Introduction Algonurodystrophy Algodystrophy Sudek atrophy Shoulder hand syndrome Complex...
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IntroductionIntroduction AlgonurodystrophyAlgonurodystrophy AlgodystrophyAlgodystrophy Sudek atrophySudek atrophy Shoulder hand syndromeShoulder hand syndrome Complex regional syndromeComplex regional syndrome sympathetically mediated pain sympathetically mediated pain
syndrome( SMP)syndrome( SMP)
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What is CRPS What is CRPS
CRPS (CRPS (Chronic regional pain syndromeChronic regional pain syndrome)is a )is a debilitating neurologic syndrome , ‘ follows a debilitating neurologic syndrome , ‘ follows a musculoskeletal trauma :musculoskeletal trauma :
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PathogenesisPathogenesis A- original injury A- original injury
initiate a pain in pulseinitiate a pain in pulse
which is carried fromwhich is carried from
sensory nerves to the to sensory nerves to the to
the central nervousthe central nervous
systemsystem
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PathogenesisPathogenesis B-pain impulse in turn B-pain impulse in turn
trigger an impulse in the trigger an impulse in the
sympathetic nervous sympathetic nervous
system which return tosystem which return to
original area of injuryoriginal area of injury
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PathogenesisPathogenesis C- Sympathetic impulseC- Sympathetic impulse
trigger the inflammatorytrigger the inflammatory
response causing the vesselsresponse causing the vessels
to dilate . This leads to to dilate . This leads to
swelling an increased painswelling an increased pain
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PathogenesisPathogenesis D- Pain trigger anotherD- Pain trigger another
impulse establishing a impulse establishing a
cycle of pain and cycle of pain and
swellingswelling
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Epidemiology Epidemiology
Common in younger adultsCommon in younger adultsMean 41.8 years Mean 41.8 years 2.3 to 3 times more frequent in females than 2.3 to 3 times more frequent in females than malesmalesUsually involves a single limb in the early Usually involves a single limb in the early stagestage
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Causes of RSDSCauses of RSDS No clear etiology in 25-35%. No clear etiology in 25-35%. Trauma (about 60-65% of cases), Trauma (about 60-65% of cases), Treatment with antituberculous drugs or Treatment with antituberculous drugs or
phenobarbitalphenobarbital Atypical causes such as pregnancy or Atypical causes such as pregnancy or
postpartum causes, diabetes mellitus, postpartum causes, diabetes mellitus, malignant tumors, parkinsonism or other malignant tumors, parkinsonism or other CNS disorders(stroke, hemiplegia)CNS disorders(stroke, hemiplegia)
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Statistically significant associations Statistically significant associations
Cigarette smoking Cigarette smoking Patients frequently show high Patients frequently show high
scores on schizophrenia or scores on schizophrenia or depression scales..depression scales..
wartime casualties.wartime casualties.
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Clinical Aspects of CRPSClinical Aspects of CRPS
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Sensory Changes in CRPSSensory Changes in CRPS
AllodyniaAllodynia(Increased sensitivity to a nonpainful (Increased sensitivity to a nonpainful sensory stimulation)sensory stimulation)
Hyperalgesia Hyperalgesia (Abnormally exaggerated subjective (Abnormally exaggerated subjective response to painful stimuli )response to painful stimuli )
HyperesthesiaHyperesthesia Pain disproportionate to any inciting eventPain disproportionate to any inciting event
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Autonomic Signs in CRPSAutonomic Signs in CRPS
EdemaEdema Swelling in limbSwelling in limb Color changeColor change TemperatureTemperature (cooler or warmer)(cooler or warmer)
Sweating Sweating
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Swelling in limb Swelling in limb
Diffuse Diffuse
Nonpitting or pittingNonpitting or pitting Occur in distal part of Occur in distal part of
limblimb Don’t occur in hip or Don’t occur in hip or
shouldershoulder
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Trophic ChangesTrophic Changes
Altered nail growthAltered nail growth
Altered hair growthAltered hair growth
Skin changes Skin changes
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Abnormal Sweating Abnormal Sweating
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Skin changesSkin changes
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Psychological ChangesPsychological Changes
FearFear
AnxietyAnxiety
AngerAnger
DepressionDepression
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Neurologic changesNeurologic changes
hyperesthesia (glove and stocking distribution)hyperesthesia (glove and stocking distribution)
in coordinationin coordination tremortremor muscle spasms muscle spasms Limited range of movementLimited range of movement
and paresisand paresis
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Spread of CRPSSpread of CRPS
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Stages of RSD / CRPSStages of RSD / CRPSSTAGE I STAGE I Onset of severe, Onset of severe, pain limited to pain limited to
the site of injurythe site of injury Increased Increased sensitivity of skinsensitivity of skin to to
touch and light pressure touch and light pressure (hyperasthesia).(hyperasthesia).
Localized swellingLocalized swelling Muscle crampsMuscle cramps Stiffness and limited mobilityStiffness and limited mobility At onset,At onset, skin skin is usually is usually warm, warm,
red and dryred and dry and then it may and then it may change to a blue (cyanotic) in change to a blue (cyanotic) in appearance and become cold appearance and become cold and sweaty.and sweaty.
Increased Increased sweatingsweating (hyperhydrosis).(hyperhydrosis).
. .
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Stages of RSD / CRPSStages of RSD / CRPSSTAGE IISTAGE II
PainPain becomes even more becomes even more severesevere and more and more diffusediffuse..
Swelling tends to spreadSwelling tends to spread and it and it may change from a soft to hard may change from a soft to hard (brawny) type.(brawny) type.
Hair may become coarse then Hair may become coarse then scant, nails may grow faster scant, nails may grow faster then grow slower and become then grow slower and become brittle, cracked and heavily brittle, cracked and heavily grooved.grooved.
Spotty wasting of bone Spotty wasting of bone ((osteoporosisosteoporosis) occurs early but ) occurs early but may become severe and diffusemay become severe and diffuse
Muscle wasting Muscle wasting beginsbegins . .
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Stages of RSD / CRPSStages of RSD / CRPSSTAGE IIISTAGE III
Marked wasting of tissue Marked wasting of tissue ((atrophicatrophic) eventually ) eventually become irreversible.become irreversible.
For many patients the For many patients the painpain becomes intractable becomes intractable and may and may involve the involve the entire limb.entire limb.
A A small percentagesmall percentage of of patients have developed patients have developed generalized RSD affecting generalized RSD affecting the entire body. the entire body.
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patchy or diffuse patchy or diffuse
osteopenia of theosteopenia of the
underlying bones underlying bones
X Ray finding
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Bone scanning Bone scanning
Three-phase technetium Tc 99m Three-phase technetium Tc 99m commonly is used.commonly is used.
Scan findings are considered Scan findings are considered positive if flow is asymmetric in positive if flow is asymmetric in phase 1, 2, and/or 3.phase 1, 2, and/or 3.
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bone scintography
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Imaging : Imaging : bone scintographybone scintography
Immediate Immediate Flow phaseFlow phase Pooling phasePooling phase
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MRIMRI Non spesific soft tissue changeNon spesific soft tissue change Low signal in T1-T2Low signal in T1-T2
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Differential DiagnosesDifferential Diagnoses
Diabetic and small-fiber peripheral Diabetic and small-fiber peripheral neuropathiesneuropathiesEntrapment neuropathiesEntrapment neuropathiesThoracic outlet syndromeThoracic outlet syndromeDiscogenic diseaseDiscogenic diseaseDeep vein thrombosisDeep vein thrombosisCellulitis Cellulitis Vascular insufficiencyVascular insufficiencyLymphedemaLymphedema
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TreatmentTreatment
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physical therapies physical therapies Active and passive range of motion Active and passive range of motion
exercises exercises Transcutaneous electrical nerve Transcutaneous electrical nerve
stimulation (TENS) stimulation (TENS) Desensitization techniques Desensitization techniques
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Pharmacologic agents Pharmacologic agents SteroidSteroid Antidepressants: These drugs modulate Antidepressants: These drugs modulate
sympathetic activity and provide analgesia (eg, sympathetic activity and provide analgesia (eg, amitriptyline). amitriptyline).
Anticonvulsants (eg, phenytoin, carbamazepine) Anticonvulsants (eg, phenytoin, carbamazepine) Membrane stabilizing agents (eg, lidocaine, Membrane stabilizing agents (eg, lidocaine,
tocainide) tocainide) Adrenergic compounds (clonidine)Adrenergic compounds (clonidine) Calcium channel blockers Calcium channel blockers Intranasal calcitoninIntranasal calcitonin IV alendronate (bisphosphonate)IV alendronate (bisphosphonate)
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Surgical Care Surgical Care
Chemical sympathectomyChemical sympathectomy Surgical sympathectomySurgical sympathectomy Implantable electrical stimulatorsImplantable electrical stimulators
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PrognosisPrognosis weakness of the extremity resulting from this weakness of the extremity resulting from this
condition is seen in almost 50-65% of patients, condition is seen in almost 50-65% of patients, 18-24 months following initial diagnosis18-24 months following initial diagnosis
Full range of movement accompanying the Full range of movement accompanying the above aggressive therapies is seen in 60-74% above aggressive therapies is seen in 60-74% of patients.of patients.
Prolonged morbidity is observed in about Prolonged morbidity is observed in about 50% of patients with psychiatric diathesis50% of patients with psychiatric diathesis
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