ans disorders, rsd, hypertonicity

7/26/2019 ANS Disorders, RSD, Hypertonicity

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MES 2 : ANS Disorders,MES 2 : ANS Disorders,

Reflex Sympathetic Dystrophy,Reflex Sympathetic Dystrophy,

HypertonicityHypertonicity

Ramon Antonio S. Sarmiento ,MDRamon Antonio S. Sarmiento ,MD

DLSU-HSCDLSU-HSC


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ANS DisordersANS Disorders

I.I. Autonomic DysreflexiaAutonomic Dysreflexia

II.II. Central PainCentral Pain

A. CRPSA. CRPSB. Reflex Symat!etic Dystro!yB. Reflex Symat!etic Dystro!y

C. Su"ec#$s atro!yC. Su"ec#$s atro!y

IIIIII. Hyertonicity. Hyertonicity


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Autonomic DysreflexiaAutonomic Dysreflexia

syn"rome of massi%esyn"rome of massi%e

symat!etic "isc!ar&esymat!etic "isc!ar&e

tri&&ere" 'y a noxious stimulitri&&ere" 'y a noxious stimulicommon in SCI atients (it!common in SCI atients (it!

lesions a'o%e )* le%ellesions a'o%e )* le%el


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Clinical ManifestationsClinical Manifestations

+. Hyertension+. Hyertension

. Hea"ac!e. Hea"ac!e

. S(eatin&. S(eatin&. /asal con&estion. /asal con&estion

0. 1acial flus!in&0. 1acial flus!in&

*. Piloerection*. Piloerection2. Reflex 'ra"ycar"ia2. Reflex 'ra"ycar"ia


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Causes Noxious stimuliCauses Noxious stimuli

Bla""er an" 'o(el "istention "ue toBla""er an" 'o(el "istention "ue toneuro&enic 'la""erneuro&enic 'la""er

Pressure soresPressure soresIn&ro(n toenailsIn&ro(n toenails)i&!t clot!in& an" s!oes)i&!t clot!in& an" s!oesUrinary tract infectionsUrinary tract infectionsUterine contractionsUterine contractionsIn%asi%e roce"ureIn%asi%e roce"ure


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!athophysiolo"y!athophysiolo"y

Interrution of in!i'itory si&nalsInterrution of in!i'itory si&nalsPeri!eral an" slanc!nic %asoconstrictiPeri!eral an" slanc!nic %asoconstricti

HyertensionHyertension

Mass symat!etic "isc!ar&es 3Mass symat!etic "isc!ar&es 3

# s(eatin& an" iloerections(eatin& an" iloerection

# Reflex 'ra"ycar"ia an"Reflex 'ra"ycar"ia an"

%aso"ilation 4facial flus!in& an"%aso"ilation 4facial flus!in& an"

con&estion5con&estion5


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!athophysiolo"y!athophysiolo"y

/oxious stimuli/oxious stimuli

ImulsesImulses

Dorsal column 6 Sinot!alamic tractsDorsal column 6 Sinot!alamic tracts In!i'ition of imulsesIn!i'ition of imulses

Symat!etic neuronsSymat!etic neurons

Symat!etic resonseSymat!etic resonse


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ComplicationsComplications

ConfusionConfusion7isual "istur'ance7isual "istur'anceLoss of consciousnessLoss of consciousness8nce!aloat!y8nce!aloat!yIntracere'ral !emorr!a&eIntracere'ral !emorr!a&eSei9uresSei9uresAcute myocar"ial failureAcute myocar"ial failurePulmonary e"emaPulmonary e"ema


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$reatment$reatment

+. I"entify an" remo%e t!e noxious+. I"entify an" remo%e t!e noxious

stimulistimuli

. Sit t!e atient u an" monitor 'loo". Sit t!e atient u an" monitor 'loo"

ressureressure

. Me"ications for !yertension3. Me"ications for !yertension3

/itrates, nife"iine, !y"rala9ine/itrates, nife"iine, !y"rala9ine

. Pre%ention of recurrence. Pre%ention of recurrence

0. Patient an" family e"ucation0. Patient an" family e"ucation


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Central !ainCentral !ain

Pain associate" (it! a central ner%ousPain associate" (it! a central ner%ouslesionlesion

8xamles38xamles3

# )!alamic ain syn"rome)!alamic ain syn"rome# Comlex Re&ional Pain Syn"romesComlex Re&ional Pain Syn"romes4CRPS54CRPS5

# Causal&iaCausal&ia# Reflex Symat!etic Dystro!yReflex Symat!etic Dystro!y44RSD5RSD5


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CR!SCR!S

Clinical fin"in&s3Clinical fin"in&s3

+. Pain an" sensory a'normalities+. Pain an" sensory a'normalities

. A'normal 'loo" flo( an". A'normal 'loo" flo( an" s(eatin&s(eatin&

. A'normality in motor system. A'normality in motor system. )ro!ic c!an&es. )ro!ic c!an&es


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CR!S $ype ':CR!S $ype ':

Reflex Sympathetic DystrophyReflex Sympathetic DystrophySyn"rome t!at "e%elos after aSyn"rome t!at "e%elos after a

noxious e%entnoxious e%ent

not limite" to a eri!eral ner%enot limite" to a eri!eral ner%e

"istri'ution"istri'ution

symtoms "isroortionate tosymtoms "isroortionate tot!e incitin& e%entt!e incitin& e%ent

Distal < roximalDistal < roximal


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Reflex Sympathetic DystrophyReflex Sympathetic Dystrophy

8tiolo&y3 Un#no(n8tiolo&y3 Un#no(n

=t!er terms3=t!er terms3

+. Su"ec#$s atro!y+. Su"ec#$s atro!y. S!oul"er !an" syn"rome. S!oul"er !an" syn"rome


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Sudec()s atrophySudec()s atrophy

Symat!etic symtoms associate"Symat!etic symtoms associate"

(it! traumatic fractures(it! traumatic fractures

Presents (it! ain, L=M, musclePresents (it! ain, L=M, muscleatro!y, cyanosis an" e"emaatro!y, cyanosis an" e"ema

Dia&nostic3 x-rayDia&nostic3 x-ray

In%ol%es "istal extremitiesIn%ol%es "istal extremities

Lasts (ee#s to mont!sLasts (ee#s to mont!s


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Shoulder Hand SyndromeShoulder Hand Syndrome

Associate" (it! coronaryAssociate" (it! coronary

isc!emia an" C7Aisc!emia an" C7A

Painful s!oul"er, !an" an" fin&erPainful s!oul"er, !an" an" fin&erSe%erity not roortional toSe%erity not roortional to

extent of un"erlyin& "isor"erextent of un"erlyin& "isor"er


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RSD: Si"ns and symptomsRSD: Si"ns and symptoms

ain follo(s traumaain follo(s trauma onset3 + mont! after in>uryonset3 + mont! after in>ury

'urnin& an" continuous ain'urnin& an" continuous ain exacer'ate" 'y mo%ement,exacer'ate" 'y mo%ement,

stimulation an" stressstimulation an" stress

4?5 allo"ynia an" !yeral&esia4?5 allo"ynia an" !yeral&esia c!an&e in s#in temerature an"c!an&e in s#in temerature an"

color, e"emacolor, e"ema


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RSD: Si"ns and SymptomsRSD: Si"ns and Symptoms

increase"@ "ecrease" s(eatin&increase"@ "ecrease" s(eatin& imairment of motor functionimairment of motor function

atro!y of s#in an" nailsatro!y of s#in an" nails alterations in !air &ro(t!alterations in !air &ro(t!

loss of >oint mo'ilityloss of >oint mo'ility

(ea#ness an" tremor(ea#ness an" tremor

fluctuatin& si&ns an" symtomsfluctuatin& si&ns an" symtoms


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* Sta"es of RSD* Sta"es of RSD

I. Acute sta&eI. Acute sta&e

# Constant 'urnin& ainConstant 'urnin& ain

# !yeral&esia, !yerest!esia!yeral&esia, !yerest!esia

# !yerat!ia!yerat!ia

# locali9e" e"emalocali9e" e"ema

#increase" !air an" nail &ro(t!increase" !air an" nail &ro(t!

# Increase s#in temeratureIncrease s#in temerature

# muscle (ea#ness, sasmsmuscle (ea#ness, sasms


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Sta"es of RSDSta"es of RSD

II. Dystro!ic sta&eII. Dystro!ic sta&e# !yersensiti%ity an"!yersensiti%ity an"

'urnin& ain'urnin& ain

# lo(ere" s#in temeraturelo(ere" s#in temerature# cessation of !air@ nail &ro(t!cessation of !air@ nail &ro(t!# !yer!y"rosis!yer!y"rosis

# cyanotic s#in colorcyanotic s#in color# muscle atro!ymuscle atro!y# sotty osteoorosissotty osteoorosis


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Sta"es of RSDSta"es of RSD

III. Atro!ic sta&eIII. Atro!ic sta&e

# "ecrease !yersensiti%ity"ecrease !yersensiti%ity

# normali9ation of 'loo" flo(normali9ation of 'loo" flo(an" temeraturean" temerature

# smoot!, &lossy s#insmoot!, &lossy s#in

# se%ere muscle atro!yse%ere muscle atro!y

# "iffuse osteoorosis"iffuse osteoorosis


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RSD: Dia"nosisRSD: Dia"nosis

Difficult to "ia&noseDifficult to "ia&nose

Use anatomic@ !armacolo&icUse anatomic@ !armacolo&ic

ner%e 'loc#sner%e 'loc#s)ec!netium "i!os!onate 'one)ec!netium "i!os!onate 'one

scansscans


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RSD: ComplicationsRSD: Complications

P!le'itisP!le'itis

Inaroriate "ru& useInaroriate "ru& use

Suici"eSuici"e


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RSD: $reatmentRSD: $reatment

)!eraeutic exercise)!eraeutic exerciseSymat!etic ner%e 'loc#sSymat!etic ner%e 'loc#sPsyc!olo&ical counselin&Psyc!olo&ical counselin&P!armacolo&ical inter%ention3P!armacolo&ical inter%ention3

anal&esics, /SAIDS, narcoticsanal&esics, /SAIDS, narcotics

Sur&ery3 r!i9otomies,Sur&ery3 r!i9otomies,cor"otomies, symat!ectomycor"otomies, symat!ectomy


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RSD: $reatmentRSD: $reatment

P!ysical mo"alitiesP!ysical mo"alities- cryot!eray %s. !eat t!eray- cryot!eray %s. !eat t!eray

- )8/S- )8/S

- Acuuncture- AcuunctureBe!a%ioral treatment mo"alitiesBe!a%ioral treatment mo"alities

- Be!a%ior mo"ification@- Be!a%ior mo"ification@

Relaxation tec!ni:ueRelaxation tec!ni:ue- Biofee"'ac#- Biofee"'ac#


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HypertonicityHypertonicity

Increase in muscle toneIncrease in muscle tone

Muscle tone - t!e resistance ofMuscle tone - t!e resistance of

muscle to assi%e elon&ation ormuscle to assi%e elon&ation or

stretc!stretc!A'normalities3A'normalities3

+. Hyertonia+. Hyertonia

. Hyotonia. Hyotonia

. Dystonia. Dystonia


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Muscle $one DisordersMuscle $one Disorders

SasticitySasticity

Ri&i"ityRi&i"ity

Hyotonia@ 1lacci"ityHyotonia@ 1lacci"ity


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SpasticitySpasticity

7elocity-"een"ent increase intonic stretc! reflexes (it!exa&&erate" !asic stretc!reflexes

Results from "ysfunctional sinalan" surasinal mec!anisms

A comonent of uer motorneuron syn"rome


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Conditions presentin"Conditions presentin"

+ith Spasticity+ith Spasticity+.+. Sinal cor" in>urySinal cor" in>ury

.. Demyelinatin& "iseaseDemyelinatin& "isease

.. Stro#eStro#e

.. )raumatic 'rain in>ury)raumatic 'rain in>ury

0.0. Decorticate an" "ecere'rateDecorticate an" "ecere'rateri&i"ityri&i"ity

*.*. Cere'ral alsyCere'ral alsy


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Spasticity: symptomsSpasticity: symptoms

a'normal reflex 'e!a%iora'normal reflex 'e!a%ior

loss of autonomic controlloss of autonomic control

imaire" muscle acti%ationimaire" muscle acti%ationaresisaresis

"ecrease" "exterity"ecrease" "exterity

fati&a'ilityfati&a'ility


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Spasticity: Clinical EaluationSpasticity: Clinical Ealuation

Clinical !istoryClinical !istory

Reflex examinationReflex examination

Passi%e an" acti%e motionPassi%e an" acti%e motionexaminationexamination

1unctional examination1unctional examination

Determine (!et!er sasticity isDetermine (!et!er sasticity is

'eneficial or "etrimental'eneficial or "etrimental


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-enefits from spasticity-enefits from spasticity

Ai" to stan"in& an" (al#in&Ai" to stan"in& an" (al#in&

Maintaine" muscle massMaintaine" muscle mass

Maintaine" 'one minerali9ationMaintaine" 'one minerali9ationRe"uce" "een"ent e"emaRe"uce" "een"ent e"ema

Re"uce" ris# of "ee %enousRe"uce" ris# of "ee %enous

t!rom'osist!rom'osis


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Detrimental effects of spasticityDetrimental effects of spasticity

Imaire" stan"in& 'alanceImaire" stan"in& 'alance

Imaire" s(in& !ase of &aitImaire" s(in& !ase of &ait

Slo( %oluntary mo%ementsSlo( %oluntary mo%ementsRis# of contractureRis# of contracture

Imaire" slee, erineal !y&ieneImaire" slee, erineal !y&iene

PainPain


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Spasticity: $reatmentSpasticity: $reatment

8liminate nocicetion8liminate nocicetion

Pro%i"e atient e"ucation an"Pro%i"e atient e"ucation an"

a"ati%e e:uimenta"ati%e e:uimentRan&e of motion exercisesRan&e of motion exercises

Proer seatin& an" ositionin&Proer seatin& an" ositionin&


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Daily R=M an" static stretc!Daily R=M an" static stretc!

Bracin&, slintin&Bracin&, slintin&

Biofee"'ac#, 8SBiofee"'ac#, 8SIcin&Icin&

Sur&ery3 )en"on len&t!enin&,Sur&ery3 )en"on len&t!enin&,

selecti%e "orsal r!i9otomy,selecti%e "orsal r!i9otomy,

tenotomytenotomy


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=ral3 Baclofen, Cloni"ine,=ral3 Baclofen, Cloni"ine,

Dia9eam, )i9ani"ine,Dia9eam, )i9ani"ine,

DantroleneDantroleneIntrat!ecal BaclofenIntrat!ecal Baclofen

C!emical ner%e 'loc#s3 B=)=C!emical ner%e 'loc#s3 B=)=

in>ection, P!enol 'loc#in>ection, P!enol 'loc#


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Ri"idityRi"idity

Resistance is increase" in 'ot!Resistance is increase" in 'ot!a&onist an" anta&onist musclesa&onist an" anta&onist muscles

Bo"y arts 'ecome stiff an"Bo"y arts 'ecome stiff an"immo%a'leimmo%a'leSeen in lesions of 'asal &an&liaSeen in lesions of 'asal &an&lia

e.&. Par#inson$s "iseasee.&. Par#inson$s "iseaseDue to excessi%e surasinalDue to excessi%e surasinalmec!anismmec!anism


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Ri"idityRi"idity

Associate" (it!3Associate" (it!3

# 'ra"y#inesia'ra"y#inesia

# tremortremor# loss of ostural sta'ilityloss of ostural sta'ility


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$ypes of Ri"idity$ypes of Ri"idity

Cogwheel rigidityCogwheel rigidity - rac!etli#e- rac!etli#e

resonse to assi%e mo%ement resonse to assi%e mo%ement

alternatin& lettin& &o an"alternatin& lettin& &o an"

increasin& resistance toincreasin& resistance to

mo%ementmo%ement

Leadpipe rigidityLeadpipe rigidity ; ri&i"ity; ri&i"ityconstant t!rou&!out t!econstant t!rou&!out t!e

mo%ementmo%ement


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Hypotonia and .laccidityHypotonia and .laccidity

Decrease" or a'sent muscularDecrease" or a'sent muscular

tonetone

Diminis!e" resistance to assi%eDiminis!e" resistance to assi%emo%ementmo%ement

Imaire" mo%ementsImaire" mo%ements


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Hypotonia and .laccidityHypotonia and .laccidity

Seen in t!e follo(in& con"itions3Seen in t!e follo(in& con"itions3

+. UM/ lesions affectin&+. UM/ lesions affectin&

cere'ellum or yrami"al tracts cere'ellum or yrami"al tracts. Sinal or cere'ral s!oc#. Sinal or cere'ral s!oc#

. LM/ lesions affectin& P/S. LM/ lesions affectin& P/S

ans disorders, rsd, hypertonicity

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