Download Reflex Sympathetic Dystrophy/ Chronic Regional Pain Syndrome

Reflex Sympathetic Dystrophy/
Chronic Regional Pain
Syndrome
OT 5291: Physiological Module
Natalie Cathcart, Melissa Chang,
Colleen Day, Leslie Pottorf,
Jackie Webel
Definition/ Symptoms
“Painful complications that occur after an injury and
progress over time. The pain exceeds expectations
in magnitude and duration”
Main Symptoms:
–
–
–
–
Pain
Swelling
Stiffness
Discoloration
(Trombly & Radomski, 2002)
Other Symptoms:
– Sudomotor changes
(sweating)
– Temperature changes
– Trophic changes
– Osseous
demineralization
– Vasomotor instability
– Pilomotor activity
(goose bumps)
Causes/ Types
• Injury/Stress to the
Sympathetic Nerves:
– Trauma (Acute or
Chronic)
– Heart Disease
– Spinal Cord Disorders
– Cerebral Lesions
– Surgery
– Infections
– Repetitive-Motion
Disorder
(Williams,1995)
• Types:
– Type I caused by
noxious event; pain
that is not limited to
the territory of a single
peripheral nerve and is
disproportional to the
inciting noxious event
– Type II same as Type I
except develops after
a nerve injury
– Type III otherwise not
classified
(Trombly & Radomski, 2002)
Examples of CRPS
• RSD Photos
Case Study – Mrs. P(erserverance)
P
• Single 49 y/o athletic
woman
• Dominant right hand
• Comminuted displaced
right distal radius fracture
• Significant pain, edema
and increased autonomic
signs
• Digital P/AROM
significantly limited
• Nauseous when looking
at hand
E
• Family assisting w/ ADLs
& self-care
• Lives alone
O
• Computer software
manager
• Enjoys vacationing and
kayaking
OP Issues and Goals
OP Issues
• Disruption of independent living, job performance, and
job-related travel
• Difficulty sleeping and completing self-care due to pain
• Significant edema decreases ROM
• Risk of CRPS due to decreased use of UE and increased
autonomic signs
Goals
• Mrs. P will utilize effective pain management strategies
that will facilitate functional restoration
• Mrs. P will increase spontaneous use of UE in daily
activity
• Mrs. P will increase P/AROM to regain typing skills to
return to work
Frame of Reference
• Biomechanical:
– Remediates deficits in ROM and strength; decreases
edema
– Body needs to be stressed in order to restore and
regain strength and ROM
– Gradually increase weight bearing or level of aerobic
exercise
• Application to Stress Loading:
– Steady progression from very gentle movements to
gentle weight bearing increases stress placed on the
body
– Overload on efferent sympathetic system will lead to
desensitization to pain and functional restoration
(Harden, 2001)
Assessment
• Principal areas to assess: AROM, edema,
pain/sensation, psychosocial factors,
strength, coordination dexterity,
skin/vasomotor changes, and functional use
of extremity.
– AROM is measured with a goniometer
– Edema is gauged with a volumeter
– Comprehensive Pain Evaluation Questionnaire
• Measures Activity Inference, Pain Intensity, Social
Support(s), Emotional Distress (covers P, E, & O
factors)
Assessment (continued)
– Symptom Checklist
• Client identifies areas of pain based on 9
descriptors by circling palmar and/or dorsal surface
of right and or left hand.
• Eight subjective questions follow to describe level
and duration of pain resulting in functional deficits
– Psychosocial Evaluation
• Assessment of pain coping skills and drug abuse
potential
• Stress, depression, and anxiety are known causes
of exacerbation of this disease
• The potential for committing suicide needs to be
assessed! (www.rsdfoundation.org)
(Williams, 1995; rsdfoundation.org, 2005)
Treatment/ Intervention
• As CRPS varies in severity and duration,
the OT must demonstrate enthusiasm,
support, and encouragement of the patient
during the treatment process.
• The patient must be involved in integration
of treatment techniques into all daily
activities to achieve optimal function of the
affected extremity.
Pain Management
• Closely monitoring pain levels is key to
prevention and management
– Early diagnosis likely to lead to better outcomes
• Self-protection or immobilization to avoid pain is
a risk factor
– Best to learn to use extremity actively in pain-free way
• Management Strategies:
– Close communication with medical experts
specializing in pain management
– Medications
– Stellate ganglion blocks
– Trancutaneous electrical nerve stimulation (TENS)
(Trombly & Radomski, 2002; Mayo Clinic, 2005)
Stress Loading Intervention
• Taps into the body’s ability to adapt in response
to demand. (Active sustained exercise requiring
forceful use of the entire extremity, with minimal
motion of painful joints.)
• Used with patients who are at risk for CRPS to
change sympathetic efferent activity.
• Two components of stress loading are
“scrubbing the floor” and a weighted briefcase,
done with the extremity in extension.
Stress Loading (continued)
• Goal: Achieve compressive loading and distraction
of the upper extremity.
– If actually scrubbing cannot be tolerated,
substitute comfortable weight-bearing exercises.
– If tolerated, frequency and duration of scrub and
carry are upgraded.
– Overload is needed to achieve a training effect,
and exercise must be sufficient intensity, duration,
and frequency to achieve it.
(Carlson, 1996; Trombly & Radomski, 2002)
Splint option #1:
Resting Hand Splint
• Goals: Minimize ROM & strength losses,
manage edema, & provide pain mgmt
• Can initially provide rest, reduce pain, & relieve
muscle spasm
• Splint in comfortable position & avoid causing
more pain
• Wearing schedule: wear at all times except
during therapy, hygiene, & ADLs. Ct. should
wean off as pain reduces & ROM improves
(Coppard & Lohman, 2001)
Splint option #2:
Wrist Immobilization
• Goals: pain relief, muscle spasm relief, regain
functional resting wrist position
• Can decrease wrist pain or inflammation, provide
support, enhance digital function, prevent wrist
deformity, minimize pressure on median nerve, &
minimize tension on involved structures
• Wearing schedule: wear during all functional
activities
• Circumferential wrist splint may be used to help
avoid pressure on the edges & edema problems
(Coppard & Lohman, 2001)
References
Carlson, L. (1996). The treatment of reflex sympathetic dystrophy through stress loading. Physical
Disabilities: Special Interest Section Newsletter, 19(2), 1-4.
Coppard, M. & Lohman, H. (2001). Introduction to Splinting (2nd Ed.). St. Louis: Mosby, Inc.
Harden, R.N. (2001) Complex Regional Pain Syndrome. British Journal of Anaesthesia.
87(1): 99-106.
Harvard Medical School Pain Management Center. Stellate Ganglion Blocks. Retrieved September
27, 2005. http://www.hmcnet.harvard.edu/ brighampain/faqs/stellate.html
Mayo Clinic Medical Services. Complex Regional Pain Syndrome. Retrieved September 27, 2005.
http://www.mayoclinic.com/invoke.cfm?objectid= 8F3237C2-D7C0-4063AE87DC86D78085FE&dsection=7
RSD Foundation. Reflex Sympathetic Dystrophy. Retrieved September 25, 2005.
www.rsdfoundation.org
Spine Universe. Transcutaneous Electrical Nerve Stimulation (TENS). Retrieved September 27,
2005. http://www.spineuniverse.com/ displayarticle.php/article1694.html
Trombly, C. & Radomski, M. (2002). Occupational Therapy for Physical Dysfunction (5th Ed.)
Baltimore: Lippincott Williams & Wilkins.
Williams, R. (1995). Reflex Sympathetic Dystrophy. Bethesda, MD: American Occupational Therapy
Association, Inc.