Sudeck’s disease

Sudeck’s disease: description

Sudeck’s disease (CRPS) is the result of a tissue injury. Such an injury often results from accidents, but can also be the result of surgical procedures. Several weeks after the injury, pain suddenly appears in the affected area, which can not be explained by the original injury. The most commonly affected are the arms or legs (extremities), but in rare cases also the face or other parts of the body.

In addition to the pain, the sufferers show other symptoms, so that the disease is now mostly referred to as “complex regional pain syndrome” or CRPS. Other Sudeck’s symptoms include, for example, a disorder of body awareness, hypersensitivity to touch, disturbed mobility, or fluid retention. These disturbances occur exclusively at the injury site, or in spatial proximity to this.

The disease has other synonyms, some of which are outdated but still frequently used by doctors. The following terms describe the same disease:

• Sudeck’s disease
• complex regional pain syndrome
• Complex regional pain syndrome (CRPS)
• Sudeck syndrome
• Reflex sympathetic dystrophy
• Reflex sympathetic dystrophy
• Sudeck’s disease
• Sympathetic reflex dystrophy

There are two types of CRPS: CRPS type I and CRPS type II. Both CRPS types have the same symptoms, but they differ in the type of original injury that caused the CRPS:

When CRPS I no direct nerve damage is detectable at the initial injury. This can be the case with a sprained ankle, for example. CRPS I is also referred to as the classic Sudeck’s disease. About 90 percent of CRPS cases are CRPS type I.

With the CRPS II The disease is based on a detectable nerve damage, for example, by a major surgery or a fracture, which is almost always also the injury of nerve tracts. CRPS II is also referred to as causalgia. About ten percent of CRPS cases are Type II CRPS.

In about two to five percent of the patients who injure themselves on one extremity, a post-traumatic Sudeck’s disease develops. Women are affected more frequently than men, as are people between the ages of 40 and 70 years. The disease is more common on the arms than on the legs. If Sudeck’s disease is diagnosed early and adequately treated, the symptoms can ease or disappear in more than half of patients with CRPS syndrome if they are uncomplicated.

Sudeck’s disease: symptoms

Sudeck’s symptoms are directly related or at least close to the original site of injury. The disorders affect both the sensation (sensor), as well as the movement (motor skills) and the unconscious control of body functions (autonomic nervous system). The namesake of the disease, the surgeon Paul Sudeck, described in the symptoms of three stages, which follow one another in the course of the disease. However, this phase-like course is almost never so clearly recognizable in practice. Basically, the three phases give a good overview of possible symptoms:

Stage I – Inflammatory stage: At this stage, the symptoms are similar to those of acute inflammation. There are typical signs of inflammation at the affected area:

• Redness (rubor)
• Doughy swelling (edema)
• Spontaneous pain (Dolor)
• Function restriction (Functio laesa)
• Overheating (calor)

Stage II – Dystrophic stage: The pain is somewhat declining at this stage. The skin is rather cool and pale in contrast to stage I. Affected joints can stiffen and the muscles can be broken down (muscular dystrophy). In the X-ray image, a decalcification of the bones in the affected body region occurs.

Stage III – Atrophic stage: The pain is much weaker or completely gone at this stage. The skin looks remarkably thin and shiny. Overall, a significant loss (atrophy) of connective tissue and muscle falls on. Affected joints can be completely stiffened and dysfunctional.

As described above, Sudeck syndrome has effects on all three qualities of the nervous system: sensation, motor function, and the autonomic nervous system.

The sensor technology can be impaired in the following way:

• Permanent pain both at rest and during exercise
• paresthesia
• Excessive pain sensitivity to harmless stimuli such as a touch (hyperalgesia)
• Disruption of body perception (for example, non-perception of the affected limb, neglect-like syndrome)

Motor failures can be characterized by:

• Limited mobility, both active and passive
• The execution of small, precise movements is disturbed
• The force with which movements are carried out is diminished by the pain
• Rarely, involuntary muscle tremors, twitching and tensioning can occur

Signs of autonomic nervous system damage include:

• An altered skin circulation and thus a different skin color and temperature compared to the healthy limb
• Increased sweating at the affected area
• Water retention (edema)
• Hair and nails, connective tissue, muscles and bones may be disturbed in growth (trophic), for example, increased hair may grow at the affected body site.

Not to be ignored is also the psychological stress that afflicts patients suffering from Sudeck’s chronic symptoms. The constant pain and limited mobility can lead to depression and social withdrawal. Therefore, if there is a great deal of suffering, the psychological effects of a CRPS syndrome should be specifically treated, for example psychotherapeutically.

Sudeck’s disease: causes and risk factors

Theoretically, Sudeck dystrophy can develop after each injury. The extent of the injury is not necessarily related to the severity of the pain. For example, a very small lesion can cause severe Sudeck’s disease. Likewise, massive injuries can heal without causing algodystrophy.

In total, two to five percent of patients with an extremity injury develop Sudeck’s disease. Women are more often affected by the disease, as are people between the age of 40 and 70 years. Especially common is Sudeck’s syndrome after a fracture of the radius (radius fracture). In surgery, tissue is also injured, causing the disease to develop. In Germany, however, a thousand surgical procedures are performed every day without corresponding symptoms. Why Sudeck’s disease develops in some cases remains completely unclear.

Possible risk factors that make occurrence after injury more likely are:

• Joint-like fractures (the paradigm is the fracture of the spine)
• Painful narrowing (reposition) of dislocated joints
• Long-lasting, untreated pain after a bone fracture
• Restrictive bandages after an injury

Another risk factor is traumatic, inadequately-processed experiences in the past. Other psychological factors such as increased anxiety or self-esteem problems can also influence the development or course of Sudeck’s disease.

Sudeck’s Disease Causes: Dysregulation of the Autonomic Nervous System

After the injury of a nerve, it is above all the parts of the unconscious (autonomous) nervous system that are probably the main reason for the development of Sudeck’s disease. In particular, the sympathetic nervous system (a part of the autonomic nervous system) seems to be significantly involved in the formation of a CRPS. The two antagonists of the autonomic nervous system (sympathetic and parasympathetic) provide for an involuntary control of body functions such as blood circulation, sweat secretion or heart function.

Which mechanisms are behind this is not yet known. But there are some hypotheses. The damage to these nerve fibers due to tissue injury leads to an excessive dysregulation of the sympathetic, which disturbs the healing process. Therefore, Sudeck’s disease is also referred to as sympathetic reflex dystrophy. The hyperactivity of the sympathetic affects the sensation of pain. At the affected area more pain-causing substances are released. These in turn interfere with blood flow and water retention forms. Increasingly, it comes to the conversion of various structures, which is why the pain and dysfunction continue.

Sudeck’s disease: examinations and diagnosis

Patients often err from doctor to doctor until the diagnosis is made. This is partly due to the variety of possible symptoms of the disease. Basically, however, Sudeck’s disease should always be considered when, after weeks of injury or surgery, pain occurs and the affected area of ​​the body is also visually altered.

The right ones Contact Person In this suspicion, for example, the family doctor, a surgeon or a doctor with the additional name pain therapy can be. Also physiotherapists and ergotherapists often have a lot of experience with the diagnosis and treatment of Sudeck’s disease. The detection of a CRPS is referred to as a so-called exclusion diagnosis. This means that other possible causes of the symptoms have to be ruled out before this diagnosis can be made.

For the diagnosis the doctor inquires about your current complaints and possible pre-existing diseases and operations (Anamnese), Typical questions of the doctor could be:

• How long have you already had the pain?
• Have you injured or been operated on at this point?
• Do you have the x-rays of the injury?
• How long is the injury / surgery?
• Do you have any other medical conditions, for example rheumatic diseases?
• Do you take any medicine?

In the physical examination In particular, the doctor pays attention to an obvious change in the region of the injury. These include tissue loss of connective tissue and musculature (atrophy), overheating of the skin, a functional impairment of joints, and possibly increased sweating and remarkably increased hair growth directly at or near the original injury. In addition, the temperature of the skin can be measured and compared with the healthy opposite side. Temperature differences of the skin speak for a CRPS.

To formally diagnose Sudeck’s disease, the so-called Budapest criteria be fulfilled. These criteria include:

• Permanent pain that can not be explained by the original injury
• The patient must report at least one symptom from each of three of the following four categories, and the examiner must identify at least one symptom from each of two of the following four categories:
  • excessive sensitivity to pain or touch
  • in the page comparison differences in skin temperature or color
  • in the page comparison differences in sweating or water retention
  • limited mobility, increased muscle tension, trembling or weakness, altered hair or nail growth

• Other illnesses as causes of the complaints are excluded (for example rheumatic diseases, compartment syndrome, thrombosis, inflammation, osteoarthritis, etc.)

If ambiguities persist, the following may be used to confirm Sudeck’s disease further investigations be performed:

• roentgen: on the affected limb, small spot decalcifications of the bone are formed, especially in comparison to the side of the big differences.
• Mehrphasenszintigramm (“Three-Phase Skeleton Scintigraphy”): Banded accumulations of the so-called tracer near the joints show up
• Skin temperature measurement: permanently or repeatedly measured differences in the side comparison by more than 1 to 2 ° C

Sudeck’s disease: treatment

Morbus-Sudeck therapy should be performed by an experienced specialist, as the treatment is relatively complex and requires the collaboration of professionals from various disciplines (physiotherapists, occupational therapists, physicians). In addition, both the patient and the therapist must be very patient. Even small improvements should be considered a success. In the case of Sudeck’s disease, interdisciplinary pain therapy is in the foreground. This consists of:

• Medical therapy
• physical therapy
• occupational Therapy
• psychotherapy
• Interventional therapy

Medical therapy

Depending on the symptoms, various groups of drugs are used. In the foreground of the Sudeck therapy is a targeted pain therapy according to the WHO grading scheme for the treatment of chronic pain. Usually, one starts with so-called non-opioid analgesics (Step 1), such as paracetamol or ibuprofen. If these are not sufficient, weak opioids may be added in addition to stage 1 (Level 2) or strong opioids (Level 3) be added. Opioids are descendants of morphine, but a dependency is not expected in the rule. Against the shooting, burning (neuropathic) pain, the drugs gabapentin, ketamine or so-called tricyclic antidepressants can be administered. These medicines are primarily used for other diseases. However, it has been known for some time that they are also very effective against neuropathic pain.

As a further substance group so-called bisphosphonates are used. They inhibit those cells (osteoclasts) that break down the bone. If the degradation of the bone substance is prevented by medication, this often relieves the pain in CRPS. Especially at the beginning of Sudeck’s disease, when there is an acute inflammation, the drugs calcitonin or cortisone are useful because they have an anti-inflammatory effect. In addition to the anti-inflammatory effect cortisone works well against water retention (anti-oedematous).

physical therapy

Physiotherapy occupies a central position in the treatment of Sudeck’s disease. It aims to correct pathological patterns of movement or evasive movements provoked by the pain, and to mobilize the patient bit by bit. It takes a lot of patience and encouragement, so that the patient tries, even in pain, to move the affected limb. The physiotherapeutic measures also include the lymphatic drainage and the so-called proprioceptive neuromuscular facilitation (PNF). Also recommended are daily physiotherapy exercises.

occupational Therapy

With the help of occupational therapy, patients should learn to cope better with their everyday lives and to cope with their environment. This is an attempt to restore normal movement and to improve the feeling. Above all, the excessive sensitivity to pain in the affected limb should be reduced.

psychotherapy

Psychotherapy for Sudeck’s disease is often useful because the chronic pain can lead to depression and despair. In psychotherapy, those affected learn techniques to better cope with the psychological effects of their illness. For example, relaxation techniques or specific techniques are used to help them cope better with emotional and physical stress and possible fears. Especially for patients who had mental illness prior to the disease of Sudeck’s disease, a psychotherapeutic treatment in addition to purely physical therapy makes sense.

Interventional therapy

Interventional therapy is understood as intervention where the disease is treated by specific interventional techniques. The interventional Morbus-Sudeck therapy should only be performed by specialists because of possible complications. These therapies include sympathetic nervous system blockages, spinal cord electrical stimulation and the introduction of baclofen into the spinal canal. Both sympathetic blockade and spinal cord stimulation aim to relieve the pain. Baclofen is a medication that is used to relieve muscle tension.

Sudeck’s disease: disease course and prognosis

Sudeck’s disease is a mostly chronic disease. Fortunately, more than half of the patients experience a decrease or even disappearance of the symptoms. Especially in children, the prognosis is favorable. For this case to occur, the disease must be recognized as quickly as possible and treated appropriately.

Since Sudeck’s disease also rarely occurs after surgical interventions, in principle non-necessary surgical interventions should be avoided. An operation should always have a medically justifiable cause (an indication). Even if Sudeck’s disease is extremely unlikely if the surgical technique and pain numbness are appropriate, it can prevent unnecessary cases of Sudeck’s disease.

If the disease is not diagnosed for a long time, the right therapy is not used, or complicating factors such as mental illness can be added Sudeck’s disease run chronically.