Reflex sympathetic osteodystrophy (RSD), also known as complex regional pain syndrome (CRPS), is a painful and often chronic condition that can occur following various traumas or injuries. RSD is categorized into three types and stages, each characterized by specific symptoms and impairments, including severe pain, swelling, and changes in skin condition. Management of CRPS typically involves a combination of pharmacotherapy, physiotherapy, and psychotherapy tailored to the patient's specific needs.

1. REFLEX SYMPATHETIC OSTEODYSTROPHY
PRESENTED BY
DR.SHIVANI GOYAL (PT)

2. CONTENTS
 DEFINATION
 TYPES OF CRPS
 STAGES AND SIGNS AND SYMPTOMS
 ETIOLOGY
 COMMON IMPAIRMENTS
 MANAGEMENT OF CRPS

3. Some other common names of RSD???
• REFELX SYMPATHETIC OSTEODYSTROPY (RSD)
• COMPLEX REGIONAL PAIN SYNDROME (CRPS)
• SUDEAK DYSTROPY
• REFEX NEUROVASCULAR DYSTROPY
• TRAUMATIC ANGIOSPASM

4. DEFINATION
• It is a painful , disabling and often chronic condition occur due to sympathetic disturbances.
• Associated with
- repeated trauma to hand (occupational workers ,truck drivers )
- Direct trauma ,crush injury ,injury to nerves
- Colle’s fracture
- CVA
- Systemic disease.

5. TYPES OF CRPS
CRPSTYPE 1
(RSD)
• Develops after an initiating
an noxious event.
• Spontaneous pain or
allodynia/hyperalgesia.
• Edema , vascular
abnormalities.
• Non-nerve origin.
CRPSTYPE 2
(COXALGIA)
• Develops after nerve injury.
• Not limited to territory of
injured nerve.
• Edema, skin blood flow
abnormality.
• Abnormal sudomotor
activity.
CRPS-NOS
(not otherwise specified)
• Specific injury or origin has
not been determined as a
cause of symptoms.

6. STAGES OF CRPS ANDTHEIR SIGN AND
SYMPTOMS
STAGE 1
(lasts up to 3-6 months)
• Burning and aching pain
with tenderness which is
aggravated by movement
or emotional stress.
• Pitting edema is observes.
• Warm erythematic hand
becomes cool and
cyanotic with excessive
sweating.
• Osteoporosis sets in.
STAGE 2
(lasts up to 3-6months)
• Pain and edema continue
,resulting in decrease in
joint mobility
(contractures).
• Muscle atrophy may sets
in.
• Trophic changes (smooth
and shiny skin , brittle and
grooved finger nails).
STAGE 3
• Diffuse marked
osteoporosis .
• Stiffness of distal finger
joint occurs.
• Intrinsic muscle atrophy
,especially interossei.
• Pain during attempted
movement continue .

7. ETIOLOGY
• Exact etiology not known.
 After trauma/surgery the presence of inflammation is physiological but in
CRPS inflammation last indefinitely .
 There is abundance of inflammatory mediators with lack of anti-
inflammatory mediators.
 This proliferation response sensitize the peripheral and spinal nociceptive
system which facilitate the release of neuropeptides inducing signs of
inflammation and stimulates bone cells and fibroblasts proliferation and
endothelial dysfunction leading to vascular changes.
 During this inflammation stage ,sensory-motor integration becomes
disturbed ,leading to loss of motor function and distortion of body
representation leading to autonomic disturbances.

8. Common impairment of structure , function,
activity limitation and participation restriction
• Pain /hyperesthesia in extremities .
• Limitation of motion/motor dysfunction (weakness , tremor, dystonia)
• Sudomotor/edema - edema ,swelling , sweating asymmetry(hyper/hypohidrosis)
• Vasomotor instability – temperature asymmetry and skin color changes or
asymmetry .
• Tropic changes – inc./dec. hair and nail growth and skin changes (thin and shinny)
• Pain avoidance behavior ,results in less use of involved limb in ADLs (which may
cause muscle atrophy /osteoporosis/osteopenia in chronic stage.

9. • Slower at initiating movement .
• Gait abnormalities (when lower extremity is involved )
• Limitations in ability to participate in gainful employment or housework.
• Limitation in ability to participate in leisure activities.

10. Important points
 Symptoms more marked in distal extremities.
 Symptoms progress in intensity and spread proximally.
 Symptoms vary with time.

11. Has 2 phases
Acute phase (warm
phase )
• Peripheral changes.
• Limb is sensitive , swollen and temperature elevated.
Chronic phase
(cold phase)
• Central changes.
• Resolution of inflammatory phase.
• Decreased temperature
• Pain and disability persists.
• Cognitive and mood alterations.

12. MANAGEMENT OF CRPS
• No specific treatment of CRPS.
• Physiotherapy given with combination of pharmacotherapy and
psychotherapy.

13. Medical management
• In acute inflammatory phase – corticosteroids
• Mild-moderate pain – simple analgesic/opioids (to pain relief )
• Interventional blocks – to manage excruciating /intractable pian .
• Neuropathic pain – anticonvulsants /TCA( tricyclic antidepressants)
• Emotional/psychological pain – antianxiety ,antidepressants , sedatives.

14. PHYSIOTHERAPYTREATMENT
• GOALS
i. Minimize the edema
ii. Desensitizing painful limb
iii. Normalizing sensation
iv. Promote normal positioning
v. Decrease muscle guarding
vi. Increase functional use of extremity

15. Control of pain
 Prolonged heat or ice (depend on vasomotor status )
 HVGS (HighVoltage Galvanic Stimulation)
 TENS
 Fluid therapy
 Paraffin wax bath
 Repeated gentle relaxed passive movement
 Connective tissue massage

16. Control of edema
 Supported elevation
 Active movement
 Retrograde massage
 Jobst gloves and air splint
 Compression gloves/sleeves
 Pneumatic compression treatment

17. Mobility
 In early stage ,gentle active exercise (manage stiffness )
 Avoid painful reactions that decrease mobility
 Patient actively move each joint for brief period of time
 IN HAND –Tendon gliding exercise
 IN FEET – towel curls ,sitting balance board progress to gradual
weight bearing on involved limb during gait training .
 Aquatic therapy

18. To increase muscle performance
 Objective is to provide tissue stress with minimal joint motion .
 Facilitate active muscle contraction proximally (shoulder/hip)
 Use active load bearing (closed chain techniques) of upper and lower
extremity .
 Distraction activities ( carrying light bag on upper limb )

19. Mirror therapy
 To correct sensiomotor incongruence by visualizing unaffected limb in felt
position of affected limb.
Graded motor imagery
 Used to activate different region in graded manner.
Treatment consist of 3 components –
I. Left/right discrimination of affected area .
II. Motor imagery rehearsal
III. Mirror therapy

20. Total body circulation and cardiac output
Low impact aerobic exercise
Aquatic ex. – to facilitate activity while minimize load in early stage.
Desensitization
Patient education

21. Phase wise PT management
Acute/early phase
• Relief pain/control edema – modalities ,retrograde
massage , elevation ,compression.
• Correct sensiomotor incongr.- mirror therapy , graded
motor therapy
• Increase mobility- gentle active motion
• Improve muscle performance- active loading , distraction
• Desensitize area
• Patient education
Chronic phase
• Manage pain – modalities, desensitization, mirror therapy
• Increase mobility – joint mobilization ,soft tissue
mobilization , neural mobilization ,passive and self stretch
• Improve functional performance – careful monitor and
progress strength ,endurance and functional exercise .