Reflex Sympathetic Dystrophy/ Chronic Regional Pain Syndrome

1. Reflex Sympathetic Dystrophy/ Chronic Regional Pain Syndrome OT 5291: Physiological Module Natalie Cathcart, Melissa Chang, Colleen Day, Leslie Pottorf, Jackie Webel

2. Main Symptoms: Pain Swelling Stiffness Discoloration Other Symptoms: Sudomotor changes (sweating) Temperature changes Trophic changes Osseous demineralization Vasomotor instability Pilomotor activity (goose bumps) Definition/ Symptoms “Painful complications that occur after an injury and progress over time. The pain exceeds expectations in magnitude and duration” (Trombly & Radomski, 2002)

3. 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 Causes/ Types • (Trombly & Radomski, 2002)

4. Examples of CRPS • RSD Photos

5. 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 Case Study – Mrs. P(erserverance)

6. 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

7. 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)

8. 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)

9. 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)

10. 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.

11. 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)

12. 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.

13. 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)

14. 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)

15. 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)

16. 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-D7C0-4063-AE87DC86D78085FE&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.