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Conséquences professionnelles des algodystrophies
Abstract
Objective: In spite of physical medicine and rehabilitation care, post-traumatic reflex sympathetic dystrophy can be at the origin of articular deficiency, which decrease the capacity to return to work. The aim of this study is to know the professional future of patients who present post-traumatic reflex sympathetic dystrophy.Material and method: Eighteen months prospective study, carried out from patients in age to work, hospitalized in physical medicine and rehabilitation unit for ostéo-articular traumatism complicated by reflex sympathetic dystrophy. Description of the population and comorbidity factors preventing professional resumption. Determination of the duration of medical certificate and the modalities of professional resumption.Results: From 16 patients in age to work, only 12 were able to resume a full time profession with an average period of 10.5 months ± 5. The importance of the, the distale articular location of reflex sympathetic dystrophy (wrist - hand, ankle - foot), the association with a comorbidity such as chronic alcoholism represent pejorative factors of working resumption. Organizations of workstation are often necessary in six cases over eight, if the job is not sedentary. In the most complicated cases, inaptitudes in the work are pronounced with demand of professional reclassifying.Conclusion: Post-traumatic reflex sympathetic dystrophy represents a real challenge for the rehabilitation team, to minimize deficiencies and to help the patient to become again a worker.
... 9 In addition, predictors for the return to work in CRPS were often based on cross-sectional or univariate analysis due to small sample sizes. [10][11][12] We expect that a multivariate longitudinal model predicting the work incapacity in patients with CRPS might help to better understand this condition. Among the indices for work incapacity, the time to fitness for work (TFW) is a valid measure and independent to the economic context. ...
Purpose
To assess and compare the healthcare costs, time to fitness for work (TFW) between chronic complex regional pain syndrome (CRPS) and non-CRPS; and identify factors associated with these outcomes in a comparative longitudinal study.
Patients and Methods
148 patients with chronic CRPS of the hand and 273 patients with chronic hand impairments but without CRPS (non-CRPS) were admitted at a Swiss rehabilitation clinic between 2007 and 2016. Healthcare costs and TFW were retrieved from insurance data over 5 years after the accident. Socio-demographic factors, biopsychosocial complexity measured by means of the INTERMED questionnaire, pain intensity and DASH disability scores were collected during rehabilitation. Generalized estimation equations and Cox proportional-hazards models were used to identify factors associated with outcomes.
Results
Healthcare costs were increased by 20% for the CRPS versus non-CRPS group (coefficient = 1.20, 95% CI = 1.08–1.35, p<0.001). The median TFW was longer for CRPS than non-CRPS patients (816 vs 672 days, p = 0.02). After adjusting for covariates, TFW did not differ between the two groups (hazard ratio = 0.94, 95% CI = 0.73–1.21, p=0.61). For CRPS patients, higher healthcare costs were associated with severe or moderate initial injury, high INTERMED or DASH disability scores. Longer TFW were associated with severe initial injury, low educational level, no work contract, and high INTERMED or DASH disability scores.
Conclusion
Overall, the healthcare costs were higher for CRPS than non-CRPS patients, but the TFW was comparable. We demonstrated also the significant associations of disability and biopsychosocial factors with the healthcare costs and TFW in CRPS patients.
... L'algodystrophie sympathique réflexe ou syndrome régional complexe douloureux de type 1 est habituellement considérée comme une affection bénigne mais peut laisser des séquelles à type de douleurs chroniques et/ou raideur articulaire [4] dans environ 30 % des cas, ce qui est source de handicap fonctionnel sévère [2]. Le but de la prise en charge rééducative associée au traitement médicamenteux est de diminuer ces séquelles fonctionnelles. ...
We report the case of a 24-years-old man with parcellar Complex Regional Pain Syndrome I (CRPS I) of the patella, responsible for major functional limitation. The diagnosis was based on physical exam and X-ray, in the absence of other articular or peri-articular diseases. The patient received two pamidronate perfusions over a week, with a spectacular decrease of pain, which allowed him to follow the rehabilitation program in good conditions. He was therefore able to go back to work. The place of this treatment in CRPS I is discussed.
Contexte et objectif : Plusieurs facteurs de risque associés à l’apparition d’un SDRC ont été découverts, mais les preuves scientifiques concernant les facteurs pronostiques associés à la progression de cette pathologie restent rares. Toutefois, la détection et la prise en charge de ces facteurs sont nécessaires pour élaborer des stratégies de prévention secondaire. L’objectif de cette revue systématique était d’identifier les facteurs pronostiques chez les adultes souffrant d’un SDRC précoce.
Base de données et traitement des données : PubMed, Embase, PsycINFO, Cochrane Library et Scopus, publiées entre janvier 1990 et novembre 2021. Deux investigateurs indépendants ont sélectionné les études transversales et longitudinales s’intéressant aux facteurs pronostiques précoces (< 12 semaines après l’apparition de la maladie) de la douleur, du score de sévérité du SDRC, de l’incapacité fonctionnelle, du retour au travail ou de la qualité de vie. L’outil QUIPS (Quality In Prognostic Studies) a été utilisé pour évaluer le risque de biais. Une métasynthèse qualitative a été réalisée.
Résultats : Sur 4 652 articles différents, six études répondaient aux critères d’inclusion. Nous avons identifié 21 facteurs précoces associés à un pronostic défavorable dans le SDRC de type I. Six d’entre eux présentaient un niveau de preuves modéré : intensité de la douleur, incapacité fonctionnelle, anxiété, peur du mouvement (kinésiophobie), sexe féminin et intensité du traumatisme physique déclencheur. Seules deux études présentaient un risque de biais globalement faible.
Conclusions : Cette étude a révélé un manque important d’informations sur les facteurs pronostiques précoces dans le SDRC. Un seul article s’est intéressé au lien entre le risque de chronicité et les caractéristiques psychologiques. Il est indispensable de réaliser des études de plus grande envergure, avec une population bien définie et des mesures validées.
Background and Objective
Several risk factors for the onset of CRPS have been found, but evidence for prognostic factors associated with progression of this condition remains sparse. However, detection and management of these factors are necessary to design secondary prevention strategies. The objective of this systematic review was to identify prognostic factors in adult individuals with early CRPS.
Database and Data Treatment
PubMed, Embase, PsycINFO, Cochrane Library, and Scopus, published between Jan 1990 and Nov 2021. Two independent investigators selected cross-sectional and longitudinal studies looking at early (<12 weeks from onset) prognostic factors for pain, CRPS severity score, disability, return to work, or Quality of life. The Quality In Prognostic Studies (QUIPS) tool was used to assess the risk of bias. A qualitative meta-synthesis was performed.
Results
Out of 4,652 different articles, six studies met inclusion criteria. We identified 21 early factors associated with poorer prognosis in type I CRPS. We found moderate evidence to support six of them: higher pain intensity, self-rated disability, anxiety, pain-related fear, being a female, and high-energy triggering event. Only two studies had an overall low risk of bias.
Conclusions
This study showed an important lack of information on early prognostic factors in CRPS. Only one article investigated the link with psychological characteristics. There is a crucial need of larger studies, with well-defined population using validated measures.
Résumé
Objectif
L’objectif principal de cette étude était de déterminer le taux de maintien en emploi, 4 ans après l’apparition d’un handicap locomoteur reconnu administrativement. Les objectifs secondaires étaient d’évaluer les modalités du maintien en emploi et le ressenti professionnel ainsi que rechercher des facteurs associés au maintien en emploi.
Méthodes
Étude descriptive, transversale et rétrospective au sein de la Maison départementale des personnes handicapées (MDPH) du département de la Vienne. Un recueil administratif a été réalisé dans les dossiers de la MDPH de 2013. Les personnes en emploi ayant obtenu une 1re Reconnaissance de la qualité de travailleur handicapé (RQTH) pour un handicap locomoteur en 2013 ont été contactées par téléphone pour connaître leur devenir professionnel. Le critère de jugement principal était le taux de personnes maintenues en emploi 4 ans après.
Résultats
Selon le recueil administratif, 352 personnes ont été inclues et contactées par téléphone entre le 30/10/2017 et le 04/02/2018 avec un taux de participation de 60,5 %. Le taux de maintien en emploi était de 64,79 % se répartissant en 13,04 % au même poste de travail sans modification, 62,32 % d’aménagement de poste, 22,5 % de reclassement interne et 2 % de reclassement externe. Une association significative positive avec le maintien en emploi était retrouvée pour l’ancienneté supérieure à 10 ans dans l’entreprise, l’établissement public et l’accompagnement individuel et une association négative pour l’arrêt de travail initial supérieur à 2 ans et les ressources de type invalidité ou rente. La satisfaction professionnelle varie selon la présence ou non d’un accompagnement individuel et le type de maintien en emploi (39 % de satisfaction si aucune modification, 81 % si aménagement(s) de poste et 84 % si reclassement interne).
Conclusion
Les résultats sur les facteurs associés au maintien en emploi soulignent l’importance de limiter les arrêts de travail prolongés et développer l’accompagnement spécifique pour le maintien en emploi avec des axes de progrès identifiés en termes d’orientation, d’information et de communication. De plus, dans la population étudiée, la RQTH semble avoir été une aide au maintien en emploi, en favorisant les aménagements et un accompagnement individuel.
Objectif : Décrire les cas de SDRC et leurs prises en charge. Méthodes : Étude descriptive des patients vus pour la première fois au CETD du CHU de ROUEN entre les 1ers novembre 2013 et 2014. Les patients étaient inclus selon les critères de Budapest. Un recueil prospectif de données épidémiologiques, cliniques, thérapeutiques, et des scores HAD, HAQ et SF-36 a été réalisé. Résultats : 39 patients d’âge moyen de 44,5 ans ont été inclus. La durée d’évolution moyenne était de 16,5 mois. Le SDRC était majoritairement post-traumatique (87,1%) et au membre supérieur (53,8%). Un contexte d’accident de travail était fréquent (43,6%). 82,0% des patients étaient inactifs. La durée moyenne d’arrêt de travail était de 13 mois. Les troubles sensoriels et moteurs étaient fréquents (94,9 et 89,7%) ainsi que la sous utilisation du membre (79,5%). L’EN douleur moyenne était de 5,6. Les patients présentaient des troubles anxio-dépressifs (51,8%). La douleur et les troubles anxio-dépressifs participaient aux limitations d’activités des patients (respectivement rho = 0,5 et 0,33). Seuls 5,1% des patients avaient une prise en charge psychologique. En moyenne, 4,6 classes médicamenteuses avaient été essayées. 59,0 % avaient bénéficié de kinésithérapie « conventionnelle » (en moyenne 74 séances), débutée tardivement (en moyenne 7,8 mois) avec une faible efficacité. Conclusion : Nos résultats incitent à une prise en charge multidisciplinaire plus adaptée tant sur le plan de l’éducation du patient, de la prise en charge psychologique, et socio-professionnelle. La faible efficacité des séances de kinésithérapie encourage à exploiter les nouvelles méthodes de rééducation.
ObjectifsDécrire l’état de santé et la prise en charge des patients atteints d’un syndrome douloureux régional complexe (SDRC), vus au centre d’évaluation et de traitement de la douleur (CETD). Matériel et méthodeÉtude descriptive des patients vus pour la première fois au CETD du CHU de Rouen entre les 1ers novembre 2013 et 2014. Tous les patients ayant un SDRC selon les critères de Budapest ont été inclus. Les données épidémiologiques, cliniques et thérapeutiques ont été recueillies. Le retentissement de la pathologie a été évalué à l’aide des scores HAD, HAQ et SF-36. RésultatsTrente-neuf patients d’âge moyen de 44,5 ans ont été inclus. La durée d’évolution moyenne du SDRC était de 16,5 mois. Le SDRC était majoritairement post-traumatique (87,1 %), aux membres supérieurs (53,8%). Le contexte d’accident de travail était fréquent (43,6 %). Une proportion élevée (79,5 %) des patients étaient inactifs. La durée moyenne d’arrêt de travail était de 13 mois. Les troubles sensoriels et moteurs étaient fréquents (94,9 et 89,7 %) ainsi que la sous-utilisation du membre (79,5 %). L’EN douleur moyenne était de 5,6/10. Les patients présentaient une limitation d’activité modérée à sévère (38,5 %), des troubles anxieux et/ou dépressifs (51,3 %) et une altération de la qualité de vie. Seuls 5,1 % des patients avaient une prise en charge psychologique. En moyenne, 4,6 classes médicamenteuses avaient été essayées. Plus de la moitié (59,0 %) avait bénéficié de kinésithérapie « conventionnelle », débutée tardivement (en moyenne 7,8 mois) avec une faible efficacité (78,3 % peu ou pas d’efficacité). Conclusion
Nos résultats incitent à une prise en charge multidisciplinaire plus adaptée tant sur le plan de l’éducation du patient, de la prise en charge psychologique et socioprofessionnelle. La faible efficacité des séances de kinésithérapie encourage à exploiter les nouvelles méthodes de rééducation.
Das CRPS I gilt in der Handtherapie als eines der heute immer noch am schwersten zu therapierenden Krankheitsbilder. In vielen therapeutischen Büchern wird über CRPS I und deren ergo- und physiotherapeutischen Behandlungsmöglichkeiten geschrieben. Innerhalb des Literaturangebots fällt auf, dass es im deutschsprachigen Raum kein einheitliches Behandlungskonzept gibt. Daher ist es nicht verwunderlich, dass sich sehr viele Experteninventarisierungen mit ungenügendem wissenschaftlichem Hintergrund finden lassen. Daher scheint eine evidenzbasierte Medizin, vor allem im Bereich der physikalischen Therapie, welche einen Eckpfeiler des Behandlungskonzepts des CRPS I darstellt, fast unmöglich. Vielleicht liegt darin mit begründet, dass nur ein Viertel der CRPS-Patienten nach 18 Monaten wieder ihre ursprüngliche Arbeit aufnehmen konnte, bei einem weiteren Viertel blieb die Arbeitsunfähigkeit bestehen.
Factors influencing disability and work absence in CRPS-1 have not been thoroughly described in the literature. We sought to determine whether demographic variables, work-related factors, CRPS clinical severity ratings, pain scores or psychological variables were associated with disability and sick leave in early CRPS-1.
66 CRPS-1 patients were recruited within 12 weeks of CRPS-onset. Patients completed measures of pain, depression, anxiety, stress, pain-catastrophizing and pain-related fear. A physical examination was conducted to assess signs and symptoms of CRPS and to calculate a CRPS severity score. Demographic details, clinical details, treatments, work type and work status were recorded.
In multivariate analyses, the following factors were associated with greater disability: higher pain scores, more restricted ankle or wrist extension, and higher levels of depression. Amongst the 49 who were either working or studying prior to developing CRPS, 28 had stopped work or study at the time of assessment. Multivariate analyses showed that sick leave was more likely amongst those whose CRPS was triggered by more severe injuries, whose work was more physically demanding, amongst those with higher disability scores, and there was also a significant effect of depression on sick leave, which was mediated by disability.
Although the study was cross-sectional so cannot differentiate cause from effect, results suggest that even in the early stages of CRPS, a cycle of pain, disability, depression and work absence can emerge. Treatments aimed to prevent this cycle may help prevent adverse long-term outcomes.
Background/aims
Spinal cord stimulation (SCS) is able to provide significant pain relief in individuals with complex regional pain syndrome (CRPS). Less is known about how this treatment impacts on function, particularly from the patients' perspective. This qualitative exploratory study was part of a larger service evaluation into current and future management of this patient group. This evaluation aimed to gain insight into the influence of SCS on daily activity and work and to explore the patients' journey from symptoms to diagnosis, SCS implant and afterwards.
Methods
A purposive sample of three patients took part in semi-structured interviews. Thematic content analysis of the data was then used to extract themes and subthemes.
Results
Thematic content analysis identified two emerging concepts: freedom and conflict. Within these two concepts, seven subthemes were apparent. Although participants described feelings of independence due to the effect of SCS on activity levels, other less encouraging issues were identified. These include a dependence on the stimulator, a lack of control over the future, and a perceived lack of understanding of their condition by others.
Conclusion
How these concepts relate to patients' ability to return to work is explored and areas for further research are identified.
Complex regional pain syndrome (CRPS) is a term used to describe a variety of disorders characterized by spontaneous or stimulus-induced pain that is disproportional to the inciting event and accompanied by a myriad of autonomic and motor disturbances in highly variable combinations. There are no standards which can be applied to the diagnosis and would fulfill definitions of evidence-based medicine. Indeed, there are almost as many diagnostic criteria as there are names to this disorder. The umbrella term CRPS has been subdivided into type I and type II. CRPS I is intended to encompass reflex sympathetic dystrophy and similar disorders without a nerve injury; while CRPS II occurs after damage to a peripheral nerve. There are numerous etiological pathophysiological events that have been incriminated in development of CRPS, including inflammation, autoimmune responses, abnormal cytokine production, sympathetic-sensory disorders, altered blood flow and central cortical reorganization. However, the number of studies that have included appropriate controls and have sufficient numbers of patients to allow statistical analysis with appropriate power calculations is vanishingly small. This has led to over-diagnosis and often excessive pharmacotherapy and even unecessary surgical interventions. In this review we provide a detailed critical overview of not only the history of CRPS, but also the epidemiology, the clinical features, the pathophysiological studies, the proposed criteria, the therapy and, in particular, an emphasis that future research should apply more rigorous standards to allow a better understanding of CRPS, i.e. what it is, if it is, and when it is.
OBJECTIVE: The aim of this systematic review was to merge and summarize the current evidence about prognostic factors relevant to the course of complex regional pain syndrome 1.
METHODS: MEDLINE, Embase, PsychINFO, CENTRAL and screened reference lists of included studies were searched for studies of parameters associated with the prognosis of the condition. Studies investigating stroke-related complex regional pain syndrome were excluded.
RESULTS: Searches retrieved 2,577 references, of which 12 articles were included in the study. The preferred diagnostic criteria were the Veldman and the International Association for the Study of Pain criteria. The mean level of study quality was insufficient. A total of 28 prognostic factors was identified. Sensory disturbances and cold skin temperature appear to represent parameters associated with poor prognosis in complex regional pain syndrome 1. For many parameters the evidence is contradictory.
CONCLUSION: Evidence about prognostic factors for complex regional pain syndrome 1 is scarce, which prevents firm conclusions being drawn. Further high-quality aetiological and clinical research is needed.
We report a case of a 47 years old patient, suffering from a parcellar knee algodystrophy with severe pain and significant functional impairment. The diagnosis was carried by magnetic resonance imaging (MRI). A treatment with alendronate (Fosamax 70 mg), three times a week for one month was prescribed because of non-response to antiosteoclastic treatment by calcitonin, analgesics and rehabilitation. An improvement was seen since the third week with a complete regression of pain. This clinical improvement allowed a speedy return to work and a good satisfaction.
To evaluate the efficacy of biphosphonates (BPs) in complex regional pain syndrome I or reflex sympathetic dystrophy and to specify their place in this chronic painful syndrome.
A literature review of Medline and Embase with use of a combination of 3 key words: biphosphonates therapy, reflex sympathetic dystrophy, complex regional pain syndrome I, controlled study. Each article was classified by 2 independent reviewers according to Aguilar's method into high, middle or low quality.
Three second-generation BPs were tested in the treatment of reflex sympathetic dystrophy: pamidronate, alendronate and clodronate. Many open studies investigated pamidronate, but only 2 were randomised and controlled: a low-quality trial comparing pamidronate with placebo and a middle-quality trial comparing pamidronate with calcitonine. Two high-quality trials were performed, 1 with alendronate and 1 with clodronate. Middle-quality trial and high-quality trials reported positive effects on pain with BPs in recent reflex sympathetic dystrophy (disease duration less than eight months). Side effects (fever, asymptomatic hypocalcemia) were observed frequently but disappeared quickly.
BPs can be used in recent reflex sympathetic dystrophy when calcitonin is inefficient or when calcitonin injections are not well tolerated.
This double-blind, randomized, multicenter study was designed to determine the short-term and long-term efficacy of intravenous regional block with guanethidine in patients with reflex sympathetic dystrophy (RSD)/causalgia. Sixty patients were enrolled to receive four intravenous regional blocks at 4-day intervals with either guanethidine or placebo in 0.5% lidocaine. Each patient was randomized to receive either one, two, or four blocks with guanethidine. Follow-up visits were scheduled for 4 days, 1 mo, 3 mo, and 6 mo after their final block. At 4 days after the initial block, the group treated with placebo experienced a greater decrease in pain scores than those treated with guanethidine, although this difference was not statistically significant. On long-term followup there was no difference in pain scores between groups receiving one, two, or four guanethidine blocks. Overall, only 35% of patients experienced clinically significant relief on long-term followup even though all were treated early in the evolution of RSD.
(Anesth Analg 1995;81:718-23)
This study of 60 cases confirmed the very great value of thyrocalcitonin for treatment of algodystrophy of the extremities: a satisfactory result was obtained in 74% of the cases, it was obtained in less than 20 days in 50% and was spectacular in 27%. Although the report concerns an open study, these results are sufficiently convincing to allow the conclusion that thyrocalcitonin often gives excellent effects in a disease which, when left untreated by traditional methods, often drags along for 6 months to 2 years and sometimes even longer.
The paper presents the results of a prospective trial to examine the natural history of early reflex sympathetic dystrophy (RSD). Thirty patients with post-traumatic RSD of the hand were observed without treatment. They were reassessed 1, 2 and 6 months after diagnosis with a final assessment at 10 to 18 months (average 13 months). Twenty-seven patients completed the study. Three were withdrawn during the study because of persistence of signs and symptoms of RSD and were given further treatment. Of the 27 patients who completed the study, only one showed sufficient features of the condition to warrant the diagnosis of mild RSD. In the remaining 26, most features of RSD had resolved spontaneously. Pain and swelling disappeared more quickly than other features of RSD. Although the signs and symptoms of RSD had largely gone at 13 months, the hands were still functionally impaired because of weaker grip strength.
Case histories of 125 patients with reflex sympathetic dystrophy syndrome of the upper extremity seen from July 1973 to March 1976 were reviewed. There was a 2.9:1 female preponderance. Twenty-four patients had documented litigation pending; however, it did not alter the final outcome significantly. On medical records, progress was noted for 86 patients with 16% having excellent results, 35% good, 26% satisfactory, 6% fair and 17% poor (all subjective evaluations by treating physicians). Median duration of follow-up prior to this study was approximately 2.5 months. Median duration between last clinic visit and follow-up study was 14.5 months. Follow-up letters sent to 123 patients who were believed to be alive showed that 4 patients had died; 77 (63%) replied. The majority of patients (53/77) reported that they still had pain in the shoulder/or hand, but 68% were taking no medications and only 15.3% (12) were taking narcotics. Twenty-eight patients (36%) claimed they were continuing physical therapy at home. Twenty-four (31%) retired or did not go back to the same work. Thirty-five percent were officially disabled, 30% were back at their same jobs and 29/59 female patients (49%) were able to do all the housework. Eighteen patients (23%) were able to return to 100% daily activity, 23 patients (30%) to 75% activity. Eleven patients (14%) had modified their activities considerably and were not able to do well.
The efficacy of intranasal salmon calcitonin was examined in a double-blind randomized study in reflex sympathetic dystrophy. Sixty-six patients were randomly divided in two groups receiving physiotherapy. In addition group I also received 3 x 100 U/day of salmon calcitonin by intranasal spray whereas group II received 3 sprays of placebo. The pain and the range of motion were improved by calcitonin administration. Similarly the patients' ability to work was also improved. The results confirmed that salmon calcitonin has an effect but that this effect was not equally observed on all parameters analyzed. It was most marked on pain (at rest and on movement) and on the ability to work.
We report the results of a prospective study of the incidence of algodystrophy following Colles' fracture in 60 patients, using sensitive or quantitative techniques for the assessment of each feature of the syndrome. Nine weeks after fracture, 24 patients had evidence of vasomotor instability, 23 had significant tenderness of the fingers and 23 had lost finger movement. These three abnormalities were significantly associated (p less than 0.001). Swelling was also significantly associated with these three variables. There was no statistical association between the occurrence of algodystrophy and the patient's age or sex, the severity of the fracture, the number of reductions performed or the adequacy of the reduction. We conclude that algodystrophy constitutes a precisely definable and quantifiable syndrome which is more common than has been suspected.
This retrospective review presents the results of treating 199 patients with sympathetic reflex dystrophy of the foot: 141 of traumatic and 58 of non-traumatic origin. Calcitonin (177 patients) improved or cured 62.2 p. 100 of these patients and was equally effective for pseudo inflammatory and ischemic (cold) stages of the disease. Among the therapeutic means available, regional sympathetic blockade with guanethidine (49 patients, 163 treatments) provided 80 p. 100 improvement or cure, with twice as many patients in the hot phase as in the cold. All patients were cured: 75 p. 100 in less than a year, 4.6 p. 100 with moderate, non-handicapping sequelae. Normal activities were partially reinstituted 3.5 +/- 2.8 months (post-trauma) or 1.9 +/- 1 months (non-trauma) after treatment. They were completely possible 5 months after the end of treatment in both groups. In the trauma group, 73 patients had work-related accidents: their evolution was the same as that of the other patients in this group. When present, psychological background (35 p. 100 of the cases) only delayed progress in the non-traumatic group (9.9 vs 6.5 months).
This double-blind, randomized, multicenter study was designed to determine the short-term and long-term efficacy of intravenous regional block with guanethidine in patients with reflex sympathetic dystrophy (RSD)/causalgia. Sixty patients were enrolled to receive four intravenous regional blocks at 4-day intervals with either guanethidine or placebo in 0.5% lidocaine. Each patient was randomized to receive either one, two, or four blocks with guanethidine. Follow-up visits were scheduled for 4 days, 1 mo, 3 mo, and 6 mo after their final block. At 4 days after the initial block, the group treated with placebo experienced a greater decrease in pain scores than those treated with guanethidine, although this difference was not statistically significant. On long-term followup there was no difference in pain scores between groups receiving one, two, or four guanethidine blocks. Overall, only 35% of patients experienced clinically significant relief on long-term followup even though all were treated early in the evolution of RSD.
The pathogenesis of reflex sympathetic dystrophy--variously known as Sudeck's atrophy, causalgia, algodystrophy, and peripheral trophoneurosis--is not yet understood, and diagnosing and treating patients is difficult. We have prospectively studied 829 patients, paying particular attention to early signs and symptoms. In its early phase, reflex sympathetic dystrophy is characterised by regional inflammation, which increases after muscular exercise. Pain was present in 93% of patients, and hypoaesthesia and hyperpathy were present in 69% and 75% respectively. With time, tissue atrophy may occur as well as involuntary movements, muscle spasms, or pseudoparalysis. Tremor was found in 49% and muscular incoordination in 54% of patients. Sympathetic signs such as hyperhidrosis are infrequent and therefore have no diagnostic value. We found no evidence consistent with the presence of three consecutive phases of the disease. Early symptoms are those of an inflammatory reaction and not of a disturbance of the sympathetic nervous system. These data support the concept of an exaggerated regional inflammatory response to injury or operation in reflex sympathetic dystrophy.
We present a revised taxonomic system for disorders previously called reflex sympathetic dystrophy (RSD) and causalgia. The system resulted from a special consensus conference that was convened on this topic and is based upon the patient's history, presenting symptoms, and findings at the time of diagnosis. The disorders are grouped under the umbrella term CRPS: complex regional pain syndrome. This overall term, CRPS, requires the presence of regional pain and sensory changes following a noxious event. Further, the pain is associated with findings such as abnormal skin color, temperature change, abnormal sudomotor activity, or edema. The combination of these findings exceeds their expected magnitude in response to known physical damage during and following the inciting event. Two types of CRPS have been recognized: type I, corresponds to RSD and occurs without a definable nerve lesion, and type II, formerly called causalgia refers to cases where a definable nerve lesion is present. The term sympathetically maintained pain (SMP) was also evaluated and considered to be a variable phenomenon associated with a variety of disorders, including CRPS types I and II. These revised categories have been included in the 2nd edition of the IASP Classification of Chronic Pain Syndromes.
The aim of this retrospective long-term follow-up study was to describe the psychosocial aspects, such as social life events (SLE), around the causative event of reflex sympathetic dystrophy (RSD) and the psychological history of 65 patients, 3–9 years after RSD of the upper extremity. General health and long-term changes in occupation were assessed by means of a general health questionnaire (RAND-36) and a structured interview, respectively.
SLE, with a life-change unit rate more than 35, was present in 32 patients. A psychological (or psychiatric) history was found in 22 patients. In total, 60% of the patients had a SLE and/or a psychological history. The pain scores of the RAND-36 among RSD patients differed significantly from those of the control group. 17 patients changed occupation after RSD. Nearly 30% of the patients had to stop work for more than one year.
The results show a high coincidence between RSD and associated psychosocial disorders and this may play a role in intensifying and prolonging the symptomatology of RSD.
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