SYNONYMS. Dr. Jyoti Patel

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1 Dr. Jyoti Patel SYNONYMS ERYTHROMELAGIA CAUSALGIA SUDECK S ATROPHY TRAUMATIC ANGIOSPASMS RSD SHOULDER HAND SYNDROME SYMPATHALGIA HYPERPATHIC PAN SMP (SYMPATHETIC MEDIATED PAIN)

2 HISTORY RSD /CAUSALGIA/SHOULDER HAND SYNDROME/SUDECK S ATROPHY ETC Silas Weir Mitchell Drs. Moorehouse and Keen 1993 Name Changed ISAP CRPS DEFINED CHRONIC PROGRESSIVE NERVE DISORDER DYSFUNCTION IN THE CONTROL OF THE CENTRAL AND PERIPHERAL NERVOUS SYSTEM A COMPLEX BETWEEN SENSORY, MOTOR, ANS AND IMMUNE SYSTEM CHARACTERIZED BY PAIN, SWELLING, AND SKIN CHANGES. AFFECT ANY BODY PART

3 An injury that does not follow the normal healing path It does not depend on the magnitude of the injury Sympathetic nervous system responds abnormally rule out other possibilities DVT CTSMI MI Tumor DDD SYMPATHETIC INCREASE TEMPERATURE INCREASE BLOOD PRESSURE, STRENGTHENS THE PROTECTIVE FUNCTIONS INCREASES MUSCLE METABOLISM INCREASES BONE CIRCULATION PARASYMPATHETIC

4 PAIN IN CRPS PAIN constant, burning, stabbing (causalgia) relentless, allodynia, hyperpathic SPASMS blood vessels, muscles dystopia, weakness INFLAMMATION color changes, swelling, decrease mobility PSYCHOLOGICAL insomnia, emotional, depression, irritability agitation PAIN IN CRPS HYPERPATHIA UNMYELINATED C THERMORECEPTORS ALLODYNIA MYELINATED A BETA BURNING PAIN UNMYELINATED CHEMORECEPTORS CAUSALGIA SHORT BETWEEN MYELINATED AND UNMYELINATED FIBERS

5 TYPE I RSD SUDECK S ATROPHY ALGONURODYSTROPHY NO NERVE DAMAGE A TRIGGERED TISSUE INJURY CAUSALGIA TYPE II OBVIOUS NERVE DAMAGE TRAUMA CEREBRAL LESIONS CAD, MI CVA, HEMIPLEGIA, PARALYSIS RADIATION REPEATIVE MOTION SURGERY IMMOBILIZATION NO CAUSE

6 BURNING PAIN SKIN SENSITIVITY CHANGE IN SKIN TEMP SYMPTOMS CHANGE IN SKIN COLOR CHANGE IN TEXTURE CHANGE IN HAIR AND NAIL GROWTH CHANGE IN MOVEMENT DEPRESSION ANXIETY WIND UP PATHOPHYSIOLOGY CNS SENSITIZATION NMDA CYTOKINASE RELEASE GLUTAMATE NEUROGENIC SYMPATHETIC AFFERENT COUPLING ADRENORECEPTOR GLIAL CELL

7 CORTICAL PATHOPHYSIOLOGY OXIDATIVE CHANGES IMMUNE RESPONSE INFLAMMATORY RESPONSE CRPS? DISTRUBANCE OF THE ANS NEUROPATHIC PAIN SYNDROME DIABETIC NEUROPATHY POSTHERPETIC NEURALGIA AIDS NEUROPATHY SHOULDER HAND SYNDROME MS

8 ANY AGE SUSCEPTIBILITY 3 TIMES GREATER IN FEMALES YOUNG ADUTLTS 30% CIGARETTE SMOKERS GENETIC INCIDENCE 2 5% PERIPHERAL NERVE INJURY 13 70% HEMIPLEGIA 1 2% BONE FX

9 BURNING SYMPTOMS ELECTRICAL SENSATIONS SHOOTIN PAIN MUSCLE SPASMS LOCAL SWELLING HYDROSIS TEMP CHANGES LOCAL SWELLING HYDROSIS TEMP CHANGES JOINT TENDERNESS BONE CHANGES SYMPTOMS SOFTENING AND THINNING OF BONES RESTRICTED MOVEMENT

10 STAGE I SEVERE BURNING PAIN MUSCLE SPASMS JOINT STIFFNESS RESTRICTED MOBILITY RAPID HAIR GROWTH VASOSPASMS TEMP AND COLOR CHANGES DYSTROPIC STAGE II SWELLING SPREADS DECREASED HAIR GROWTH NAILS CRACKED,BRITTLED, GROOVED,SPOTTY OSTEOPORSIS JOINTS THICKEN MUSCLE ATROPHY INFECTIONS PAIN

11 ATROPHIC STAGE STAGE III IRREVERSIBLE CHANGES CONSTANT P[AIN MARKED MUSCLE ATROPHY SEVERE MOBILITY LOSS CONTRACTURES BONE SOFTENING /THINNING STAGE IV IMMUNE SYSTEM FAILURE DECREASED HELPER T CELLS INCREASED KILLER T CELLS RTHOSTATIC HYPOTENSION INTRACTABLE EDEMA ULCERATIVE SKIN LESIONS MI/ STROKES INCEASED CANCER AND SUICIDE EXHUSTED SYMPATHETIC AND IMMUNE SYSTEM

12 DIAGNOSIS SPONTANEOUS PAIN 80 % HAVE TEMP DIFFRENCES ALLODYNIA EDEMA DIAGNOSIS OF EXCLUSION TYPES DIFFER ONLY IN NATURE IASP CRITERIA THE PRESENCE OF AN INITIATING NOXIOUS EVENT THE IMMIBILIZATION OF A LIMB CONTINUATION OF PAIN, ALLODYNIA, HYPERALGESIA EVIDENCE AT SOMETIME OF EDEMA, CHANGE IN BLOOD FLOWW, SUDOMOTOR CHANGES DIAGNOSIS OF EXCLUSION SENSITIVITY % SPECIFITY 35 55%

13 TESTS DIAGNOSIS OF EXCLUSION DIAGNOSIS OF SYMPTOOMS X RAY THERMOGRAPHY ELECTRODIAGNOSTICS SYMPTHETIC BLOCKS SWEAT TEST SOME PTS IMPROVE WITHOUT TREATMENT TESTS Triple Phase Bone scan Thermography Diagnostic Blocks Infrared Thermal Imaging QST quantitative thermal sensory evoked test Not valuable EMG/NCV, CT Scan, MRI

14 NSAID OF LIMITED USE PHYSICAL THERAPY PSYCHOTHERAPY SYMPATHETIC BLOCKS MEDICATIONS SURGICAL SCS INTRATHECAL PUMPS AVOID INACTIVITY TREATMENTS TREATMENTS MIRROR BOX TRERAPY AVOID ICE CONSERVATIVE USAGE OF NARCOTICS BUPRE NORPHINE ANTIDEPRESSANTS ANTICONVULSANTS PHYSICAL TX PARFIN,HYDRO AND HYPEROSMOLAR TREATMENTS

15 TREATMENTS PROPRIOTHERAPY MUSCLE RELAXANTS MANNITOL CONSERVATIVE USE OF BENZODIAZEPINE KLONIPIN ALPHA BLOCKERS PHENOXYBENZAMINE CLONIDINE PATCH Rational polypharmacy TREATMENTS Drugs will no completely prevent the need for abortive/rescue agents Mixed evidence that pts are unique Traditional agents Tramadol, mexiletine, methadone, Psychological interventions relaxation training, biofeedback, cognitive changes Centrally mediated

16 TREATMENTS BOTULIUM TOXIN KETAMINE NMDA BLOCKING INFUSION COMA CONCLUSION CRPS: complex form of neuropathic pain associated with hyperpathia, neurovasuclar,instability, neuroinflammation and limbic system dysfunction triggered by stimulation of neurovascular thermorecepetors c fibers sensitized to norepiephine this afferent sensory impulse leads to CRPS Early stages of up regulation super sensitivity Chronic stages shows dysfunctional of the system

17 ACCURATE DIAGNOSIS CONCLUSION EARLY TREATMENT PSYCHOLOGICAL SUPPORT 1 Crps both sympathetically independent pain And sympathetically maintained pain RF controversial Ablative controversial Stepwise progression for treatments