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Complex Regional Pain Syndrome , Reflex Sympathetic Dystrophy Syndrome (RSDS)
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Post traumatic osteodystrophy
Causalgia acute bony atrophy sudeck,s atrophy post traumatic
osteoporosis traumatic angiospasm algodystrophy reflex dystrophy of limbs minor causalgia post infarction
sclerodactyly
Post traumatic osteodystrophy
Shoulder hand syndrome reflex neurovascular
dystrophy reflex
sympathetic dystrophy
complex regional pain syndrome
Post t.o,d/RSDS/CRPS
MITCHEL.1864 certain vague/
ildefined/widespread painful conditions after/-trauma--infection-thrombophlebitis.
Leriche-1916.sympathetic a.
RSDS/CRPSreported associated conditions:
(etiology) Post traumatic cerebro vascular disorders djd of cervical spine discal herniation polymyelgia rh. Myocardial infarction post surgical post infection calcific tendinitis vasculitis neoplasm
RSDS/CRPSrep.ass.cond,cont
Neoplasm: -brain -lung -ovary -breast -pancreas -bladder -other
RSDS/CRPS prospective std,n=829
Trauma,65% fx operation,19% other enhancing
fact(im,iv inject) 4% inflamatory
process,2% unknown,10% colles fx,7-37% tibia shaft fx30%
RSDS/CRPSpathogenesis
Holistic concept chronic sensory
stimulus persistant vasomotor
response motor response upregulated sensitivity
of @-adrenergic receptores for catecholamines
Rsds/crpspathogenesis
1942 Sudeck th.. -exaggerated regional inflamatory response to: 1-injyry or 2-operation
indium-111 anti.inflam.drug.
RSDS/CRPSpathogenesis
Inter-nuncial pooling in lesion site
(interconnectingpool)
initiated series of reflexes spreads to central nervous system
Rsds/crpspathogenesis
Reduced concentration of _norepinephrine _neuropeptide-y
increased numbers of@1-adrenorecept ors in the skin
2 double-blind studies,sym block/placebo…..
Rsds/crpspathogenesis
Psycosocial fact emotional instab depresion anexiety life events,style BUT NO DECISIVE
REASONS
Rsds/crpsdiff,diag
Phlebothrombosis arterial insufficiency infection inflammatory condition compartment sy carp.tars.tun.sy neuropathies
Rsds/crpsdiff,diag.
Rsds/crpsdiff,diag.
Rsds/crpsdiff,diag.
Rsds/crpssigns&symptoms
Unexplained diffuse pain difference in skin color(red or blue) diffuse edema difference in skin temperature(warm or cold) limited active ROM accentuation after limb use symptom area is distal to&more than injuried
area
Rsds/crpssymptoms&signs
Pain swelling stiffness--->palmar faciitis discoloration vasomotor instability sudomotor effects temperature changes osteoporosis trophic skin changes
Rsds/crpsspreading symptoms patterns
continuity type
mirror-image type
independent type
Rsds/crpsstaging
Stage I-(1st 3 months)
stage II-(3 to 9 months)
stage III-(9 months to 2 or more years)
Rsds/crpsstage I
1.Onset of severe, pain limited to the site of injury
2.Increased sensitivity of skin to touch and light pressure(parasthesia)
3.Localized swelling
4.Muscle cramps
5.Stiffness and limited mobility
6.At onset, skin is usually warm, red and dry and then it may change to a blue (cyanotic) in appearance and become cold and sweaty.
7.Increased sweating (hyperhydrosis).
8.In mild cases this stage lasts a few weeks, then subsides spontaneously or responds rapidly to treatment./
Rsds/crpsstage II
1.Pain becomes even more severe and more diffuse 2.Swelling tends to spread and it may change from a soft to hard (brawny) type
3.Hair may become coarse then scant, nails may grow faster then grow slower and become brittle, cracked and heavily grooved
4.Spotty wasting of bone (osteoporosis) occurs early but may become severe and diffuse
5.Muscle wasting begin./
Rsds/crpsstage III
1.Marked wasting of tissue (atrophic) eventually become
irreversible
2.For many patients the pain becomes intractable and may
involve the entire limb.
A small percentage of patients have developed
generalized RSD affecting the entire body./
Rsds/crpsincidence
1. The exact prevalence of RSDS is unknown; however, data from several studies suggest it is more frequent than commonly believed.
2. Both sexes are affected, but the incidence of the syndrome is higher in women.
3. The RSD/CRPS Databank shows the average age to be in the mid thirties.
There is increasing evidence that the incidence of RSD/CRPS in adolescents and young adults is on the rise./
Rsds/crpsdemographic features in children
(1) Children and adolescents have lower extremity involvement 6 times more often than upper extremity involvement.
(2) Girls are affected roughly 5 times as often as boys.
(3) RSD/CRPS1 is rare below age 8; the incidence increases markedly just before puberty.
(4) Female dancers, gymnasts and competitive athletes comprise a high percentage of the patients
Rsds/crpsclinical types
Minor causalgia minor traumatic
dystrphy shoulder-hand
syndrome major traumatic
dystrophy major causalgia
Rsds/crpsdiagnosis-clinical***
Cardinal signs:1-PAIN.2-SWELLING-3-STIFFNESS.4 -DISCOLORATION
secondary signs:1-osseous demineralization 2- sudomotor changes.3-temperature changes.4-trophic changes.5-vasomotor instability.6-palmar faciitis./
Rsds/crpsdiagnosis
Radionuclide imaging thermography Sympathetic blocks X-rays EMG, Nerve Conduction
Studies, CAT scan and MRI studies
no any lab. test
Rsds/crpsX-ray findings
Patchy osteoporosis
small bones hands,feet
forearm,tibia distal metaphysis
Rsds/crpsetiology
Persistent painful lesion(trauma or disease)
diathesis(predisposition,suceptility,inherent trait)
abnormal sympathetic reflex
Rsds/crps
Rsds/crps
Rsds/crpstreatment
PREVENTION promtly effective
treatment should be started
pain-free exercise program
Rsds/crpstreatment
Prompt immobilization of injuried part may obviate further treatment.
Many patients recover spontaneously by functional use of affected limb.
Rsds/crpstreatment
Rsds/crpstreatment
Educate About Therapeutic Goals
Encourage Normal Use of the Limb (Physical Therapy)
Minimize Pain
Determine the Contribution of the Sympathetic Nervous
System to the Patient’s Pain
Rsd/crpstreatment
1. Establish a written treatment protocol. 2. Psychosocial modalities must be considered in all patients with RSD/CRPS. 3. Sequential Drug Trials: 4. Physical and Occupational Therapy: 5. Sympathetic Blocks: 6. Sympathectomy: 7. Placebo 8. Spinal Cord Stimulation (SCS) : 9. Morphine Pump: 10. How to Determine the Effectiveness of Treatments:
Rsd/crpstreatment
Sequential Drug Trials: Constant pain Pain causing sleep problems Inflammatory pain or pain due to recent tissue
injury Spontaneous jabs (paroxysmal dysesthesias
and lancinating pain) Sympathetically maintained pain (SMP) Muscle cramps
Rsd/crpstreatment
For constant pain associated with inflammation:
Nonsteroidal anti-inflammatory agents (e.g. aspirin,
ibuprofen, naproxen, indomethacin, etc).
Rsd/crpstreatment
For constant pain not caused by inflammation:
Agents acting on the central nervous system by an
atypical mechanism (e.g. tramadol)
Rsd/crpstreatment
For constant pain or spontaneous (paroxysmal) jabs and sleep
disturbances;
Anti-depressants (e.g. amitriptyline, doxepin, nortriptyline, trazodone, etc) Oral lidocaine
Rsd/crpstreatment
For spontaneous (paroxysmal) jabs:
Anti-convulsants (e.g. carbamazepine)
Rsd/crpstreatment
For widespread, severe RSD/CRPS pain, refractory to less
aggressive therapies:
Oral opioid. (e.g. narcotics with names such as
Darvon, Vicodin, Loratab, Percocet, morphine, codeine, etc).
Rsds/crpstreatment
For the treatment of sympathetically maintained pain (SMP):
Clonidine Patch,injection block,sympathectomy.
Rsds/crpstreatment
For muscle cramps (spasms and dystonia) which can be very
difficult to treat:
Klonopin (clonazepam) Baclofen
Rsds/crpstreatment
For localized pain related to nerve injury:
Injection,surgical procedures
Rsd/crpstreatment,nerve-block
Sympatholytic drugs.benzamine,prazosin somatic nerve blocks periodic perineural blocks stellate ganglion blocks continuous stellate blocks regional intravnous
sym.block.guanethidine,reserpine sympathectomy
Rsd/crpstreatment
Adjunctive T. trigger points ablation trans cutaneus n.stimulation(TENS) oral steroids calcitonin diathesis t. hand, therapy:exercise,heat,glove,TENS, splinting,functional activity. Surgical reconstruction.
Rsd/crpstreatment
Free radical scavenger T. manitol 10% 1000cc/24h,,via cent.ven,cath.7d
Dimethyl sulfoxide 50% 5t/daily,2-3mon. (cream)
N-acetyle cisteine.3t/600mg/d/oral.
Rsd/crpstreatment
vasodilation verapamil ketanserin pentoxifilin
Rsd/crpstreatment
Painful trigger points #50% trigger p. is present. Cts,tendinitis,bic.T.scap.tendinitis,
neuroma,trigger fing.epicond,lat&med.ant.metatarslgia,jumper knee,…...
local neurogenic inflamation.
Rsds/crpslegal issues
Subjective data objective data 80% of RSD/CRPS
cases have differences in temperature limbs
portable infrared thermometer
Rsd/crpssummary
Inclusive term 5-clinical types 3-etiologic factors 4-cardinal signs&symptoms 5-secondary symptoms confirmed diag.sympathic influnce; traumatic;CTS exercise/splinting,prog. Reconstructive surg.
Rsd/crpsپايان
شما تحمل و دقت؛صبر از تشكر با گرانقدر وهمكاران اساتيد
گنجي دكتر 1382/2/22
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