RSD-REFLEX SYMPATHETIC DYSTROPHY

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1. MOHAMMAD AKEEL B.P.Th 3 rd year

2. WHAT IS RSD ?

3. DEFINITION- RSD A group of disorder may develop as a consequence of trauma affecting body parts, with or without an obious nerve lesion. *1 The trauma is sometimes relatively minor, but symptoms are out of proportion to the trauma. *2

4. CRPS(complex regional pain syndrome) consist of – Pain sensory abnormalities, abnormal blood flow & sweating, abnormalities in the motor system, & trophic changes in the structure of both superficial & deep tissues. *1

5. SYNONYMS- Sudeck's Atrophy Shoulder hand syndrome CRPS Caugalgia Algodystrophy Algoneurodystrophy Reflex Neurovascular Dystrophy Post-traumatic sympathetic dystrophy

6. History- John Bonica - term RSD, describes 3-stages Paul Sudeck - sugested symptoms of RSD,sudeck atrophy=bone loss asso . With RSD.

7. Classification- IASP NOMENCLATURE CRPS-1 CRPS-2.... causalgia

8. STAGES- There are generally 3- stages associated with RSD- *1 1.early/acute stage 2.Dystrophic 3.Atrophic

9. EPIDEMIOLOGY- 26/100,000 person/ years F>M (3X) *5 UE>LE ( usually distal part) U/L>B/L ( but may spread to other extremeties )

10. CAUSE- Idiopathic A variety of events can trigger the RSD, including: Trauma, Surgery Crush injury Human bite Nerve injury or lesion Entrapment neuropathy Breast cancer.

11. CLINICAL FEATURES-

12. Acute/early stage- Pain-burning/aching Skin-more sensitive Swelling-localised Temp.-increase 2-4’F than normal ROM-decrease x-ray- normal

13. 2. Dystrophic stage- Pain- worsen,burning Skin color -pale cynotic skin Swelling-hard temp.-lowered Muscle atrophy ROM-decrease Cessation of hair and nail growth Emotional changes- seculsion X-ray-Spotty osteoporosis

14. 3.Atrohic stage- Pain-spreads proximally & occasionally to entire body Swelling-hardening Severe muscle atrophy Fingernails & toes are atrophic Abnormal movement-tremor Contracture may developed Pericapsular fibrosis X-ray-significant osteoporosis

15. DEMOGRAPHIC DATA- Name- Age-40-60 Gender- F>M Occupation- Address C/C - burning pain c swelling...

16. HISTORY- Trauma (+) illness Past illness Medical/surgical PAIN HISTORY- Onset Location Type Duration Agrevating factor Relieving factor

17. O/E- * GBPD * Gait INSPECTION- PALPATION- Skin color Temp. Nail Tenderness Scar Swelling Swelling Tone Attitude of limb MOVEMENT- .

18. Neurovascular examination- Sensory Motor Vascular DTR – Special test-

19. D/D- * 6 Bony or soft tissue injury Peripheral neuropathy, nerve lesions Compartment syndrome Thoracic Outlet Syndrome (TOS)

20. Provisional Diagnosis- RSD=?

21. INVESTIGATION- CRPS diagnosis is mainly based on patient history, clinical examination, and supportive investigations. Some other test include- X-Ray- Shows, sign of osteoporosis

22. 3 phase bone scan- Magnetic resonance imaging (MRI) Sympathetic Blockade-

23. MANAGEMENT- Patient education- Educate about therapeutic goals. Tells aboutoutcomes worseningof symptoms over time What complication

24. PHYSIOTHERAPY- The main goals of treatment are a reduction in pain, preservation of limb function and a return to work.

25. Medical- Pain killer- baclophen Anti-inflammatory- dimethyle sulphoxide Anti- covulsive drugs- phenytoin Antiepileptic drugs- Pregabalin / gabapentin Ca- channel blockers

26. Biphosphonates are potent inhibitors of bone resorption ; Topical application- to relieve the localized hyperalgesia

27. Hormone therapy- Testosterone is important to pain control. Your body produces natural opioids —called endogenous opioids —such as endorphins , that are important for pain control.

28. PSYCHO THERAPY-- RSD causes psychological problems. Antidepressants   - amytryptilene Anti-anxiety- Benzodiazepam

29. If all conservative management is failed. Sympathetic ganglion block- *4 INTERVENTION THERAPY-

30. SPINAL INFUSION PUMPS -implanting pumps with pain medication into the spinal canal. PERIPHERAL NERVE STIMULATION (PNS). SPINAL CORD STIMULATION (SCS). SYMPATHECTOMY

31. REFRENCE- 1*.SUSAN B.O’SULLIVAN-physical rehabilitation.1 st INDIAN edition 2001 2*.J.MAHESHWARI-essential orthopaedics-4 th edition-2011 3*DAVID J. MAGEE- orthopedic assessment-4 th edition 4*DAVID L. HAMBLEN- Adam’s outline of orthopaedics-4 th edition 5* SRINIVASA N. et al., Complex Regional Pain Syndrome I (Reflex Sympathetic Dystrophy). American Society of Anesthesiologists , 2002.

32. 6* TURNER-STOKES, L., e.a ., Complex regional pain syndrome in adults: concise guidance. Clinical Med, 2011. 7*Schott GD-Reflex sympathetic dystrophy- Journal of Neurology, Neurosurgery & Psychiatry  2001. 8* Karmarkar A, Lieberman I (2006) Mirror box therapy for complex regional pain syndrome. 8*Schott GD-Reflex sympathetic dystrophy- Journal of Neurology, Neurosurgery & Psychiatry  2001. Stengel M, Binder A, Baron R. Updates on the diagnosis and management of complex regional pain syndrome.Adv Pain Manage. 2007;