Complex Complex Regional Pain Regional Pain

SyndromeSyndromeBy: Jessi Ann Goodwin and By: Jessi Ann Goodwin and

Lydia NixonLydia Nixon

Pathology defined:Pathology defined: Complex Regional Pain Syndrome Complex Regional Pain Syndrome

(CRPS) is also known as Reflex (CRPS) is also known as Reflex Sympathetic Dystrophy (RSD), Sympathetic Dystrophy (RSD), Shoulder-Hand Syndrome, Sudeck’s Shoulder-Hand Syndrome, Sudeck’s Atrophy, and Causalgia Atrophy, and Causalgia

Pathology defined, cont..Pathology defined, cont.. Chronic pain syndrome was first Chronic pain syndrome was first

described in 1864.described in 1864. Persistent burning pain accompanied Persistent burning pain accompanied

by certain abnormalities that occur in by certain abnormalities that occur in the same area as the painthe same area as the pain

Essentially this condition is related to Essentially this condition is related to changes in the sympathetic nervous changes in the sympathetic nervous system.system.

CRPS Type I and IICRPS Type I and II Type I is a syndrome that develops after Type I is a syndrome that develops after

an initiating noxious event affecting tissue an initiating noxious event affecting tissue other than nerve tissue; known as RSDother than nerve tissue; known as RSD

Minor injuries such as a sprain or fall are Minor injuries such as a sprain or fall are frequent causes of RSDfrequent causes of RSD

Shoulder-Hand Syndrome characterized Shoulder-Hand Syndrome characterized by pain and limited motion in the affected by pain and limited motion in the affected armarm

Type II is a syndrome that develops after Type II is a syndrome that develops after a nerve injury; known as causalgiaa nerve injury; known as causalgia

Incidence:Incidence: CRPS is 2-3 times more frequent in CRPS is 2-3 times more frequent in

females than in malesfemales than in males Mean age at diagnosis is 42 yearsMean age at diagnosis is 42 years Children as young as 3 years can get Children as young as 3 years can get

CRPSCRPS

Signs and Symptoms:Signs and Symptoms: Early on, pain is much greater than Early on, pain is much greater than

expected for the degree of tissue expected for the degree of tissue traumatrauma

Pain spreads from a localized to a Pain spreads from a localized to a regional distributionregional distribution

This is not a psychological syndromeThis is not a psychological syndrome RSD has 3 different stagesRSD has 3 different stages

STAGE I: ACUTE STAGE I: ACUTE INFLAMMATIONINFLAMMATION

Begins up to 10 days following Begins up to 10 days following injury; lasts 3-6 monthsinjury; lasts 3-6 months

Pain: more severe than expected; increased by Pain: more severe than expected; increased by dependent position, physical contact, or dependent position, physical contact, or emotional disturbancesemotional disturbances

Edema: soft and localizedEdema: soft and localized Vasomotor/thermal changes: affected limb Vasomotor/thermal changes: affected limb

warmerwarmer Skin: increased hair and nail growthSkin: increased hair and nail growth

STAGE II: DYSTROPHICSTAGE II: DYSTROPHIC Occurs 3-6 months after onset of pain, Occurs 3-6 months after onset of pain,

lasts about 6 monthslasts about 6 months Pain: worsens; constant burning and achingPain: worsens; constant burning and aching Edema: becomes hard, causing joint stiffnessEdema: becomes hard, causing joint stiffness Vasomotor/thermal changes: neither warm or Vasomotor/thermal changes: neither warm or

coldcold Skin: thin, glossy, cool (vasoconstriction), Skin: thin, glossy, cool (vasoconstriction),

sweaty, thin, rigid nailssweaty, thin, rigid nails X-rays reveal osteoporosisX-rays reveal osteoporosis

STAGE III: ATROPHICSTAGE III: ATROPHIC Begins about 6-12 months after onset; Begins about 6-12 months after onset;

may last for years or may resolve and may last for years or may resolve and recurrecur

Pain: Spreads proximally, occasionally to entire skin Pain: Spreads proximally, occasionally to entire skin surface or plateaussurface or plateaus

Edema: continues to hardenEdema: continues to harden Vasomotor/thermal changes: SNS regulation Vasomotor/thermal changes: SNS regulation

decreased on affected extremity, affected limb coolerdecreased on affected extremity, affected limb cooler Skin: thin, shiny, cyanotic, drySkin: thin, shiny, cyanotic, dry

Fascia thickened, contracture may occurFascia thickened, contracture may occur X-rays demonstrate bony demineralization & ankylosisX-rays demonstrate bony demineralization & ankylosis

MEDICAL MEDICAL INTERVENTION:INTERVENTION:

Treatments include medication for underlying Treatments include medication for underlying cause, Physical Therapy, psychological cause, Physical Therapy, psychological support, sympathetic nerve blocks, and/or support, sympathetic nerve blocks, and/or spinal cord stimulation.spinal cord stimulation.

Although external TENS units have been Although external TENS units have been minimally effective, implanted dorsal column minimally effective, implanted dorsal column stimulation has been shown to decrease stimulation has been shown to decrease intensity and perception of pain.intensity and perception of pain.

Amputation may be considered for persistent Amputation may be considered for persistent pain or if recurrence of pain is common pain or if recurrence of pain is common

PHYSICAL THERAPY PHYSICAL THERAPY TREATMENT:TREATMENT:

Physical Therapy is indicated; treatments Physical Therapy is indicated; treatments and goals for CRPS include:and goals for CRPS include: Patient educationPatient education Normal use of involved extremityNormal use of involved extremity Modalities, TENS (electrical stimulation) for pain Modalities, TENS (electrical stimulation) for pain

controlcontrol Heat or ice may be used but avoid extreme Heat or ice may be used but avoid extreme

temperaturestemperatures Weight bearing exercisesWeight bearing exercises Aquatic therapyAquatic therapy MassageMassage