Reflex Sympathetic

Dystrophy
Complex regional pain syndrome type 1
Definition
• Painful, Debilitating condition characterised by sensory,
vasomotor, pseudomotor and local trophic changes of skin.
• There are two types of Complex regional pain syndrome
CRPS 1 – RSD
CRPS 2 – causalgia
CRPS 1 ( RSD )
• After a noxious stimulus
• Spontaneous pain / allodynia i.e experience of pain from stimuli that isn’t
normally painful.
• Not limited to the territory of a single nerve
• Vague pain
• Evidence of oedema, skin blood flow abnormality, abnormal sudomotor activity
( sudomotor is anything that stimulates the sweat glands )
• More common in women
• More common in bone injury
 CRPS 2 ( causalgia )

Spontaneous
After nerve
pain or
injury
allodynia
Pathophysiology
• Normal response to an injury begins when pain receptors deliver pain
messages in the form of nerve impulses via C fibers to the spinal cord and
then the brain
• Once they reach the pain centre in the brain it activates the sympathetic
nervous system and sends signals to area of injury which causes
vasoconstriction of blood vessels followed by vasodilatation.
• In CRPS the vasoconstriction persists due to inappropriate continuation of
sympathetic activity which results in oedema, with capillary collapse and
ischaemia causing continued pain in the form of positive feedback loop
Pathophysiology
• This is believed to occur due to damage in the nerves that supply
the blood vessels leading to persistent vasoconstriction causing
pain and ischaemia, skin becomes shiny, dry, lack of hair, scaly in
nature.
• The most common H/O given by RSD patients is trivial trauma or
minor initial injury accompanined by disproportionate pain
persisting long after healing.
• CRPS 2 is always associated with a nerve injury
Symptoms and signs
• Pain out of proportion to initial injury – pain is constant persistent
aching burning exaggerated by emotional factors
• Initial signs – swelling discolouration stiffness
• Primary signs – sever allodynia/hyperalgesia. Initially localised,
progressing to diffuse distribution that does not fit the dermatomal
distribution
- Oedema spreads rapidly proximally and changes from soft to hard
- Stiffness is rapid onset following swelling if not treated then may lead
to Fibrous ankylosing of joints
 Symptoms and signs
Sudomotor
and
Temperature
vasomotor
Secondary changes – Trophic
Osteopenia changes,
signs cold changes
mottling
sensitivity
discolouratio
n
Palmar Hyperhydros Loss of skin Decreased
Loss of hair
fibrosis is crease moisture

Dystonic
posture of
affected
limbs
Diagnostic Criteria
• Follows an initially innocuous event
• Spontaneous pain
• Edema skin changes
Stages of RSD
• 1. Stage I (Traumatic Phase) a. Onset: at the time of initial injury or within several weeks
• b. Increase in edema i. Soft and localized
• ii. Spreads to periarticular tissue, resulting in increasing stiffness
• c. Hyperhidrosis d. May see fine tremor (3 to 6 Hz) e. Skin i. Cool, pale, cyanotic, mottled
• ii. May show erythema and warmth secondary to an increase in superficial blood flow
• f. Increased hair and nail growth g. Pain i. Increased by movement and weight-bearing
• ii. Voluntary disuse to minimize discomfort iii. Increases in severity over time iv. Diffuse
• h. Osteopenia on x-rays within 4 to 8 weeks after onset of pain
• i. Duration: 3 to 6 months
Stages of RSD
• 2. Stage II (Dystrophic Phase) a. Onset: 3 to 6 months after onset of
pain b. Pain becomes more diffuse, increases in severity c. Edema
changes from soft to brawny edema (creases disappear)
• d. Warmth followed by cyanosis e. Trophic changes i. Hair loss
• ii. Nails brittle, cracked, grooved iii. Glossy skin iv. Decreased
moisture
• f. Joint range of motion (ROM) decreased, increased stiffness
• g. Muscle weakness or atrophy h. Less responsive to sympathetic
blockade i. Radiographs: osteopenia j. Duration: 3 to 6 months
Stages of RSd
• a. Onset: 6 to 12 months after injury b. Pain i. Intractable; although it may decrease
• ii. Proximal spread iii. Worsens with motion
• c. Joints i. Decreased ROM or lack of functional motion
• ii. Rigid (fibrous ankylosiS) iii. Flexor tendon contraction iv. Joint subluxation v.
Potentially ankylosed
• d. Skin i. Marked trophic changes owing to decreased blood flow
• 11. Cool, pale, dry, glossy iii. Subcutaneous fat atrophy (fingers narrow)
• e. Muscle atrophy f. Radiographs i. Diffuse
• ii. Disuse osteoporosis or osteopenia g. Duration: years or permanent
Physical therapy management