Reflex Sympathetic Dystrophy (RSD), also known as Complex Regional Pain Syndrome (CRPS), is a chronic condition that causes persistent burning pain, swelling, and abnormal nerve activity in an affected limb, usually following an injury. It has two types: RSD (type I) occurs without major nerve damage and Causalgia (type II) occurs due to nerve injury. Symptoms include allodynia, hyperalgesia, changes in skin temperature and color. Diagnosis involves assessing sensory, vasomotor, sudomotor and motor symptoms. Treatment includes medications, surgery such as sympathectomy, and physiotherapy involving exercises, massage, and splinting to relieve pain and edema.

1. Reflex Sympathetic Dystrophy
and
Causalgia
By- kajal sansoya

2. Introduction
Reflex sympathetic dystrophy (RSD) is a
chronic condition that causes persistent
burning pain , swelling and abnormal nerve
activity affected upper or lower limb followed
by any major or minor injury .
RSD is also known as complex regional pain
syndrome (CRPS)
Commonly occurs to proximal or contralateral
limb or also occur as mirror pain.

3. Image showing mirror pain in CRPS

4. Terminology
Algodystrophy
Sudeck’s atrophy
Complex regional pain syndrome
Shoulder-hand-syndrome(SHS)
Sympathetically-maintained pain(SMP)
Causalgia
Post traumatic dystrophy

5. History
in 1864, MITCHELL introduced first concept of
CAUSALGIA .
Mitchell noticed that injuries to periphery
nerves may causes pain as well as changes in
color& temperature of skin within affected
area.
In 1990, JOHN BONICA first used the term RSD
PAUL SUDECK suggested symptoms &
assesment of RSD

6. • In 1994, IASP renamed the term reflex
sympathetic dystrophy and causalgia
COMPLEX REGIONAL PAIN SYNDOME (CRPS)

7. Epidemiology
 According to IASP incidence of RSD or CRPS
occurs at any age. Number of cases reported
for RSD is more than causalgia.
In USA every 5th person in 10,000 has RSD and
1 in 10,000 has causalgia.
CRPS is three times more common in females
than males.
 IAPS Diagnostic criteria of 2012 shows
decrease in cases by 50%

8. Complex regional pain
syndrome
In CRPS , there is complex interaction of
somatic psychological , behavioural factors &
the regional distribution of symptoms.
This abnormal activity occur because of any
minor or major injury.
CRPS has two types namely :-
REFLEX SYMPATHETIC DYSTROPHY (RSD) type I
CAUSALGIA (type II)

9. Etiology
CRPS occurs as a result of varying amount of
trauma or injury to tissues.
 This can be major or minor injuries such as...
Blunt injuries
Inflammatory diseases
Degenerative joint diseases
Burns
Sprains
Fall from stairs
Stroke
mastectomy

10. Pathophysiology conti….
INJURY
Inflammatory &immune response
(B-cell activation, increase interleukins, substance P)
Result in noxious primary afferent traffic
Central sensitization, “wind up”
Increase abnormal alteration in sympathetic system.

11. Classification
IASP classify CRPS into RSD or type-I &
CAUSALGIA or type-II
CRPS (type-I)- condition triggered by an illness
or injury but you do not have a nerve injury in
affected area
CRPS(type-II)- condition is clearly linked to a
nerve injury in affected area.

12. Type-I (RSD)
IASP definition of CRPS type-I
“ It is syndrome that usually develops after an
initiating noxious event, is not limited to the
distribution of a single peripheral nerve. It is
associated at some point with evidence of edema,
changes in skin blood flow, abnormal sudomotor
activity in the region of the pain or allodynia ( pain
experienced from non-painful stimulus)or hyperalesia
(increase abnormal sensitivity to pain)”

13. Points to remember…RSD
 Develops after an Noxious event
 Not limited to single peripheral nerve and no
nerve injury at affected area.
 Presence of allodynia & hyperalesia, changes
in skin color& temperature.
“ reflex nature is unclear, however the role of
sympathetic system is also not well
understood..so term CRPS used”

14. RSD often poorly
misunderstood by conditions
such as..
Pain and altered sensations
Motor disturbance and soft tissues changes
Vasomotor, autonomic changes
Psychological distrubances

15. Type-II CAUSALGIA
Causalgia derives from Greek word causos
which describes the burning pain sometimes
associated with neuropathy pain
Occur due to any major or minor trauma or
lesion followed by nerve injury

16. Causalgia
Syndrome develops after a nerve injury.
Spontaneous pain or allodynia &
hyperalesia
Evidence of pain, edema, skin changes
 Abnormal sudomotor(sweat glands)
activity in the region of the pain since the
inciting event.

17. Stages of progression
There are three stages of progression of
condition namely…
First stages/acute/hyperaemic
Second/dystrophic/ischaemic
Third/atrophic

18. Acute or Hyperaemic
Acute stages lasts few weeks after injury.
Spontaneous pain which is aching and burning
in nature.
Affected area is red and warm than usuall
Presence of edema.
Hyperpathia – painful syndrome caused by
increase reaction to stimulus

19. Dystrophic or Ischaemic
Dystrophic stage is begin after 3 months of injury.
Vascular and dermatome region of injury.
Affected area is moist, cold
Skin is pale or cyanotic.
Increase joint stiffness.
Muscle wasting
Edema
Limiting ROM

20. Atrophic
Atrophic stage is end stage. Atrophic stages
begins 6 months after injury, when condition is
not treated properly.
Changes that occur in tissues and skin are
irreversible.
Sever pain in muscles, joints and tendons.
Abnormal growth of hairs and nails, nails are
brittle also.
Extreme weakness
Limiting ROM which results in ankylosis

21. Clinical features
Allodynia
Hyperpathia
Hyperesthesia
Hyperalgesia
Sweating/edema
Muscle weaking
Joint stiffness
Tremor
Changes in temperature& color of skin

22. Conti..
Dystonia
Limiting ROM
Abnormal nail and hair growth
Glossy skin
Behavioral illness

23. Assesment and diagnosis
IASP criteria for RSD:-
Presence of an inciting noxious event or cause
of immobilization
Presence of allodynia , hyperalgesia
Presence of edema
Changes in skin.

24. Budapest criteria
Patient has pain which is disproportionate to
the inciting event.
Patient has at least one sign in two or more
categories i.e sensory, vasomotor, sudomotor,
motor.

25. Sensory
allodynia( light touch,
temperature, deep somatic
pressure) hyperalgesia from
pin prick. Hyperasthesia
Vasomotor Temperature assymetry, skin
and color changes
Sudomotor /edema Edema and sweating changes,
sweating assymetery
motor/trophic Decreased ROM, motor
dysfunction

26. Investigation
X-rays – demonstrate patchy demineralization
in affected area.

27. MRI
Shows soft tissues swelling , joint effusion,
periarticular marrow.
Arrow indicates joint contracture &effusion

28. Investigation conti..
Bone scans shows changes that occur in early
stages.
EMG &NCV are used to check the conductive
properties of nerve.
Thermograph – used to check the skin
temperature within affected area .
Stage 1 – increased temperature
Stage 2- normalized or warm temperature
Stage 3- decreased temperature.

29. Thermography shows temperature difference in affected areas

30. Management
Prevention is best treatment in such cases.
However, medical and surgical interventions
reported to be benefit in RSD and CAUSALGIA
Treatment includes – pharmacological
intervention , surgical and physiotherapy
management.

31. Pharmacological
Bisphosphonates
Calcitonin
Morphine
Corticosteroids
Spinal cord stimulators

32. Surgical
Destruction of the local sympathetic supply by
By sympathectomy
Lumbar sympatholysis
Interrpution of the affected portion of sympathetic nervous system

33. Physiotherpy
The goal is symptomatic treatment which
includes treatment for pain relief , edema ,
joint stiffness, allodynia & most important
patient education .
For pain relief- TENS, cryotherapy, vibrations.
For edema relief- elevation , massage,
compression bandages& active exercises.
For allodynia – contrast bath, massage,
vibration, active exercieses.

35. For joint stiffness- active and passive
exercises, ultrasound, gentle stretching, cold,
heat fermentation, biofeedback activities,
splinting.

36. Thank you
Happy reading 