weakness, tremor,
dystonia) and/or trophic changes (hair, nail, skin)

15. STAGES

16. Phases of CRPS
• Acute phase – painful,
red, warm, swelling,
allodynia, hyperalgesia
(mechanical, thermal),
nail and hair changes,
muscle weakness,
negative sensory signs
Marinus J, Moseley GL et al. Lancet Neurol 2011; 10: 637–48

17. Cold phase
Marinus J, Moseley GL et al. Lancet Neurol 2011; 10: 637–48

18. Dystonic changes
Marinus J, Moseley GL et al. Lancet Neurol 2011; 10: 637–48

19. Motor changes
• Weakness, Tremor, Decreased ROM, Difficulty in
performing complex movement patterns, focal
dystonia and myoclonus
• Motor symptoms increase with duration of CRPS
• Contractures and fibrosis
• Probably associated with plastic changes in sensory
and motor cortex

20. Trophic changes

21. Dystonic postures in CRPS
Munts et al. BMC Neurology2011,11:53

23. Bruehl S. Anesthesiology 2010; 113:713–25

24. Management
• Patient information and education
• Pain relief
• Physical Rehabilitation
• Psychological and Vocational rehabilitation

25. Medications
• Nifedipine in acute phase – Level 4
• Short course of steroids in acute phase – Level 1
• Intravenous bisphosphonates in acute phase – Level 1
• Opioids
• Neuropathic pain medications
• Baclofen or clonazepam for dystonia
• Intravenous ketamine infusion
(continuous/intermittent – inpatient/outpatient)

26. Rehabilitation
• Aim at activating premotor and primary motor
cortices
• Functional restoration
• Desensitization
• Gradual weight bearing

27. Graded motor imagery
• Three stages
Left/Right discrimination
Explicit motor imagery
Mirror therapy
• Activate cortical networks involved in sensory motor
processing

29. Nerve blocks/sympathetic block
• Patients with mechanical allodynia, burning pain,
temperature and colour changes might benefit
• Stellate ganglion block
• Lumbar sympathetic block
• Continuous/intermittent spinal infusions
(epidural/intrathecal)

30. SYMPATHECTOMY
• Chemical and surgical
• Regeneration of sympathetic chain
• Post sympathectomy neuralgia (44%)
• Compensatory hyperhidrosis, phantom sweating and
pathologic gustatory sweating

31. Spinal cord stimulation
• SCS + PT was better than PT alone (Kemler et al NEJM 2000, J
Neurosurg 2008) but no difference in functional outcome
• Long term benefit
• Benefit in allodynia and hyperalgesia
• Benefit with sympathetic block may indicate better
results
• Patient selection and trial
• Ideally within 12 to 16 weeks

32. Stanton-Hicks M et al. Cli J Pain
1998;14:155-66

33. Vitamin C and CRPS
• 4 Studies
• Atleast 500mg started immediately after surgery and
continued for 45 to 50 days
Shibuya N, Humpers JM. J Foot Ankle Surg. 2013;52(1):62-6

34. Other options
• Multimodal analgesia
• Nerve blocks
• Calcitonin 100 units a day for four weeks

35. EMERGING TREATMENTS
• Immunomodulation-Anti-cancer drugs such as
lenalidomide and thalidomide
• Hyperbaric oxygen therapy- 15 times daily 90-
min HBOT sessions
• Botulinum toxin-A (BTX-A)
• Plasma exchange