Reflex Sympathetic Dystrophy/ Chronic Regional Pain

Syndrome

OT 5291: Physiological Module

Natalie Cathcart, Melissa Chang, Colleen Day, Leslie Pottorf,

Jackie Webel

Definition/ Symptoms

Main Symptoms:– Pain– Swelling– Stiffness

– Discoloration

Other Symptoms:– Sudomotor changes

(sweating)– Temperature changes– Trophic changes– Osseous

demineralization– Vasomotor instability– Pilomotor activity (goose

bumps)

“Painful complications that occur after an injury and progress over time. The pain exceeds expectations in magnitude and duration”

(Trombly & Radomski, 2002)

Causes/ Types• Injury/Stress to the

Sympathetic Nerves:– Trauma (Acute or

Chronic)– Heart Disease– Spinal Cord Disorders– Cerebral Lesions– Surgery– Infections– Repetitive-Motion

Disorder (Williams,1995)

• Types: – Type I caused by noxious

event; pain that is not limited to the territory of a single peripheral nerve and is disproportional to the inciting noxious event

– Type II same as Type I except develops after a nerve injury

– Type III otherwise not classified

(Trombly & Radomski, 2002)

Examples of CRPS

• RSD Photos

Case Study – Mrs. P(erserverance)

P• Single 49 y/o athletic

woman • Dominant right hand• Comminuted displaced

right distal radius fracture• Significant pain, edema

and increased autonomic signs

• Digital P/AROM significantly limited

• Nauseous when looking at hand

E• Family assisting w/ ADLs

& self-care• Lives aloneO• Computer software

manager• Enjoys vacationing and

kayaking

OP Issues and GoalsOP Issues• Disruption of independent living, job performance, and

job-related travel• Difficulty sleeping and completing self-care due to pain• Significant edema decreases ROM• Risk of CRPS due to decreased use of UE and increased

autonomic signsGoals• Mrs. P will utilize effective pain management strategies

that will facilitate functional restoration• Mrs. P will increase spontaneous use of UE in daily

activity• Mrs. P will increase P/AROM to regain typing skills to

return to work

Frame of Reference• Biomechanical:

– Remediates deficits in ROM and strength; decreases edema

– Body needs to be stressed in order to restore and regain strength and ROM

– Gradually increase weight bearing or level of aerobic exercise

• Application to Stress Loading:– Steady progression from very gentle movements to

gentle weight bearing increases stress placed on the body

– Overload on efferent sympathetic system will lead to desensitization to pain and functional restoration

(Harden, 2001)

Assessment• Principal areas to assess: AROM,

edema, pain/sensation, psychosocial factors, strength, coordination dexterity, skin/vasomotor changes, and functional use of extremity.– AROM is measured with a goniometer– Edema is gauged with a volumeter– Comprehensive Pain Evaluation Questionnaire

• Measures Activity Inference, Pain Intensity, Social Support(s), Emotional Distress (covers P, E, & O factors)

Assessment (continued)– Symptom Checklist

• Client identifies areas of pain based on 9 descriptors by circling palmar and/or dorsal surface of right and or left hand.

• Eight subjective questions follow to describe level and duration of pain resulting in functional deficits

– Psychosocial Evaluation• Assessment of pain coping skills and drug abuse

potential • Stress, depression, and anxiety are known causes

of exacerbation of this disease• The potential for committing suicide needs to be

assessed! (www.rsdfoundation.org)

(Williams, 1995; rsdfoundation.org, 2005)

Treatment/ Intervention

• As CRPS varies in severity and duration, the OT must demonstrate enthusiasm, support, and encouragement of the patient during the treatment process.

• The patient must be involved in integration of treatment techniques into all daily activities to achieve optimal function of the affected extremity.

Pain Management• Closely monitoring pain levels is key to

prevention and management– Early diagnosis likely to lead to better outcomes

• Self-protection or immobilization to avoid pain is a risk factor– Best to learn to use extremity actively in pain-free way

• Management Strategies:– Close communication with medical experts

specializing in pain management– Medications– Stellate ganglion blocks– Trancutaneous electrical nerve stimulation (TENS)

(Trombly & Radomski, 2002; Mayo Clinic, 2005)

Stress Loading Intervention

• Taps into the body’s ability to adapt in response to demand. (Active sustained exercise requiring forceful use of the entire extremity, with minimal motion of painful joints.)

• Used with patients who are at risk for CRPS to change sympathetic efferent activity.

• Two components of stress loading are “scrubbing the floor” and a weighted briefcase, done with the extremity in extension.

Stress Loading (continued)

• Goal: Achieve compressive loading and distraction of the upper extremity.

– If actually scrubbing cannot be tolerated, substitute comfortable weight-bearing exercises.

– If tolerated, frequency and duration of scrub and carry are upgraded.

– Overload is needed to achieve a training effect, and exercise must be sufficient intensity, duration, and frequency to achieve it.

(Carlson, 1996; Trombly & Radomski, 2002)

Splint option #1: Resting Hand Splint

• Goals: Minimize ROM & strength losses, manage edema, & provide pain mgmt

• Can initially provide rest, reduce pain, & relieve muscle spasm

• Splint in comfortable position & avoid causing more pain

• Wearing schedule: wear at all times except during therapy, hygiene, & ADLs. Ct. should wean off as pain reduces & ROM improves

(Coppard & Lohman, 2001)

Splint option #2: Wrist Immobilization

• Goals: pain relief, muscle spasm relief, regain functional resting wrist position

• Can decrease wrist pain or inflammation, provide support, enhance digital function, prevent wrist deformity, minimize pressure on median nerve, & minimize tension on involved structures

• Wearing schedule: wear during all functional activities

• Circumferential wrist splint may be used to help avoid pressure on the edges & edema problems

(Coppard & Lohman, 2001)

ReferencesCarlson, L. (1996). The treatment of reflex sympathetic dystrophy through stress loading. Physical

Disabilities: Special Interest Section Newsletter, 19(2), 1-4.

Coppard, M. & Lohman, H. (2001). Introduction to Splinting (2nd Ed.). St. Louis: Mosby, Inc.

Harden, R.N. (2001) Complex Regional Pain Syndrome. British Journal of Anaesthesia. 87(1): 99-106.

Harvard Medical School Pain Management Center. Stellate Ganglion Blocks. Retrieved September 27, 2005. http://www.hmcnet.harvard.edu/ brighampain/faqs/stellate.html

Mayo Clinic Medical Services. Complex Regional Pain Syndrome. Retrieved September 27, 2005. http://www.mayoclinic.com/invoke.cfm?objectid= 8F3237C2-D7C0-4063-AE87DC86D78085FE&dsection=7

RSD Foundation. Reflex Sympathetic Dystrophy. Retrieved September 25, 2005. www.rsdfoundation.org

Spine Universe. Transcutaneous Electrical Nerve Stimulation (TENS). Retrieved September 27, 2005. http://www.spineuniverse.com/ displayarticle.php/article1694.html

Trombly, C. & Radomski, M. (2002). Occupational Therapy for Physical Dysfunction (5th Ed.) Baltimore: Lippincott Williams & Wilkins.

Williams, R. (1995). Reflex Sympathetic Dystrophy. Bethesda, MD: American Occupational Therapy Association, Inc.