1. Introduction Algonurodystrophy Algodystrophy Sudek atrophy
Shoulder hand syndrome
Complex regional syndrome
sympathetically mediated pain syndrome( SMP)

2. What is CRPS
CRPS (Chronic regional pain syndrome)is a debilitating neurologic syndrome , ‘ follows a musculoskeletal trauma :

3. Pathogenesis A- original injury initiate a pain in pulse
which is carried from
sensory nerves to the to
the central nervous
system

4. Pathogenesis B-pain impulse in turn trigger an impulse in the
sympathetic nervous
system which return to
original area of injury

5. Pathogenesis  C- Sympathetic impulse trigger the inflammatory
response causing the vessels
to dilate . This leads to
swelling an increased pain

6. Pathogenesis  D- Pain trigger another impulse establishing a
cycle of pain and
swelling

8. Epidemiology
Common in younger adults Mean 41.8 years 2.3 to 3 times more frequent in females than males Usually involves a single limb in the early stage

9. Causes of RSDS No clear etiology in 25-35%.
Trauma (about 60-65% of cases),
Treatment with antituberculous drugs or phenobarbital
Atypical causes such as pregnancy or postpartum causes, diabetes mellitus, malignant tumors, parkinsonism or other CNS disorders(stroke, hemiplegia)

10. Statistically significant associations
Cigarette smoking
Patients frequently show high scores on schizophrenia or depression scales..
wartime casualties.

11. Clinical Aspects of CRPS

12. Sensory Changes in CRPS
Allodynia(Increased sensitivity to a nonpainful sensory stimulation)
Hyperalgesia (Abnormally exaggerated subjective response to painful stimuli )
Hyperesthesia
Pain disproportionate to any inciting event

13. Autonomic Signs in CRPS
Edema
Swelling in limb
Color change
Temperature
(cooler or warmer) Sweating

14. Swelling in limb Diffuse Nonpitting or pitting
Occur in distal part of limb
Don’t occur in hip or shoulder

16. Trophic Changes
Altered nail growth
Altered hair growth
Skin changes

17. Abnormal Sweating

18. Skin changes

19. Psychological Changes
Fear
Anxiety
Anger
Depression

20. Neurologic changes hyperesthesia (glove and stocking distribution)
in coordination
tremor
muscle spasms
Limited range of movement and paresis

21. Spread of CRPS

22. Stages of RSD / CRPS STAGE I
Onset of severe, pain limited to the site of injury
Increased sensitivity of skin to touch and light pressure (hyperasthesia).
Localized swelling
Muscle cramps
Stiffness and limited mobility
At onset, skin is usually warm, red and dry and then it may change to a blue (cyanotic) in appearance and become cold and sweaty.
Increased sweating (hyperhydrosis). .

23. Stages of RSD / CRPS STAGE II
Pain becomes even more severe and more diffuse.
Swelling tends to spread and it may change from a soft to hard (brawny) type.
Hair may become coarse then scant, nails may grow faster then grow slower and become brittle, cracked and heavily grooved.
Spotty wasting of bone (osteoporosis) occurs early but may become severe and diffuse
Muscle wasting begins .

24. Stages of RSD / CRPS STAGE III
Marked wasting of tissue (atrophic) eventually become irreversible.
For many patients the pain becomes intractable and may involve the entire limb.
A small percentage of patients have developed generalized RSD affecting the entire body.

25. X Ray finding
patchy or diffuse
osteopenia of the
underlying bones

30. Bone scanning Three-phase technetium Tc 99m commonly is used.
Scan findings are considered positive if flow is asymmetric in phase 1, 2, and/or 3.

31. bone scintography

33. Imaging : bone scintography
Immediate
Flow phase
Pooling phase

35. MRI
Non spesific soft tissue change
Low signal in T1-T2

36. Differential Diagnoses
Diabetic and small-fiber peripheral neuropathies Entrapment neuropathies Thoracic outlet syndrome Discogenic disease Deep vein thrombosis Cellulitis Vascular insufficiency Lymphedema

37. Treatment

38. physical therapies Active and passive range of motion exercises
Transcutaneous electrical nerve stimulation (TENS)
Desensitization techniques

39. Pharmacologic agents Steroid
Antidepressants: These drugs modulate sympathetic activity and provide analgesia (eg, amitriptyline).
Anticonvulsants (eg, phenytoin, carbamazepine)
Membrane stabilizing agents (eg, lidocaine, tocainide)
Adrenergic compounds (clonidine)
Calcium channel blockers
Intranasal calcitonin
IV alendronate (bisphosphonate)

40. Surgical Care Chemical sympathectomy Surgical sympathectomy
Implantable electrical stimulators

41. Prognosis
weakness of the extremity resulting from this condition is seen in almost 50-65% of patients, months following initial diagnosis
Full range of movement accompanying the above aggressive therapies is seen in 60-74% of patients.
Prolonged morbidity is observed in about 50% of patients with psychiatric diathesis