So, algodystrophy otherwise called the complex regional pain syndrome (CRPS) or regional sympathetic dystrophy is not what we see or develop regularly. There are a lot of synonyms for algodystrophy. This condition was initially termed as ‘causalgia’. The condition was first described by Weir Mitchell in 1872. He observed a set of symptoms in American soldiers. They exhibited bizarre symptoms following gun-shot injuries or wounds.
Following this Peter Sudeck in the 20th century observed a phenomenon wherein the person exhibited pain, swelling, atrophy etc. following minor injuries. He named the condition Sudeck’s phenomena. A few years later the term reflex sympathetic dystrophy was increasingly used.
It is a chronic condition that causes pain and burning sensation added up with swelling in the arm, hands, legs and feet.
MECHANISM OF ALGODYSTROPHY:
Algodystrophy can be defined as a state of pain maintained by the efferent nervous system. This state of pain is caused by neurochemical activation or catecholamines.
The body’s normal response to an injury is when the pain receptors deliver pain messages in the form of nerve impulses. The three main hypotheses include,
- Autonomic dysfunction
- Neurogenic inflammation
- Neuroplastic changes within the CNS.
CRPS can strike at any age. Any person could be susceptible to this condition. But the mean age of occurrence is around 42. It affects both men and women. But women are 3 times more susceptible to CRPS than men. Further, studies have shown that 2%-5% of people with peripheral nerve injury and 13%-70% of people with hemiplegia might suffer from algodystrophy.
The mean incidence of occurrence is 5/1,00,000.
IMPORTANT PREDISPOSING FACTORS:
Certain important factors might predispose to CRPS. But, there are no defined set of symptoms that help us diagnose algodystrophy. Some of the symptoms that patients commonly complaint about are,
- Persistent pain that lingers on after an injury has healed. The history of the injury might be trivial or very minor.
- Often, a minor injury is enough to trigger algodystrophy.
Certain other factors include,
A tight cast following a fracture might trigger CRPS type 1. On the other hand, postoperative pain cannot always be due to algodystrophy. This might also be due to nerve injury during the surgery, neuropraxia, an infection when the tourniquet is tightened beyond a limit and an occult fracture.
SYMPTOMS OF ALGODYSTROPHY:
The presenting features of CRPS or algodystrophy include,
According to McGill’s pain scale, CRPS has a rating of 46/50.
- Pain is a very common symptom. But in this case the pain is usually out of proportion to the initial injury. The injury might be very minor and the person’s way of explaining the pain might not match with the injury.
- This pain might involve an entire limb (an arm or a foot)
- Further, even very minor activities or small tasks might seem hectic. Tasks like lifting objects, wearing a shirt may seem to be a lot of work. This type of pain is termed as allodynia.
- The pain is usually constant but may slightly vary in intensity over a period of time.
- Swelling is very common in this condition and the person might even develop stiffness over the joint.
- Further, certain others symptoms include temperature changes, loss of hair or skin creases over the affected area. Also, there might be palmar fibrosis, dystonia and hyperhydrosis (excess sweating).
The most reliable method of diagnosing CRPS is through, three-phase bone scanning or scintigraphy. This is done since it produces a significant uptake in the metacarpal bones. Moreover, this test has high sensitivity and specificity for CPRS. Further, an involves an angiogram, a blood pool and a delayed X-ray, wherein the imaging is done 3-4 hours after injection. The uptake of the tracer dye in the X-ray may be an important tool in diagnosis. Further, complete blood count is a routine and an important part of the diagnosis.
Thermography might help us to identify algodystrophy. But this cannot be solely depended upon for confirming the diagnosis. Further, smoking, alcohol, lotions and physical activities might alter results.
Other diagnostic tests include,
- Regional intravenous block
- Sympathetic ganglia block
- Phentolamine infusion test (alpha-1 receptor antagonist)
TYPES OF CRPS:
There are 2 types of CRPS, they are,
- Type 1 – RSD
- Tye 2- Causalgia
Further, according to the spread of pain,
|TYPE OF CRPS||FEATURES|
|Continuity Spread||The pain starts from one part of the limb and spreads upwards. For instance, the pain starts from the foot and spreads to the calf, thighs etc.|
|Mirror-image type||The pain spreads exactly opposite to the limb where the pain initially originated.|
|Independent spread||In this type, the spread of the pain is totally independent of the limb of origin.|
|Total body CRPS||Rare variant of CRPS. In this type, the pain emanates to the total body irrespective of the origin.|
There are some important strategies in managing algodystrophy. The goals of managing CRPS include,
- Effective pain management
- Psychological intervention
- Physical and voctional management
- Patient support and education
MANAGING THROUGH DRUGS:
Firstly, the earlier the diagnosis the better is the management. The drugs used in the management include Vitamin C, certain steroids, bisphosphonates, anti-arrhythmic, quinazolines, local anaesthetics, muscle relaxants etc. Drugs are administered intravenously. Your doctor will prescribe certain drugs to take orally. It’s important to have a proper diagnosis and to tailor your drugs according to your needs.
MANAGING THROUGH PHYSICAL THERAPY:
Further, physical therapy is equally important in managing CRPS. This helps to avoid contractures and to avoid atopy. Moreover, physical therapy can help to reduce pain and maintain the mobility of the joints. Also, this improves the coordination and functional ability of the limb. The person should spend a good amount of time in physical therapy to recover faster.
MANAGING THROUGH PSYCHOLOGICAL THERAPY:
Certain psychological dysfunctions might reflect the underlying disease. In this case, your doctor might suggest,
- Relaxation therapies
- Mirror therapy as in amputation patients
- Pain coping skills
- And, cognitive behavioral therapy (CBT).
MANAGEMENT THROUGH INVASIVE THERAPY OR SURGERY:
This is usually the last resort of treatment when other modalities of treatment fail. This usually involves sympathetic nerve blocks which might serve a dual purpose. This might be both diagnostic and therapeutic. This might also help patients to tolerate and physical and occupational therapy. Further, peripheral nerve stimulators in the form of TENS (Transcutaneous electric stimulation), peripheral nerve stimulation and spinal cord stimulation.
A chemical or surgical sympathectomy can be performed. These have been found to be effective. This can b achieved through excision or electrocautery. Further, surgical compression can be done in case of injury from surgery or carpal tunnel syndrome from median nerve damage, which often occurs from hypothyroidism.
Further, studies have shown early diagnosis and treatment can resolve this within 6-12 months and have an overall good outcome. If diagnosed and treated early, spontaneous resolution can occur.
To sum up, CRPS can be an extremely painful condition resulting from a very minor injury. Also, timely diagnosis and treatment of the condition can go a long way in managing CPRS effectively. Diagnosis can be made clearly based on the clinical criteria. Further, multiple approaches can effectively manage the condition.