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Diagnosis and Treatment Options of RSD/CRPS. Srinivasa N. Raja, MD Director of Pain Research Johns Hopkins University School of Medicine. Introduction. RSD/CRPS is a chronic neurologic syndrome characterized by pain of varying intensity

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diagnosis and treatment options of rsd crps

Diagnosis and Treatment Options of RSD/CRPS

Srinivasa N. Raja, MD

Director of Pain Research

Johns Hopkins University

School of Medicine

introduction
Introduction
  • RSD/CRPS is a chronic neurologic syndrome characterized by pain of varying intensity
  • Early diagnosis and appropriate treatment are essential to avoid disabling pain
  • RSD/CRPS is often under-diagnosed and under-treated by the medical community
what is reflex sympathetic dystrophy syndrome
What Is Reflex Sympathetic Dystrophy Syndrome?
  • Reflex sympathetic dystrophy syndrome (RSD) is a debilitating neurologic syndrome characterized by
    • Pain and hypersensitivity
    • Vasomotor skin changes
    • Functional impairment
    • Various degrees of trophic change
  • RSD generally follows a musculoskeletal trauma

Bogduk N. Current Opinions in Anesthesiology. 2000;14:541-546.

challenges
Challenges
  • Natural course and pathophysiology remain elusive1
  • Diagnosis made by exclusion of other causes2
  • Therapies remain controversial3
  • Underdiagnosed and undertreated
  • Significant morbidity and loss of quality of life

1. Jänig W. In: Harden , Baron Janig, eds. Complex regional Pain Syndrome, Progress in Pain Research and Management. 2001: 3-15.

2. Bogduk N. Current Opinions in Anesthesiology. 2000;14:541-546.

3. Raja SN et al. Anesthesiology. 2002;96:1254-1260.

terminology rsd vs crps
Terminology: RSD vs CRPS
  • RSD = traditional term
  • Complex regional pain syndrome
  • (CRPS) = more comprehensive term
    • Includes disorders not related to sympathetic nervous system dysfunction
  • CRPS I = RSD
  • CRPS II = causalgia (involves nerve injury)

Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001: 388-411.

name change to crps
Name Change to CRPS

Goals: standardized, reliable diagnostic criteria and decision rules

  • Allow generalization
  • Make appropriate treatment selection
  • Identify reproducible research samples

Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001:388-411.

epidemiology
Epidemiology

Age – common in younger adults

  • Mean 41.8 years
  • Mean age at time of injury 37.7 years

Mean duration of symptoms before pain center evaluation = 30 months

2.3 to 3 times more frequent in females than males1

Usually involves a single limb in the early stage 2

1. Raja SN et al. Anesthesiology. 2002;96:1254-1260. 2. Galer BS et al. In: Loeser, ed. Bonica’s Management ofPain. 2001, 388-411.

clinical features
Clinical Features
  • Presence of an initiating noxious event or a cause of immobilization
  • Continuing pain
    • Allodynia: pain from a stimulus that does not normally provoke pain
    • Hyperalgesia: excessive sensitivity to pain
  • Pain disproportionate to any inciting event

Stanton-Hicks M et al. Pain. 1995;63:127-133. Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001; 388-411.

clinical features cont d
Clinical Features(cont’d)
  • History of edema, changes in skin blood flow, or abnormal sweating in the region of pain
  • Exclusion of medical conditions that would otherwise account for the degree of pain and dysfunction  

Stanton-Hicks M et al. Pain. 1995;63:127-133.Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001: 388-411.

checklist for the diagnosis of rsd history
Burning pain

Skin, sensitivity to touch

Skin, sensitivity to cold

Abnormal swelling

Abnormal hair growth

Abnormal nail growth

Abnormal sweating

Abnormal skin color changes

Abnormal skin temperature changes

Limited movement

Checklist for the Diagnosis of RSD: History

Bogduk N. Current Opinions in Anesthesiology. 2000;14:541-546.

checklist for the diagnosis of rsd crps examination
Mechanical allodynia

Hyperalgia to single pinprick

Summation to multiple pinprick

Cold allodynia

Abnormal swelling

Abnormal hair growth

Abnormal skin color changes

Abnormal skin temperature (> or < 1ْ C)

Limited range of movement

Motor neglect

Checklist for the Diagnosis of RSD/CRPS: Examination

Bogduk N. Current Opinions in Anesthesiology. 2000;14:541-546.

revised diagnostic criteria clinical presentation
Revised Diagnostic CriteriaClinical Presentation
  • Pain and sensory changes disproportionate to the injury in magnitude or duration
  • Patients should have at least one symptom in each of these categories and one sign in 2 or more categories
    • Sensory (hyperesthesia = increased sensitivity to a sensory stimulation)
    • Vasomotor (temperature or skin abnormalities)
    • Sudomotor (edema or sweating abnormalities)
    • Motor (decreased range of movement, weakness, tremor, or neglect)

1. Bruehl et al. Pain. 1999;81:147-154. 2. Harden et al. Pain. 1999;83:211-219.

.

differential diagnoses
Diabetic and small-fiber peripheral neuropathies

Entrapment neuropathies

Thoracic outlet syndrome

Discogenic disease

Deep vein thrombosis

Cellulitis

Vascular insufficiency

Lymphedema

Erythromelalgia

Differential Diagnoses

Raja SN et al. Anesthesiology. 2002;96:1254-1260.

psychological aspects
Psychological Aspects
  • Pain can cause symptoms of psychologic distress including
    • Anxiety
    • Depression
    • Fear
    • Anger

Raja SN et al. Anesthesiology. 2002;96:1254-1260.

treatment
Treatment

Goals

  • Rehabilitation
  • Pain management
  • Psychological treatment

Multidisciplinary

  • Physiotherapy
  • Medical
  • Psychological

Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.

rehabilitation clinical pathway
Physiotherapy + pain management + psychological therapies = sequential progression through the rehabilitation pathway

PT + OT crucial to patient’s progression

Therapist assesses patient’s motivation and helps set goals

Adequate analgesia, encouragement, and education of disease process

Rehabilitation: Clinical Pathway

Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.

rehabilitation general steps
Desensitization of the affected region

Mobilization, edema control, and isometric strengthening

Stress loading, isotonic strengthening, range of motion, postural normalization and aerobic conditioning

Vocational and functional rehabilitation

Rehabilitation: General Steps

Stanton-Hicks M et al. Clin J Pain. 1998;14:155-166.

pharmacalogic pain management
Most drugs used for neuropathic pain are used to treat RSD/CRPSPharmacalogic Pain Management
  • IV alendronate (bisphosphonate)
  • Topic dimethyl sulfoxide
  • Topical clonidine
  • IV bretylium
  • IV ketanserin
  • IV phentolamine
  • IV lidocaine
  • Intranasal calcitonin

Raja SN et al. Anesthesiology. 2002;96:1254-1260.

Kingery WS. Pain.1997;73:123-139

minimally invasive therapies
Minimally Invasive Therapies

Sympathetic, IV regional, and somatic nerve blocks

Patients with a sympathetic component to their pain (SMP) should receive nerve blocks

For patients without SMP, a somatic block or epidural infusion may be indicated to optimize analgesia for PT

Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.

more invasive therapies
More Invasive Therapies

Neuroaugmentation

Spinal cord stimulation

Intrathecal drug delivery

Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.

surgical therapies sympathectomy
Surgical Therapies: Sympathectomy
  • Controversial procedure
  • In carefully selected patients, may result in reduction in pain severity and disability
    • Patients with SMP who respond to selectivesympathetic blockade
  • Radiofrequency and neurolytic techniques are alternatives to a surgical sympathectomy

Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.

Bandyk DF et al. J Vasc Surg. 2002;35:269-277.

other therapies
Other Therapies
  • Behavioral modification
  • Psychiatric consultation
  • Complimentary and Alternative therapies

Acupuncture

Raja SN et al. Anesthesiology. 2002; 96:1254-1260.

prognosis
Prognosis
  • Difficult to predict
  • Earlier intervention may be more likely to be successful
  • Some patients experience reduced symptoms or apparently full recovery
  • Some patients continue to experience significant disability

Raja SN et al. Anesthesiology. 2002;96:1254-1260.

conclusions
Conclusions
  • RSD/CRPS is a chronic neurologic syndrome
  • Not all patients have the same set of symptoms
  • Early diagnosis and appropriate treatment is essential
  • Ideal treatment should be multidisciplinary
bibliography
Bibliography

Bandyk DF, Johnson BL, Kirkpatrick AF, Novotney ML, Back MR, Schmacht DC. Surgical sympathectomy for reflex sympathetic dystrophy syndromes. J Vasc Surg. 2002;35:269-277.

Bogduk N. Complex regional pain syndrome. Current Opinions in Anesthesiology. 2000;14:541-546.

Bruehl SP, Harden RN, Galer BS, et al. External validation of IASP diagnostic criteria for complex regional pain syndrome and proposed research diagnostic criteria. Internal Association for the Study of Pain. Pain. 1999;81:147-154.

Galer BS, Schwartz L, Allen RJ. In: Loeser, ed. Bonica’s Management of Pain. 2001: 388-411.

Harden RN, Bruehl SP, Galer BS, et al. Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive? Pain. 1999;83:211-219.

bibliography continued
Bibliography (continued)

Jänig W. CRPS-I and CRPS-II: A strategic view, In: Harden , Baron Jänig, eds. Complex regional Pain Syndrome, Progress in Pain Research and Management. 2001: 3-15.

Kingery WS. Pain. A critical review of controlled clinical trials for peripheral neuropathic pain and complex regional pain syndromes. 1997;73:123-139.

Raja SN , Grabow TS. Complex regional pain syndrome I (Reflex Sympathetic Dystrophy) Anesthesiology. 2002;96:1254-1260.

Stanton-Hicks M, Burton AW, Bruehl SP, et al. An updated interdisciplinary clinical pathway for CRPS: Report of an expert panel. Pain Practice. 2002;2:1-16.

Stanton-Hicks M, Jänig W, Hassenbusch S, et al. Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain. 1995;63:127-133

Stanton-Hicks M, Baron R, Boas R, et al. Complex Regional Pain Syndrome: guidelines for therapy. Clin J Pain. 1998;14:155-166.