Simpozij: Sudeckov sindrom
KBC Dubrava, 6. i 7. listopada 2000. godine
Sudeck disease in modern rehabilitation
Aleš DEMŠAR i Lidija PLASKAN
Complex regional pain syndrome type I. (CRPS – type I.) is the newest name for the entity, which we knew for 100 years as Sudeck dystrophy. The confusing conditions on behalf of terminology, epidemiology, etiopathogenesis and therapy of Sudeck disease as an entry for the authors, who will present the matter more precisely, are discussed in this article.
The frequency of injuries in a sample of middle-aged population Croatia prior to the 1991-1995 war
As a part of a global research of frequency of chronic diseases in Croatia, there was an evidence of frequency of injuries, included in the «corpus» of diseases of musculoskeletal system. A random sample of citizens, born between 1915 and 1935, was taken from six Croatian municipalities. Of the 4 320 invited, 78 % responded. Other than anamnesys and clinical examination, there was a use of earlier diagnoses as well as X-ray pictures, and the diseases have been divided into six grades. We registered 281 injuries, of which only 4,6 % were recent. In a smaller sample of 250 who didn’t respond to the invitation, and who were examined at their homes, we estimated their physical and health conditions and the reason for not responding and didn’t find a significant difference in morbidity. Male examines in urban areas (Zagreb, Split) were often registered with sprain (0,3 % : 0,1 %), while femals in rural areas (Virovitica, Vis) were registered with fractures (4,2 % and 4,4 % : 1,7 %). Perforating wounds were more often registered in Split, Virovitica and Omiš (1,3 %, 1,7 % and 1,6 % : 1,1 % in total population, P < 0,001). We analyze a possible connection between injuries and occurance of the Sudeck’s syndrome. It’s necessary to conduct an active epidemiologic study of injuries in same regions after the 1991-1995 war in Croatia and introduce a register of injuries in Croatia.
Epidemiology of Sudeck’s syndrome
Drago BRILEJ, Lidija PLASKAN, Božidar BUHANEC and Radko KOMADINA
Epidemiology of reflex symphatetic distrophy (RSD) is influenced by historic and taxonomic factors. RSD is a complex regional pain syndrome defined during different decades and in different countries differently. More than 30 different names in the French literature, more than 80 different names in the Anglo-Saxon literature and more than 50 were found in the German literature. Former American retrospective studies reported on low incidence (1-2%), later prospective studies report on high incidednce (25-30 %). By the opinion of the authors, the reports are influenced by entering criteria.
Sudeck’s syndrome (Complex Regional Pain Syndrome): Pathogenesis
Alenka HÖFFERLE FELC
Sudeck’s syndrome, in medical jargon usually called simply «Sudeck», has been officially named Complex Regional Pain Syndrome (CRPS) since 1994 to replace the term Reflex Sympathetic Systrophy (RSD).
RSD was officially introduced in 1986 to put an end to confusion of numerous terms to denote the same disease, like Sudeck’s dystrphy, algodystrophy, post-traumatic painful osteoporosis, shoulder-arm syndrome. For decades, it was namely believed that this rather frequent painful condition after surgery or injury was due to pathological reaction of the sympathetic nervous system. Indeed, sympathetic blockade was considered to be the treatment of choice for a long period of time. However, it did not always prove to be effective. Further investigations showed that pain can be sympathetically maintained (SMP) or sympathetically independent (SIP). In CRPS, there is usually SMP in the beginning, later often SIP, or both.
Pathogenesis of CRPS is, however, still poorly understood: there are many theories, all of them more or less on the level of hypotheses. However, all of them seem to be at least partly acceptable, for each of them explains it at least to a certain extent, so they all contribute to better understanding of the syndrome.
The reason could be prologation of otherwise normal sympathetic response to injury. Vasoconstriction normally ends up in vasodilatation. In pathological (exaggerated) sympathetic reaction there are vasomotor instabilities with changes in skin temperature and colour as well as edema, and disorders of sudmotor function (hyper/hypohydrosis). The consequence of prolonged vasoconstriction is ischemia. This deteriorates pain and increases the number of pain stimuli, reactivating sympathetic reflex and increasing the sensibility of
Prolonged vasoconstriction could also be the consequence of over-active adrenergic receptors. Further investigations will answer the question whether adrenergic blockade is more effective than sympathetic.
Higher blood concentration of pain-producing (algogenic) substances (like norepinephrine, bradykinin, P substance, prostaglandins) or ineffectiveness of natural opiods because of their disturbed metabolism are also believed to be the cause of hyperalgesia. According to some investigators, CRPS is exaggerated inflammatory response.
Allodynia, on the other hand, is believed to be the consequence of changes in the posterior horns of the spinal cord.
A report on the 8th World Congress of IASP, held in May 1998 in Tenerife, Spain, brought some new, important data about the syndrome: scientists in Netherlands focused their attention on the development of ischemia and consequently disturbed metabolism: they first tried to cure CRPS with kentanserine, a serotonin-antagonist, thus restoring the circulation and removing the effects of ischemia: since hyperalgesia and allodynia persisted, they added carnitine, which is essential in aerobic metabolism. It takes part in the oxidation of fatty acids within mitochondria, thus increasing the formation of ATP which is believed to be a co-transmitter in the sympathetic nerve endings. They succeeded in curing both, hyperalgesia and allodynia. The trial was done on 12 patients only, so it cannot be considered reliable. However, the results are promising: maybe this opens new perspective not only in understanding the syndrome, but also in curing it.
Diagnostics of Sudeck syndroma
Franjo ŠKREB, Gordana AUGUŠTAN, Berislav ROŽMAN and Gordana KURNIK
Reflex sympathetic dMystrophy (RSD) or Sudeck syndroma is marked with pain and sensibility on distal parts of extremities, and with signs and symptoms of vasomotor lability. Also present are trophical skin changes, and fast demineralisation, usually after minor or major trauma. Because of possible irreversible changes quick diagnosis is necessary. Without adequate therapy RSD may progress to other extremities, and whole body, with contractures of extremities.
Pharmacologic therapy of complex regional pain syndrome
Sudeck’s syndrome, complex regional pain syndrome (CRPS) is a complex patho-physiological entity characterized by pain, functional impairment, trophic changes, vasomotor abnormalities, and the rapid development of bony demineralization. A precipitating event can be identified in two-thirds of cases. These include local trauma, strokes, peripheral nerve injuries, barbiturate, antituberculosis drugs, and cyclosporin. Early recognition and treatment are important to prevent permanent disability. Pain should be properly controlled. A short course of high-dose prednisone has been beneficial in some patients when given early in phase. Oral corticosteroids (30-40 mg of prednisone) in first 4-6 weeks for 2 weeks. Calcitonin 100-160 IU daily for 4-8 weeks, followed by one injection every second day for 3-6 weeks. Bisphosphonate has also been used in open studies with promising results. Aminopropylene diphosphonate has been given intravenously 15-60 mg daily during 3-5 days. Alendronate and pamidronate may improve pain, but an evaluation of these results is difficult in this disease characterized by very variable natural history. Sympathetic nerve block may be effective in reducing pain by blocking the pain cycle. The development and application of drug that act through selective receptor antagonism or enzymatic synthesis inhibition to prevent further stimulation of cascade mediators of inflammation that could inevitably lead to chronicity of this disease are discussed.
Continuous sensory analgesia allows early and painless physiotherapy in CRPS 1
Krunoslav MARGIĆ i Jelka PIRC
Twenty patients with CRPS 1 were treated from 1988 to 1998. Until 1996 active «stress loading» program was used. In 1996 continuous sensory analgesia was introduced in treatment. Today, the patient with working diagnosis CRPS 1 is hospitalized. We start immediately with cryotherapy, elevation and active movements. Prompt and positive reaction in two cases was interpreted as sign of unclear posttraumatic condition with spontaneous recovery. If there were no signs of recovery the axillary catheter was inserted and continuous sensory analgesia applied. Painless unaffected motor function has permitted vigorous physiotherapy without pain. Improvement was noted in nine of eleven patients. In two refractory cases one was assumed as «manus psychoflexa», and the other as chronic systemic disease with pronounced psychical disturbances. One patient has had few episodes of CRPS 1 on both hands, final result is poor. Six of nine patients use their hands in everyday duties and at work.
Sudeck’s syndrome and magnetotherapy
Zmago TURK, Jože BAROVIČ and Dragan LONZARIĆ
The rehabilitation of injured persons with complex regional pain syndrome type 1 (CRPS I) (Sudeck’s syndrome, SS) and numerous consecutive disabilities is a pretentious therapeutic challenge particularly for specialists from physical and rehabilitation medicine. Low-frequency pulsed magnetic fields (LFPMF) stimulate ionic membrane carriers increasing synthesis of cells’ ATP and partial oxygen pressure in body tissues. The beneficial effect on the healing of skin wounds, deeper lesions, bone fracture and pain is based on this mechanism. One hundred seventy one patients with postinjury SS were enrolled in one of our largest clinical prospective and randomised study (1990-1992). They were divided into two groups matched by age. The test group included 86 patients (42 women and 44 men, average age 49ys, 44 upper and 42 lower extremities, SS I 40 patients, SS II 40, SS III 6) and control group included 85 patients (43 women and 42 men, average age 44ys, 48 upper and 37 lower extremities, SS I 29 patients, SS II 46, SS III 10). Patients from both groups had prescribed individual kinesitherapy, hydrotherapy and occupational therapy ( in case of upper extremity injury), patients from the test group had also magnetotherapy (LFPMF, Magnetotron 90W, Elecsystem, 50 Hz, five to ten mT, 30 minutes daily, five working days in week for the period of three to eight weeks.) The combination of therapeutic modalities including LFPMF resulted in statistical significant better improvement in almost all measured impairments (X2-test, p<0,01):the range of active motion (evaluated sufficiently after the treatment in 81 (94,2%) patients from test group versus 69 (81,2%) patients from control group), muscular strength (sufficiently in 56 (65,1%) versus 15 (17,6%) patients, respectively), pain (evaluated with six-level descriptive pain scale, painless 46 (53,5%) patients versus 0 (0%) patients, respectively), bone and callus density (evaluated with computer tomographic densytometry, amelioration to the sufficient grade reached in 32 (37,2%) patients from thest group versus 0 (0%) patients from control group). The statistical significant improvement was not reached only in one measured parameter-reduction of circumference of the xtremity. Examined combination of therapeutic modalities including magnetotherapy gave better results. Magnetotherapy is useful physical therapy modality in treatment of patients with Sudeck’s syndrome.
The rehabilitation of damage and disability in Sudeck dystrophy
Sanda DUBRAVČIĆ-ŠIMUNJAK, Ana BOBINAC-GEORGIEVSKI and Mira JAKŠIĆ
Sudeck dystrophy is a vasomotor disfunction, which causes the symptoms of pain, swelling, changes in skin color, and joint stifness, and the aggraviation of syndrome is usually caused by negative surrounding factors and by patients emotional state. In the whole process of rehabilitation prevention is playing an extremely important role, by early and interdisciplinary approach to the primary damage. Reflex sympathetic dystrophy may be considered as the secondary damage, and it deserves the real rehabilitation approach which includes: patients information and education, use of different procedures of physical therapy in which kinesytherapy with active patients approach is playing the important role, with use of occupational therapy for functional recovery. It is important to look the person in holistic way, because in many cases the organic and biomedical component of reflex sypathetic dystrophy is subject to successful recovery. Besides that it is important to work on psychological, emotional and psychosocial factors, by including in interdisciplinary rehabilitation program adequate experts like psychologist or social worker, and other experts if needed. It is important to stress that the patients motivation is playing almost the most important role in the whole rehabilitation process, because without patients cooperation it is impossible to repair the organic part of extremity damage.
Investigation of healing patients with Complex Regional Pain Syndroma, CRPS
Alboran DELIJA, Ladislav KRAPAC, Gordana KURNIK and Franjo ŠKREB
For Sudeck syndroma, described hundred years ago is most apropriate explanation by anglosaxon terminology Reflex Sympathetic Dystrophy-RSD or today more acceptable name-Complex Regional Pain Syndroma (CRPS) which explains relation of reaction between soft and hard tissues in the meaning of laesion of small blood circulatory system and peripheral nervous system as well as microcirculation in bones due to traumatic laesions od distal parts of extremities. Pathogenesis of development of CRPS is yet not known, no matter what possible positive feedback between bones, conective and ligament system increase negative feedback mechanism resulting in making dystrophic changes type: «vicious circle» on the very place of trauma and expanding on bigger part and volume of extremity as well as making «mirror image» on the proceedures in evaluation in CRPS is needed.
Dissimulation in Complex Regional Pain Syndrome (CRPS)
Ladislav KRAPAC and Zlatko RELJICA-KOSTIĆ
The case of a 53-year old teacher with complex regional pain syndrome (CRPS) of the right ankle joint, as a consequence of an injury as well as of premature overload is presented. In February 2000, he suffered the complicated fracture of the two bones of the low leg that was surgically treated by means of external fixation in the UH Dubrava. After removal of the xternal fixation an overloading of the lower extremity lead to the development of the CRPS, in Europe known as Sudeck Syndrome. The discussion has been varried on the importance of recognizing the comorbidity of circulatory disorders and arthrotic changes in lower extremities joints. The satisfaction with as well done job led this patients to prematurely overload the extremity affected by the disease.
Evaluation of work ability in Sudeck’s syndrome
Modern concept on classification of Sudeck’s syndrome is exposed. The importance of prevention, early institution of therapy and adequate rehabilitation are stressed. In the evaluation of work ability the step-wise approach is needed to evaluate the impairment, disability and handicap. Most frequently the hand, the foot, and psychological profile of the patient are the subject of evaluation. The need for the interdisciplinary team-approach in the process of rehabilitation and disability and handicap evaluation is stressed.