1 / 54

Whatever happened to RSD?

Whatever happened to RSD?. Andrew Muir. History . 1872 Mitchell described a syndrome of causalgia: Limbs of American Civil War soldiers who sustained nerve injuries Burning pain, hyperaesthesia, trophic changes with glossy skin

Télécharger la présentation

Whatever happened to RSD?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.


Presentation Transcript

  1. Whatever happened to RSD? Andrew Muir

  2. History • 1872 Mitchell described a syndrome of causalgia: • Limbs of American Civil War soldiers who sustained nerve injuries • Burning pain, hyperaesthesia, trophic changes with glossy skin • The nomenclature relates to the Greek ‘kausis’ burning and ‘algos’ pain after a nerve injury • 1901 Sudeck (bone changes after injury) • 1940 Reflex Sympathetic Dystrophy (RSD)

  3. CRPS: Nomenclature The nomenclature of CRPS Types I, II was adopted after a Consensus Conference in 1993 • Standardised terminology • Avoid unsustainable pathophysiological implications • Take up has been patchy but increasing: 11% of articles between 1995 and 1999 used it but 3.5% 1995 & 27.5% in 1999 • Type II refers to major nerve injury, Type I to the rest.

  4. CRPS: Diagnostic Criteria • A. Presence of an initiating noxious event or cause of immobilisation. • B. Continuing pain, allodynia or hyperalgesia with which the pain is disproportionate to any inciting event. • C. Evidence at some time of oedema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain. • D. This diagnosis is precluded by the existence of conditions that would otherwise account for the degree of pain or dysfunction.

  5. CRPS: Diagnostic Criteria • One group found that the criteria did not discriminate between CRPS I and Diabetic Peripheral neuropathy and positive predictive value between 40 and 60%. • Criteria used in a check list can improve PPV to 0.91, sensitivity to 0.71 and specificity to 0.95 • Baron suggests current presence of 3 symptoms and 2 signs.

  6. Pathophysiology: • It can be shown that cooling the body with affected limb isothermic causes pain associated with sympathetic tone. • Controversial pharmacological challenge of Raja etc • Some studies have demonstrated an overall decrease in sympathetic nervous system activity explaining the • Acute ‘hot’, hypercirculation phase • Chronic ‘denervation supersensitivity’ phase with the cold blue limb.

  7. Pathophysiology: • Most of the following have been demonstrated in animal models of nerve damage. • Peripheral changes • Expression of adrenoceptors on a subset of C-fibres, OR • Noradrenaline mediated release of prostanoids • Central changes • ‘wind up’ • Autonomic/somatic crosstalk & sprouting after nerve injury.

  8. Pathophysiology: • Sympathetic nervous system elaboration of noradrenalin can activate mast cells, inviting a immuno-inflammatory aspect to this.

  9. Glu Glu SP Glu Mao et al, Pain, 1995 NMDA-R AMPA-R mGluR G Mg++ Na+ IP3 Ca++ Ca++ L-arg Gene expression PKC activation Nos NO

  10. Pain Allodynia Temperature change Colour change Sweating Dystrophy Motor change Non dermatomal Should be marked Should be marked Uncommon Non-specific Practical Clinical Features:

  11. Practical Clinical Features: A continuum from: Icy cold, immobile, dripping with sweat, profound allodynia TO Hey! The X-ray looks OK … so how come it still hurts?

  12. Practical Clinical Features: • There exist a number of potential differential diagnoses, the most common and important one is DISUSE secondary to persistent pain, (where the clinical signs are likely to be less marked). • Unrecognized local pathology(sprain, #, sepsis, cellulitis, allergy) • Vascular insufficiency (Raynaud’s disease, thromboangiitis obliterans, thrombosis)

  13. Practical Clinical Features: • In all cases, the aims of treatment must be considered through the same process as any other patient with chronic pain. • RESTORATION OF FUNCTION !

  14. Treatment algorithms • Guideline published in 1998 • Functional restoration • Physical and psychological methods • To move through to another modality if no response in defined period • Consensus report Complex Regional Pain Syndrome: • Guidelines for therapy Stanton Hicks et al Clin J of Pain 14: 155-66 1998 (now more recent)

  15. Response to Algorithm • 100 experienced pain specialists • Referral • 32% orthopaedic specialist • 12% neurologist, 12% GPs • 9% self referred, 9% anaesthetist • 8%neurosurgeon, 8%physiotherapist • 6% lawyer/ case manager • 4% podiatrist

  16. Frequency of Treatments

  17. Pharmacotherapy

  18. Timing of treatment • 97% believed better outcome if referred within 3 months of onset

  19. Evidence based guidelines • Don’t really exist • Cochrane data base of RCTs • Critical analysis of 22 RCTs • Poor methodology • Only looking at one modality • Difficult to compare • Calcitonin deceases pain of CRPS • Perez et al Journ of Pain and Sympt Mgt 21, No6, June 2001

  20. What do we know? • Oral corticosteroids are effective (2 papers, 1 RCT) • Bisphosphanates: • Alendronate improved bone density with a trend to decrease in pain and swelling • Clodronate improved pain substantially • Spinal cord stimulation – moderate improvement • Some support for: • DMSO cream • Epidural clonidine • Intravenous bretyllium, ketanserin

  21. What do we know? • IVRB • guanethidine is ineffective, • bretyllium works (single trial) • Ketanserin effective • Ketorolac effective (1 paper)

  22. A Reasonable Approach: • Physiotherapy – (rest or mobilisation) • Adequate analgesia • Early pulse of corticosteroids • Early referral to Pain Clinic for: Repeated temporary sympathectomies Epidural clonidine Bisphosphanates • Long term management of chronic pain

  23. Case study 1: History • Mrs C • Italian woman 70 years old • History: 3mths ago gardening • Stick pierced palm R hand • Hot, swollen, dry, painful • Treated antibiotics, sling • deteriorated

  24. Case 1: History • Referred to orthopaedic hand surgeon • ? Hysterical, ?CRPS type 1 • unable to move arm, fingers • unable to hold knife and fork • unable to do washing, cooking

  25. Case 1: History • Investigations • x-ray, bone scan, ultrasound • inflammatory markers • Referred to pain clinic

  26. Case 1: Examination • Pain on light touch, • Increased reaction to pain in most of arm viz palm, classic tender points • Motor neglect. • All upper limb movements impaired • tissue swelling • temperature cooler than other limb • colour change

  27. Case 1: Management • Management: Initial • TCA, oxycontin, physiotherapy • cease sling, • start hanging washing on clothes line • Series of 3 stellate ganglion blocks • Good response for some days with lasting improvement(SMP) • Combined with physiotherapy: • EMLA cream to palm, trigger point injections extensor origin

  28. Case 1: Management • Outcome good. • Swelling gone, • Movements substantially improved • Function: returned to most activities • Residual thickening of palmar flexion tendon middle finger • Swelling substantially reduced • Pain Medications ceased

  29. Case 2: History • Mr U • Turkish man aged 48 • Injured at work end 1999 • conveyor belt fault results in open injury to R hand • laceration palmar branch of digital nerve • repair of digital nerve

  30. Case 2: History • Pain increased • burning, painful on light touch • extending up arm • No progress with hand therapy • Referred to pain clinic for SGBs

  31. Case 2 : Examination • Wearing glove • Holding arm up close to chestdifficulty swinging arm/initiating movement • decrease grip strength • Hand cold blue sweaty, swollen

  32. Case 2 : Management • Diagnosis of CRPS type 2 • Trial of oral medications • neuorpathic agents, SR opioids, TCAs • Trial of stellate ganglion blocks/ activation • temporary improvement (SMP) • poor compliance • Multi-disciplinary pain assessment

  33. Case 2 : Management • Not suitable for pain management • seeking cure • unresolved anger/ litigation • Referred for in-patient rehabilitation program (Plan: Cx epidural/ phys ther) • Unsuccessful

  34. Case 2 : Management • further interventional Mx by pain specialist number 3 • guanethidine blocks • Spinal cord stimulation • Unsuccessful

  35. Case 2 : Management • Further deterioration • now back and leg pain, using stick • not working/ low function at home • depressed • arm wasted, sweaty hand, no movement • heavily involved with litigation, • still focussed on cure and blame • seeking multiple medical opinions

  36. Case 2 : Management • ASSESSED AS “NOT READY” for CBT based Pain Management Program

  37. Case 3 : History • Mr M.R. • Aged 24, Australian born • Had a venipuncture from R cubital fossa (lateral aspect) November 2000 • Felt pain shoot up to shoulder/ felt faint • 36hrs later woke up with clawed R hand • Has not been able to open hand since • Has not worked since

  38. Case 3 : History • Referred by GP for pain management • 2 overdoses • Had been working at previous job for 3 days prior to Venipunture • No real indication for VP • did not attend a doctor prior to VP • Litigation in progress against pathology firm

  39. Case 3 : History • Now living with grandparents who are “looking after him” • Has initiated referral to multiple specialists • No reports available • Difficulty contacting referring GP • Using self prescribed splints at night

  40. Case 3 : Examination • Presentation • agitated • conflicting history with Mother • Pain not a major complaint • Both hands cool sweaty • Holding R hand in tight claw • Resistance to opening

  41. Case 3 : Management • No wasting in arm in general • Increased forearm muscle bulk • Possibly some wasting dorsum of hand • No difference in temperature, swelling, sweating • No allodynia • No motor akinesia of arm in general • Normal movements of shoulder and upper arm. Cannot move fingers

  42. Case 3 : Management • Diagnosis? • ??????????Nerve injury • ?????????CRPS • ??Conversion disorder • Management • Full assessment (multi-disc) • Counselling/ Reassurance • No medications, general gym program

  43. Case 3 : Management • Participating in competitive manner in Gym program • Enjoys being videoed • Has taken up a correspondence course (sports psychology) • Will have an EUA • Unable to get any reports

  44. Case 4 : History • MRS B • 58 year old woman (Australian born) • Working as nurse in aged care • MCA 1997: injured shoulder and ankle(soft tissue) • Recovered, RTW • Persistent swollen R leg • Intermittent shoulder stiffness

  45. Case 4 : History • 1998 R leg gave way, fell • fractured ankle POP/ int fixn • pain and spasm swelling persistent problem when in POP • prolonged rehabilitation 2X 3 mths IP • persisting pain, swelling, spasm • 2 further operations • No progress, Referred to pain clinic

  46. Case 4 : Examination • Pleasant co-operative woman • Wearing rigid ankle brace/ using wheelchair • leg swollen, cool compared to L side • intense allodynia, skin dry, discoloured • multiple tender points over entire leg, back shoulder • out of brace grossly abnormal gait and devel of spasm on light touch/ movet

  47. Case 4 : Management • Management initial • Oxycontin/ gabapentin: Good analgesia • No improvement in function/spasm • Lumbar sympathetic block • Excellent block with no change in symptoms (SIP)

  48. Case 4 : Management • Case conference Rehab/ Physio • in-patient admission: epidural opiate/ clonidine/ Local Anaesthetic • Allodynia/ spasm disappeared • gait re-training, gym program • ceased all analgesics • returned to normal activities • no splint/ no wheelchair • skin/ temp/ swelling abated

  49. Case 4 : Management • 12 months later • noted recurrence of spasm and pain • skin changes/ allodynia • trial hydrotherapy/ gym • finding this difficult, • further deterioration • requested epidural treatment • underwent multi-disc assessment

  50. Case 4 : Management • Cure focussed, not interested in CBT Program • Admitted for epidural • Similar response to previous • Pt anxious that found walking difficult. • Had persistent muscle cramp • Referral to IP rehab (Not accepted by TAC) • OP physio attempted: poor progress

More Related