Diagnosis and Treatment Options of RSD/CRPS

1
Diagnosis and Treatment Options of RSD/CRPS

• Srinivasa N. Raja, MD
• Director of Pain Research
• Johns Hopkins University
• School of Medicine

2
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

3
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.
200014541-546.
4
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.
200014541-546. 3. Raja SN et al.
Anesthesiology. 2002961254-1260.
5
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. Bonicas
Management of Pain. 2001 388-411.
6
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. Bonicas
Management of Pain. 2001388-411.
7
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.
2002961254-1260. 2. Galer BS et al. In
Loeser, ed. Bonicas Management of Pain. 2001,
388-411.
8
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. 199563127-133.
Galer BS et al. In Loeser, ed. Bonicas
Management of Pain. 2001 388-411.
9
Clinical Features(contd)

• 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. 199563127-133.
Galer BS et al. In Loeser, ed. Bonicas
Management of Pain. 2001 388-411.
10
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

Bogduk N. Current Opinions in Anesthesiology.
200014541-546.
11
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 (gt or lt 1? C)
• Limited range of movement
• Motor neglect

Bogduk N. Current Opinions in Anesthesiology.
200014541-546.
12
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. 199981147-154. 2.
Harden et al. Pain. 199983211-219. .
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Swelling and Color Changes
14
Abnormal Sweating in RSD
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Differential Diagnoses

• Diabetic and small-fiber peripheral neuropathies
• Entrapment neuropathies
• Thoracic outlet syndrome
• Discogenic disease

• Deep vein thrombosis
• Cellulitis
• Vascular insufficiency
• Lymphedema
• Erythromelalgia

Raja SN et al. Anesthesiology. 2002961254-1260.
16
Psychological Aspects

• Pain can cause symptoms of psychologic distress
  including
• Anxiety
• Depression
• Fear
• Anger

Raja SN et al. Anesthesiology. 2002961254-1260.
17
Treatment

• Goals
• Rehabilitation
• Pain management
• Psychological treatment
• Multidisciplinary
• Physiotherapy
• Medical
• Psychological

Stanton-Hicks M et al. Pain Practice.
200221-16.
18
Rehabilitation Clinical Pathway

• Physiotherapy pain management psychological
  therapies sequential progression through the
  rehabilitation pathway
• PT OT crucial to patients progression
• Therapist assesses patients motivation and helps
  set goals
• Adequate analgesia, encouragement, and education
  of disease process

Stanton-Hicks M et al. Pain Practice. 200221-16.
19
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

Stanton-Hicks M et al. Clin J Pain.
199814155-166.
20
Pharmacalogic Pain Management

• Most drugs used for neuropathic pain are used to
  treat RSD/CRPS

• IV bretylium
• IV ketanserin
• IV phentolamine
• IV lidocaine
• Intranasal calcitonin

• IV alendronate (bisphosphonate)
• Topic dimethyl sulfoxide
• Topical clonidine

Raja SN et al. Anesthesiology. 2002961254-1260.
Kingery WS. Pain.199773123-139
21
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.
200221-16.
22
More Invasive Therapies

• Neuroaugmentation
• Spinal cord stimulation
• Intrathecal drug delivery

Stanton-Hicks M et al. Pain Practice.
200221-16.
23
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.
200221-16. Bandyk DF et al. J Vasc Surg.
200235269-277.
24
Other Therapies

• Behavioral modification
• Psychiatric consultation
• Complimentary and Alternative therapies
• Acupuncture

Raja SN et al. Anesthesiology. 2002
961254-1260.
25
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. 2002961254-1260.
26
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

27
Bibliography
Bandyk DF, Johnson BL, Kirkpatrick AF, Novotney
ML, Back MR, Schmacht DC. Surgical sympathectomy
for reflex sympathetic dystrophy syndromes. J
Vasc Surg. 200235269-277. Bogduk N. Complex
regional pain syndrome. Current Opinions in
Anesthesiology. 200014541-546. 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. 199981147-154. Galer BS, Schwartz
L, Allen RJ. In Loeser, ed. Bonicas 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.
199983211-219.
28
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. 199773123-139. Raja SN , Grabow
TS. Complex regional pain syndrome I (Reflex
Sympathetic Dystrophy) Anesthesiology.
2002961254-1260. Stanton-Hicks M, Burton AW,
Bruehl SP, et al. An updated interdisciplinary
clinical pathway for CRPS Report of an expert
panel. Pain Practice. 200221-16. Stanton-Hicks
M, Jänig W, Hassenbusch S, et al. Reflex
sympathetic dystrophy changing concepts and
taxonomy. Pain. 199563127-133 Stanton-Hicks M,
Baron R, Boas R, et al. Complex Regional Pain
Syndrome guidelines for therapy. Clin J Pain.
199814155-166.