diagnosis and treatment options of rsd/crps
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Diagnosis and Treatment Diagnosis and Treatment Options of RSD/CRPSOptions of RSD/CRPS
Srinivasa N. Raja, MD
Director of Pain Research
Johns Hopkins University
School of Medicine
IntroductionIntroduction
RSD/CRPS is a chronic neurologic syndrome characterized by pain of varying intensity
Early diagnosis and appropriate treatment are essential to avoid disabling pain
RSD/CRPS is often under-diagnosed and under-treated by the medical community
What Is Reflex Sympathetic What Is Reflex Sympathetic Dystrophy Syndrome?Dystrophy Syndrome?
Reflex sympathetic dystrophy syndrome (RSD) is a debilitating neurologic syndrome characterized by
• Pain and hypersensitivity• Vasomotor skin changes• Functional impairment• Various degrees of trophic change
RSD generally follows a musculoskeletal trauma
Bogduk N. Current Opinions in Anesthesiology. 2000;14:541-546.
ChallengesChallenges
Natural course and pathophysiology remain elusive1
Diagnosis made by exclusion of other causes2
Therapies remain controversial3
Underdiagnosed and undertreated
Significant morbidity and loss of quality of life
1. Jänig W. In: Harden , Baron Janig, eds. Complex regional Pain Syndrome, Progress in Pain Research and Management. 2001: 3-15.
2. Bogduk N. Current Opinions in Anesthesiology. 2000;14:541-546.
3. Raja SN et al. Anesthesiology. 2002;96:1254-1260.
Terminology: RSD vs CRPSTerminology: RSD vs CRPS
RSD = traditional term
Complex regional pain syndrome
(CRPS) = more comprehensive term• Includes disorders not related to sympathetic
nervous system dysfunction
CRPS I = RSD
CRPS II = causalgia (involves nerve injury)
Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001: 388-411.
Name Change to CRPSName Change to CRPS
Goals: standardized, reliable diagnostic criteria and decision rules
• Allow generalization • Make appropriate treatment selection • Identify reproducible research samples
Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001:388-411.
EpidemiologyEpidemiology
Age – common in younger adults• Mean 41.8 years • Mean age at time of injury 37.7 years
Mean duration of symptoms before pain center evaluation = 30 months
2.3 to 3 times more frequent in females than males1
Usually involves a single limb in the early stage 2
1. Raja SN et al. Anesthesiology. 2002;96:1254-1260. 2. Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001, 388-411.
Clinical FeaturesClinical Features
Presence of an initiating noxious event or a cause of immobilization
Continuing pain• Allodynia: pain from a stimulus that
does not normally provoke pain• Hyperalgesia: excessive sensitivity to
pain
Pain disproportionate to any inciting event
Stanton-Hicks M et al. Pain. 1995;63:127-133. Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001; 388-411.
Clinical FeaturesClinical Features(cont’d)(cont’d)
History of edema, changes in skin blood flow, or abnormal sweating in the region of pain
Exclusion of medical conditions that would otherwise account for the degree of pain and dysfunction
Stanton-Hicks M et al. Pain. 1995;63:127-133. Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001: 388-411.
Checklist for the Diagnosis Checklist for the Diagnosis of RSD: of RSD: HistoryHistory
• Burning pain• Skin, sensitivity to touch• Skin, sensitivity to cold• Abnormal swelling• Abnormal hair growth
• Abnormal nail growth• Abnormal sweating• Abnormal skin color
changes• Abnormal skin
temperature changes• Limited movement
Bogduk N. Current Opinions in Anesthesiology. 2000;14:541-546.
Checklist for the Diagnosis of RSD/CRPS: Examination
• Mechanical allodynia• Hyperalgia to single pinprick• Summation to multiple
pinprick• Cold allodynia• Abnormal swelling
• Abnormal hair growth• Abnormal skin color changes• Abnormal skin temperature (> or < 1 ْC)• Limited range of movement• Motor neglect
Bogduk N. Current Opinions in Anesthesiology. 2000;14:541-546.
Revised Diagnostic CriteriaRevised Diagnostic CriteriaClinical PresentationClinical Presentation
Pain and sensory changes disproportionate to the injury in magnitude or duration
Patients should have at least one symptom in each of these categories and one sign in 2 or more categories
Sensory (hyperesthesia = increased sensitivity to a sensory stimulation)
Vasomotor (temperature or skin abnormalities) Sudomotor (edema or sweating abnormalities) Motor (decreased range of movement, weakness,
tremor, or neglect)
1. Bruehl et al. Pain. 1999;81:147-154. 2. Harden et al. Pain. 1999;83:211-219.
.
Swelling and Color ChangesSwelling and Color Changes
Abnormal Sweating in RSDAbnormal Sweating in RSD
Differential DiagnosesDifferential Diagnoses
• Diabetic and small-fiber peripheral neuropathies
• Entrapment neuropathies
• Thoracic outlet syndrome
• Discogenic disease
• Deep vein thrombosis
• Cellulitis • Vascular
insufficiency• Lymphedema• Erythromelalgia
Raja SN et al. Anesthesiology. 2002;96:1254-1260.
Psychological AspectsPsychological Aspects
Pain can cause symptoms of psychologic distress including
• Anxiety• Depression• Fear• Anger
Raja SN et al. Anesthesiology. 2002;96:1254-1260.
Treatment Treatment
Goals• Rehabilitation• Pain management• Psychological treatment
Multidisciplinary• Physiotherapy• Medical • Psychological
Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.
Rehabilitation: Clinical Rehabilitation: Clinical Pathway Pathway
Physiotherapy + pain management + psychological therapies = sequential progression through the rehabilitation pathway
PT + OT crucial to patient’s progression
•Therapist assesses patient’s motivation and helps set goals•Adequate analgesia, encouragement, and education of disease process
Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.
Rehabilitation: General Rehabilitation: General StepsSteps
Desensitization of the affected region
Mobilization, edema control, and isometric strengthening
Stress loading, isotonic strengthening, range of motion, postural normalization and aerobic conditioning
Vocational and functional rehabilitation
Stanton-Hicks M et al. Clin J Pain. 1998;14:155-166.
Pharmacalogic Pain Management
• IV alendronate (bisphosphonate)
• Topic dimethyl sulfoxide
• Topical clonidine
•IV bretylium•IV ketanserin•IV phentolamine•IV lidocaine•Intranasal calcitonin
Most drugs used for neuropathic pain are used to treat RSD/CRPS
Raja SN et al. Anesthesiology. 2002;96:1254-1260.
Kingery WS. Pain.1997;73:123-139
Minimally Invasive Therapies
Sympathetic, IV regional, and somatic nerve blocks
Patients with a sympathetic component to their pain (SMP) should receive nerve blocks
For patients without SMP, a somatic block or epidural infusion may be indicated to optimize analgesia for PT
Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.
More InvasiveMore Invasive Therapies
Neuroaugmentation
Spinal cord stimulation
Intrathecal drug delivery
Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.
Surgical Therapies: SympathectomySympathectomy
• Controversial procedure• In carefully selected patients, may result
in reduction in pain severity and disability• Patients with SMP who respond to
selectivesympathetic blockade
• Radiofrequency and neurolytic techniques are alternatives to a surgical sympathectomy
Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.Bandyk DF et al. J Vasc Surg. 2002;35:269-277.
Other Therapies
• Behavioral modification • Psychiatric consultation• Complimentary and Alternative therapies
Acupuncture
Raja SN et al. Anesthesiology. 2002; 96:1254-1260.
PrognosisPrognosis
Difficult to predict
Earlier intervention may be more likely to be successful
Some patients experience reduced symptoms or apparently full recovery
Some patients continue to experience significant disability
Raja SN et al. Anesthesiology. 2002;96:1254-1260.
ConclusionsConclusions
RSD/CRPS is a chronic neurologic syndrome
Not all patients have the same set of symptoms
Early diagnosis and appropriate treatment is essential
Ideal treatment should be multidisciplinary
Bibliography
Bandyk DF, Johnson BL, Kirkpatrick AF, Novotney ML, Back MR, Schmacht DC. Surgical sympathectomy for reflex sympathetic dystrophy syndromes. J Vasc Surg. 2002;35:269-277.
Bogduk N. Complex regional pain syndrome. Current Opinions in Anesthesiology. 2000;14:541-546.
Bruehl SP, Harden RN, Galer BS, et al. External validation of IASP diagnostic criteria for complex regional pain syndrome and proposed research diagnostic criteria. Internal Association for the Study of Pain. Pain. 1999;81:147-154.
Galer BS, Schwartz L, Allen RJ. In: Loeser, ed. Bonica’s Management of Pain. 2001: 388-411.
Harden RN, Bruehl SP, Galer BS, et al. Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive? Pain. 1999;83:211-219.
Bibliography (continued)
Jänig W. CRPS-I and CRPS-II: A strategic view, In: Harden , Baron Jänig, eds. Complex regional Pain Syndrome, Progress in Pain Research and Management. 2001: 3-15.
Kingery WS. Pain. A critical review of controlled clinical trials for peripheral neuropathic pain and complex regional pain syndromes. 1997;73:123-139.
Raja SN , Grabow TS. Complex regional pain syndrome I (Reflex Sympathetic Dystrophy) Anesthesiology. 2002;96:1254-1260.
Stanton-Hicks M, Burton AW, Bruehl SP, et al. An updated interdisciplinary clinical pathway for CRPS: Report of an expert panel. Pain Practice. 2002;2:1-16.
Stanton-Hicks M, Jänig W, Hassenbusch S, et al. Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain. 1995;63:127-133
Stanton-Hicks M, Baron R, Boas R, et al. Complex Regional Pain Syndrome: guidelines for therapy. Clin J Pain. 1998;14:155-166.
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