Complex regional

pain syndromes
Introduction
 Mitchell –causalgia (1872)
 Paul sudeck – identified symptoms
 Evans (1946)-RSD
 Bonica-I,II,III RSD
 IASP-complex regional pain syndromes
Complex regional pain syndrome
Type 1
 Preceded by noxious event

 Sensory, motor and autonomic symptoms

Neurologic clinics 1998

Complex regional pain syndrome
type 2
 Presence of partial injury to a major
peripheral nerve

 Localized post-traumatic neuropathies

Neurologic clinics 1998

Sympathetically maintained pain
 Pain that is maintained by sympathetic
efferent innervation or by circulating
catecholamines

Spinal cord 2003

Clinical characteristics
 Pain and other sensory symptoms with
strong aversive character
 Autonomic dysfunction
 Inflammatory, trophic and bone
metabolism changes
 Musculoskeletal abnormalities
 Psychological aspects of CRPS
CRPS Type 1
 Pain usually burning type ,exacerbated by
stress or movement
 Alteration of skin temperature and color
 Edema

Physical Medicine and Rehabilitation,1996

Associated symptoms
 Atrophy of the skin ,nails and tissues
alterations in hair growth and loss of joint
mobility
 SMP may be seen
CRPS Type II
 Spontaneous pain described as burning or
shooting
 Allodynia and hyperalgesia
 Abnormalities in blood flow
 Edema
 Impairment of motor function

Physical Medicine and Rehabilitation,1996

Associated symptoms
 Atrophy of the skin ,nails and tissues
alterations in hair growth and loss of joint
mobility
 SMP may be seen
 Affective disorder appear
Criteria for complex regional pain
syndrome, from the international
association for the study of pain
 Criteria:-
 The presence of an initiating noxious
event or a cause of immobilization
 Continuing pain, allodynia or hyperalgesia
in which the pain is disproportionate to the
inciting event
Journal of hand therapy,2000
 Evidence at some time of edema changes
in the skin blood flow or abnormal
sudomotor activity in the region of the pain

Journal of Hand Therapy,2000

Criteria for diagnosis
 Burning pain
 Increased skin sensitivity
 Changes in skin temperature
 Changes in skin color
 Changes in skin texture
 Changes in nail and hair growth
 Swelling and stiffness

Spinal Cord,2005
Pathophysiological mechanisms
 Role of sympathetic system: there is a
functional inhibition of the cutaneous
sympathetic vasoconstrictor activity
,leading to cutaneous vasodilation
 There is decreased blood flow and
decreased skin temperature
 Unilateral sweating abnormalities
 Sympathetically maintained pain

Spinal cord 2003

Peripheral inflammation
 Paul sudeck postulated an exaggerated
inflammatory response in CRPS
 Peripheral neurogenic inflammatory
process

Spinal cord 2003

Central nervous system
 Centrally located thermoregulatory
dysfunction
 There is cortical reorganization in the
primary somatosensory cortex
 This is related to the intensity of pain
 Shrinkage of the region representing the
hand
 Subcortical and spinal mechanisms may
contribute to sensitization

 Neurology,2003
Genetic considerations
 Human leucocyte antigen II molecules
 Cytokine profile

Spinal cord 2003

Diagnosis
 Radiographic studies
 Vasomotor testing:-Thermography
 Peripheral blood flow:-Plethysmography,
laser doppler ,infrared thermometry

Physical Medicine and Rehabilitation,1996

Sudomotor testing
 Sudomotor axon reflex testing
 Resting sweating output
Sensory testing
 Cutaneous hyperalgesia
 Joint motion and strength evaluation
Sympatholytic testing
 Stellate ganglion blocks
 Phentolamine test
 Epidural injection
 Controlled use of oral sympatholytic drugs
Psychological testing
 McGill pain questionnaire
 VAS
 Minnesota Multiphasic Personality
Inventory
Pharmacological intervention
 NSAID’s
 Opioids
 Tricyclic antidepressants
 Sodium blocking agents
 GABA agonists
 NMDA receptor agonists
Arch Phys Med Rehabil,2003
Algorithm
STEP A
Rest,elevation,cooling
Analgesics
Gentle physical therapy
Psychological support and therapy
Pain specialist
Pain clinic
Interventional
Reduction of and interdisciplinary
pain and edema at rest
no
pain management

yes
no
Reduction of ongoing
STEP B increase of activity,
Pain and hyperalgesia
active physical therapy,analgesics,
after few weeks
Psychological therapy and support
Principles of physical management

 Prevention
 Early diagnosis
 Multidisciplinary team management
 Prevention of late complications
 Objective outcome measuement
Therapeutic intervention
recognize the signs and symptoms

Evaluation
Pain
 TENS
 Active exercise
 Thermal agents and cryotherapy
 Vibration
 Splinting
 CPM
Hypersensitivity or allodynia
 Desensitization
 Vibation
 Massage
 Active exercise
 Splinting
Other techniques
 Stress loading
 Multidisciplinary approach
Edema
 Elevation
 Massage
 Active exercise
 Compression
Dystonia and joint stiffness
 EMG biofeedback and activities
 Active exercises
 Splinting
 CPM
 Passive range of motion
 Modalities
 Stretching
 ultrasound
Vasomotor instability
 Low impact aerobic activity
 Thermal biofeedback
Vasoconstriction
 Thermal agents
 Massage
 Ultrasound
 TENS
 Patient education
vasodilation
 Cryotherapy
 TENS
 Symathetic trunk mobilization
 Patient education
 Remote cooling