Crps

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