IntroductionIntroduction AlgonurodystrophyAlgonurodystrophy AlgodystrophyAlgodystrophy Sudek atrophySudek atrophy Shoulder hand syndromeShoulder hand syndrome Complex regional syndromeComplex regional syndrome sympathetically mediated pain sympathetically mediated pain

syndrome( SMP)syndrome( SMP)

What is CRPS What is CRPS

CRPS (CRPS (Chronic regional pain syndromeChronic regional pain syndrome)is a )is a debilitating neurologic syndrome , ‘ follows a debilitating neurologic syndrome , ‘ follows a musculoskeletal trauma :musculoskeletal trauma :

PathogenesisPathogenesis A- original injury A- original injury

initiate a pain in pulseinitiate a pain in pulse

which is carried fromwhich is carried from

sensory nerves to the to sensory nerves to the to

the central nervousthe central nervous

systemsystem

PathogenesisPathogenesis B-pain impulse in turn B-pain impulse in turn

trigger an impulse in the trigger an impulse in the

sympathetic nervous sympathetic nervous

system which return tosystem which return to

original area of injuryoriginal area of injury

PathogenesisPathogenesis C- Sympathetic impulseC- Sympathetic impulse

trigger the inflammatorytrigger the inflammatory

response causing the vesselsresponse causing the vessels

to dilate . This leads to to dilate . This leads to

swelling an increased painswelling an increased pain

PathogenesisPathogenesis D- Pain trigger anotherD- Pain trigger another

impulse establishing a impulse establishing a

cycle of pain and cycle of pain and

swellingswelling

Epidemiology Epidemiology

Common in younger adultsCommon in younger adultsMean 41.8 years Mean 41.8 years 2.3 to 3 times more frequent in females than 2.3 to 3 times more frequent in females than malesmalesUsually involves a single limb in the early Usually involves a single limb in the early stagestage

Causes of RSDSCauses of RSDS No clear etiology in 25-35%. No clear etiology in 25-35%. Trauma (about 60-65% of cases), Trauma (about 60-65% of cases), Treatment with antituberculous drugs or Treatment with antituberculous drugs or

phenobarbitalphenobarbital Atypical causes such as pregnancy or Atypical causes such as pregnancy or

postpartum causes, diabetes mellitus, postpartum causes, diabetes mellitus, malignant tumors, parkinsonism or other malignant tumors, parkinsonism or other CNS disorders(stroke, hemiplegia)CNS disorders(stroke, hemiplegia)

Statistically significant associations Statistically significant associations

Cigarette smoking Cigarette smoking Patients frequently show high Patients frequently show high

scores on schizophrenia or scores on schizophrenia or depression scales..depression scales..

wartime casualties.wartime casualties.

Clinical Aspects of CRPSClinical Aspects of CRPS

Sensory Changes in CRPSSensory Changes in CRPS

AllodyniaAllodynia(Increased sensitivity to a nonpainful (Increased sensitivity to a nonpainful sensory stimulation)sensory stimulation)

Hyperalgesia Hyperalgesia (Abnormally exaggerated subjective (Abnormally exaggerated subjective response to painful stimuli )response to painful stimuli )

HyperesthesiaHyperesthesia Pain disproportionate to any inciting eventPain disproportionate to any inciting event

Autonomic Signs in CRPSAutonomic Signs in CRPS

EdemaEdema Swelling in limbSwelling in limb Color changeColor change TemperatureTemperature (cooler or warmer)(cooler or warmer)

Sweating Sweating

Swelling in limb Swelling in limb

Diffuse Diffuse

Nonpitting or pittingNonpitting or pitting Occur in distal part of Occur in distal part of

limblimb Don’t occur in hip or Don’t occur in hip or

shouldershoulder

Trophic ChangesTrophic Changes

Altered nail growthAltered nail growth

Altered hair growthAltered hair growth

Skin changes Skin changes

Abnormal Sweating Abnormal Sweating

Skin changesSkin changes

Psychological ChangesPsychological Changes

FearFear

AnxietyAnxiety

AngerAnger

DepressionDepression

Neurologic changesNeurologic changes

hyperesthesia (glove and stocking distribution)hyperesthesia (glove and stocking distribution)

in coordinationin coordination tremortremor muscle spasms muscle spasms Limited range of movementLimited range of movement

and paresisand paresis

Spread of CRPSSpread of CRPS

Stages of RSD / CRPSStages of RSD / CRPSSTAGE I STAGE I Onset of severe, Onset of severe, pain limited to pain limited to

the site of injurythe site of injury Increased Increased sensitivity of skinsensitivity of skin to to

touch and light pressure touch and light pressure (hyperasthesia).(hyperasthesia).

Localized swellingLocalized swelling Muscle crampsMuscle cramps Stiffness and limited mobilityStiffness and limited mobility At onset,At onset, skin skin is usually is usually warm, warm,

red and dryred and dry and then it may and then it may change to a blue (cyanotic) in change to a blue (cyanotic) in appearance and become cold appearance and become cold and sweaty.and sweaty.

Increased Increased sweatingsweating (hyperhydrosis).(hyperhydrosis).

. .

Stages of RSD / CRPSStages of RSD / CRPSSTAGE IISTAGE II

PainPain becomes even more becomes even more severesevere and more and more diffusediffuse..

Swelling tends to spreadSwelling tends to spread and it and it may change from a soft to hard may change from a soft to hard (brawny) type.(brawny) type.

Hair may become coarse then Hair may become coarse then scant, nails may grow faster scant, nails may grow faster then grow slower and become then grow slower and become brittle, cracked and heavily brittle, cracked and heavily grooved.grooved.

Spotty wasting of bone Spotty wasting of bone ((osteoporosisosteoporosis) occurs early but ) occurs early but may become severe and diffusemay become severe and diffuse

Muscle wasting Muscle wasting beginsbegins . .

Stages of RSD / CRPSStages of RSD / CRPSSTAGE IIISTAGE III

Marked wasting of tissue Marked wasting of tissue ((atrophicatrophic) eventually ) eventually become irreversible.become irreversible.

For many patients the For many patients the painpain becomes intractable becomes intractable and may and may involve the involve the entire limb.entire limb.

A A small percentagesmall percentage of of patients have developed patients have developed generalized RSD affecting generalized RSD affecting the entire body. the entire body.

patchy or diffuse patchy or diffuse

osteopenia of theosteopenia of the

underlying bones underlying bones

X Ray finding

Bone scanning Bone scanning

Three-phase technetium Tc 99m Three-phase technetium Tc 99m commonly is used.commonly is used.

Scan findings are considered Scan findings are considered positive if flow is asymmetric in positive if flow is asymmetric in phase 1, 2, and/or 3.phase 1, 2, and/or 3.

bone scintography

Imaging : Imaging : bone scintographybone scintography

Immediate Immediate Flow phaseFlow phase Pooling phasePooling phase

MRIMRI Non spesific soft tissue changeNon spesific soft tissue change Low signal in T1-T2Low signal in T1-T2

Differential DiagnosesDifferential Diagnoses

Diabetic and small-fiber peripheral Diabetic and small-fiber peripheral neuropathiesneuropathiesEntrapment neuropathiesEntrapment neuropathiesThoracic outlet syndromeThoracic outlet syndromeDiscogenic diseaseDiscogenic diseaseDeep vein thrombosisDeep vein thrombosisCellulitis Cellulitis Vascular insufficiencyVascular insufficiencyLymphedemaLymphedema

TreatmentTreatment

physical therapies physical therapies Active and passive range of motion Active and passive range of motion

exercises exercises Transcutaneous electrical nerve Transcutaneous electrical nerve

stimulation (TENS) stimulation (TENS) Desensitization techniques Desensitization techniques

Pharmacologic agents Pharmacologic agents SteroidSteroid Antidepressants: These drugs modulate Antidepressants: These drugs modulate

sympathetic activity and provide analgesia (eg, sympathetic activity and provide analgesia (eg, amitriptyline). amitriptyline).

Anticonvulsants (eg, phenytoin, carbamazepine) Anticonvulsants (eg, phenytoin, carbamazepine) Membrane stabilizing agents (eg, lidocaine, Membrane stabilizing agents (eg, lidocaine,

tocainide) tocainide) Adrenergic compounds (clonidine)Adrenergic compounds (clonidine) Calcium channel blockers Calcium channel blockers Intranasal calcitoninIntranasal calcitonin IV alendronate (bisphosphonate)IV alendronate (bisphosphonate)

Surgical Care Surgical Care

Chemical sympathectomyChemical sympathectomy Surgical sympathectomySurgical sympathectomy Implantable electrical stimulatorsImplantable electrical stimulators

PrognosisPrognosis weakness of the extremity resulting from this weakness of the extremity resulting from this

condition is seen in almost 50-65% of patients, condition is seen in almost 50-65% of patients, 18-24 months following initial diagnosis18-24 months following initial diagnosis

Full range of movement accompanying the Full range of movement accompanying the above aggressive therapies is seen in 60-74% above aggressive therapies is seen in 60-74% of patients.of patients.

Prolonged morbidity is observed in about Prolonged morbidity is observed in about 50% of patients with psychiatric diathesis50% of patients with psychiatric diathesis