This page has been designed for those of you with a scientific
approach who prefer the research literature about RSD/CPRS.Many
new things are happening in the CRPS research field. There
are many labs around the world now working on RSD/CRPS: Israel,
Turkey, Japan, Switzerland, Sweden, Germany, Canada, Japan,
Holland and in USA.
There is also a committee established by the IASP (International
Association for the Study of Pain) called PSNS SIG (Special
Interest Group on Pain and the Sympathetic Nervous System)
which consists of CRPS researchers e.g.. M Stanton Hicks MD.
All of these doctors/researchers have published papers and
are dedicated to finding out more about the cause, treatments
and cure for CRPS.
Please also see our Canadian Research
page for updated information.
Since CRPS research is a large area, we advise you to begin
with the list below and then expand to the next row of links.
NOTE: CRPS studies are listed by year and important ones
All understanding of CRPS begins with background reading.
Abu, Rahma A, Robinson P et al Sympathectomy
for reflex sympathetic dystrophy: Factors affecting outcome.Ann
Vasc Surg 1994; 8: 372-379
Boas, R. Sympathetic nerve blocks in the evaluation
of chronic pain: A plea for caution in their use and interpretation
Anesthesiology 1997 86: 4-6
Bruehl, S. Husfeldt B, et al Psychological differences
between Reflex Sympathetic Dystrophy and non-RSD chronic pain
patients Pain 1996 67: 107-114
Davis, K, Treede R, Raja S. Topical application
of clonidine relieves hyperalgesia in patients with sympathetically
maintained pain Pain 1991 47: 309-318
Geertzen, JHB et al Reflex Sympathetic Dystrophy:Early
Treatment and Psychological Aspects Arch Phys Med Rehabilitation
Vol 75 April 1994 442445
Hooshmand, H. MD Hashmi, M MDComplex regional
pain syndrome (RSD) Diagnosis and Therapy-A review of 824 Patients
Pain Digest Springer-Verlag New York Inc. 1999
Janig, W., Stanton-Hicks, M. Eds. Reflex Sympathetic
Dystrophy: A ReappraisalProgress in Pain Research and Management.Vol.
6 Seatlle IASP Press 1996.
Kirkpatrick A, Derasari M, Transdermal clonidine:
Treating reflex sympathetic dystrophy Regional Anesthesia 1993
Krames, E. MD Intraspinal opiod therapy for
chronic nonmalignant pain: current practice and clinical guidelines
J Pain Symptom Management 1996;11: 333-352
Linchitz R. MD Raheb J Subcutaneous Infusion
of Lidocaine Provides Effective Pain Relief for CRPS Patients
Clin J Pain 15; 67-72
Merskey, H. Bogduk N. Eds. Classification of
chronic pain: pain syndromes and definition of pain Second Edition
Seattle IASP Press 1996
Raja, S, Turnquest et al Monitoring the adequacy
of alpha-adrenergic blockade following systemic phentolamine
administration Pain 1996;64: 197204
Schwartz, RG MD Electric sympathetic block:
current theroetical concepts and clinical results J Back and
Musculoskeletal Rehab 1998;10: 31-46
Schwartz, RG et al Diagnostic paraspinal musculoskeletal
ultrasonography J Back Musc Rehab 1999;12: 25-33
Schwartzman, R.J., et al: The movement disorder
of reflex sympathetic dystrophy Neurology 1990 40: 57-61
Schwartzman, R.J., McLellan T.: Reflex Sympathetic
Dystrophy, A review Archives of Neurology 1987 44: 555-61
Schwartzman, RJ., The autonomic nervous system
and pain Handbook of Neurology Ed. Vinken PJ, Bruyn GW Appelnzeller
1999 In press
Stanton-Hicks, M. et al Reflex Sympathetic Dystrophy:changing
concepts and taxonomy Pain 1995 63:127-33
Stanton-Hicks,M, Baron R, et al Consensus Report:
Complex regional pain syndromes:Guidelines for Therapy Clin
Journal of Pain 1998: 14: 155-66
Van der Laan L. et al A Novel Animal Model to
Evaluate Oxygen Derived Free Radical Damage in Soft TissueFree
Rad Res. Vol 26 pp 363-72
van der Laan L., Goris RJ Reflex Sympathetic
Dystrophy: An Exaggerated Inflammatory Response? Hand Clinics
Vol 13 No 3 August 1997 p 373-385
van der Laan, L et al Complex Regional Pain
Syndrome type 1 (RSD) Pathology of skeletal muscle and peripheral
nerve Neurology 1998; 51: 2025
Veldman, PHJM et al Signs and symptoms of reflex
sympathetic dystrophy:prospective study of 829 patients Lancet
Vol 342 Oct. 23, 1993 p 1012-5
Veldman, PHJM Goris RJA Surgery on extremities
with reflex sympathetic dystrophy Unfallchirug 1995; 98:45-8
Veldman, PHJM Shoulder complaints in patients
with RSD of the upper extremity Arch Phys Med Rehabilitation
Vol 76 March 1995 p 239-441
Veldman, PHJM Goris RJA Multiple RSD:Which patients
are at risk for developing a recurrence of RSD in the same or
another limb? Pain 64 1996; 463-66
Wilder, R. et al Reflex Sympathetic Dystrophy
in Children J of Bone and Joint surgery Vol 74-A No.6 July 1992
Wilder, R RSD in Children and Adolescents:Differences
from AdultsRSD:A Reappraisal Vol 6 IASP Press Seattle 1996
This section contains journal articles listed alphabetically
by author and categorized by year. First are the newest 2001
studies, then 2000 and 1999. Some citations contain brief descriptions.
Those with a Pub Med ID number (e.g. PMID 11114289) may be searched
for by number at Pub Med.
Please take time to read the "Most Valuable Study"
of 2000 by Dr.R. Schwartzman.
Alvarez-Lario B, Aretxabala-Alcibar I, Alegre-Lopez J, Alonso-Valdivielso
JL Acceptance of the different denominations for reflex sympathetic
dystrophyAnn Rheum Dis. 2001 Jan;60(1):77-9. PMID: 11114289
Birklein et al Theory of increased neuropeptides release from
peripheral nociceptors as a possible pahtological mechanism
for RSD. Pain 2001 Apr;91;(3):251-7 PMID 11275381 "Electrically
induced neurogenic vasodilation and protein extravasation were
evaluated in patients. Neurogenic inflammation is facilitated
in CRPS and leads to an increased releasability of neuropeptides."
Geiderman JM.Sympathetic dystrophy. Ann Emerg Med 2001 Apr;37(4):412-4
Ruth and Harry Roman Emergency Department, Department of Emergency
Medicine, Burns and Allen Research Institute, Cedars-Sinai Medical
Center, Los Angeles, CA, USA. PMID: 11275838
Hewitt DJ.Web alert Curr Pain Headache Rep 2001 Feb;5(1):3-4
Leong, MS Machey S. Delayed subdural block after a stellate
ganglion block Anesth 2001 Feb;94 (2):358-9 PMID:11176103
Takahiro Ushida W. Willis Changes in dorsal horn neuronal responses
in experimental wrist contracture model J Ortho Sc. Vol. 6 Issue
1 pp. 46-52 ISSN 0949-2658.
No abstract is available.
STUDIES IN 2001 AS OF JUNE:
Our latest and greatest updated file on 2001 studies is here.
See the latest.
If you wish the full text article you may also try: http://paperchase.com
MOST VALUABLE STUDY:
Documenting the spread of CRPS
Maleki J, LeBel AA, Bennett GJ, Schwartzman RJ Patterns of
spread in complex regional pain syndrome, type I (reflex sympathetic
dystrophy). Pain 2000 Dec 1;88(3):259-66 Department of Neurology,
MCP Hahnemann University, Broad & Vine Street (Mail Stop
423), Philadelphia, PA 19102-1192, USA.
This study is an accurate analysis of the patterns of spread
in CRPS. They are identified as "Contiguous spread (CS)'
(noted in all 27 cases),. 'Independent spread (IS)' ( in 19
patients (70%)) e.g. CRPS-I/RSD appearing first in a foot, then
in a hand). 'Mirror-image spread (MS)' (in 4 patients) There
is the possibility that all three kinds of spread may be due
to "aberrant CNS regulation of neurogenic inflammation."
Source: Academic Press. PMID: 11068113
STUDIES IN 2000: CITATIONS AND DESCRIPTIONS
Birklein et al Increased skin lactate in CRPS Neurology 2000
Oct. 24;55(8)1213-5 PMID 11071503
This study focused on "oxygen metabolism in CRPS and measured
skin lactate via dermal microdialysis and blood lactate. Venous
lactate was not altered but skin lactate increased in CRPS patients
suggesting that enhanced anaerobic glycolysis from tissue hypoxia."
Birklein et al Experimental tissue acidosis leads to increased
pain in CRPS Pain 2000 Aug;87(2);227-34 PMID 10924810
The role of local acidosis in generation of pain is examined.
Pain was found in the skin but generated in deep somatic tissue
Dunn D. Manchikanti L. Oberlander TF. Robeson P. Ward V. Huckin
RS. Kamani A. Harpur A. McDonald W. Chronic regional pain syndrome,
type 1: Part I. AORN J 2000 Sep;72(3):422-32, 435-49; quiz 452-8
This article is an overview of CRPS in two parts. Part I discusses
background information such as pain, pathophysiology, diagnosis,
clinical stages, and the most common treatment modality, sympathetic
nerve blocks. Part II, discusses alternate treatment modalities,
such as sympathectomy, physical therapy, stimulators, trigger
point injections, acupuncture, tourniquet effects, placebo effects,
Geusens P. Santen M. Muir JM. Vernon H. Dunn D. Manchikanti
L. Oberlander TF. Robeson P. Ward V. Huckin RS. Kamani A. Harpur
A. McDonald W. Algodystrophy. Baillieres Best Pract Res Clin
Rheumatol 2000 Sep;14(3):499-513
Various issues in CRPS are examined including the need for a
better understanding of the pathophysiology and for prospective
clinical studies about the natural course and the effect of
Goldstein DS et al Sympathetic innervation and function in
RSD Ann Neurol 2000 Jul;48(1) 49-59 PMID 10894215
Abstract not available.
Manchikanti L. Oberlander TF. Robeson P. Ward V. Huckin RS.
Kamani A. Harpur A. McDonald W. The role of radiofrequency in
the management of complex regional pain syndrome. Curr Rev Pain
This study examines various treatments and discusses RFTC techniques
Muir JM. Vernon H. Dunn D. Manchikanti L. Oberlander TF. Robeson
P. Ward V. Huckin RS. Kamani A. Harpur A. McDonald W. Complex
regional pain syndrome and chiropractic. J Manipulative Physiol
Ther 2000 Sep;23(7):490-7
This article examines the various theories regarding CRPS and
the role of chiropractic treatment.
Muller, LP, Muller LA, Hap J, Kerschbaumer F, Johannes Gutenburg-Universitat
Mainz, Klinik und Poliklinik fur Unfallchirurgie, Germany. Frozen
Shoulder: a sympathetic dystrophy? Arch Ortho Trauma Surg 2000;120(1-2);84-7
Features of frozen shoulder syndrome and Sudeck's syndrome are
similar in many ways; Radioisotope bone scan shows an increased
uptake in affected areas in both diseases, and native radiographs
show progressive demineralization. Bone mineral density (BMD)
pointed to local decalcification processed in early stage of
frozen shoulder syndrome. Several studies support the idea that
frozen shoulder is a part of CRPS and our observations support
Oaklander AL et al Skin biopsies provide objective evidence
of injury to nociceptors in patients with CRPS Program and Abstract
of 125th Annual Meeting of American Neurol. Association Oct
15-18, 2000 Boston MA Abstract 49
Biopsies showed reduced epidermal neurites 40-100% in density
within CRPS areas. Skin biopsies are useful for finding neurologic
damage and damage to cutaneous nociceptors.
Oerlemans HM; Oostendorp RA; de Boo T; van der Laan L; Severens
JL; Goris RJA; Adjuvant physical therapy versus occupational
therapy in patients with RSD/CRPS type 1. Allied Health Services,
University Hospital Nijmegen, The Netherlands Archives of Physical
Medicine and Rehabilitation 2000 Jan;81(1):49-56
This study is to investigate the effectiveness and cost of physical
therapy (PT) or occupational therapy (OT) in patients with RSD
At two university hospitals, 135 patients with RSD who have
it for less than one year in one upper extremity, were divided
into PT, OT and a control group. Results were: improvement in
impairment level suniscore (ISS) over one year (Student's test).
Clinically relevant was the difference of 5 ISS points between
the groups. Severity of disability and handicap was measured
and cost effectiveness of the group was analyzed. Results: PT
and OT had a significant and more rapid improvement in the ISS
as compared with control groups. OT was discovered to have a
positive trend. On a handicap level, no difference were found
between groups. PT was more cost-effective than OT. In different
ways PT and OT both help in the recovery from RSD of upper extremity
Stutts JT. Kasdan ML. Hickey SE. Bruner A. Oberlander TF. Robeson
P. Ward V. Huckin RS. Kamani A. Harpur A. McDonald W. Tahmoush
AJ. Schwartzman RJ. Hopp JL. Grothusen JR. Harke H. Gretenkort
P. Ladleif HU. Rahman S. Harke O. Wesdock KA. Stanton RP. Singsen
BH. Reflex sympathetic dystrophy: misdiagnosis in patients with
dysfunctional postures of the upper extremity. J Hand Surg [Am]
The purpose of this case-control study was to assess the frequency
of the inappropriate diagnosis of reflex sympathetic dystrophy
(RSD) in patients who presented with dysfunctional postures
of the upper extremity. Patients presenting with dysfunctional
postures of the upper extremity may be misdiagnosed as having
RSD and rarely meet the criteria for this diagnosis.
Tahmoush AJ. Schwartzman RJ. Hopp JL. Grothusen JR. Harke H.
Gretenkort P. Ladleif HU. Rahman S. Harke O. Wesdock KA. Stanton
RP. Singsen BH Quantitative sensory studies in complex regional
pain syndrome type 1/RSD Clin J Pain 2000 Dec;16(4):340-4
This study focuses on thermal allodynia in CRPS by examining
its role. This study suggests that thermal allodynia in patients
with CRPS1/RSD results from decreased cold-evoked and heat-evoked
pain thresholds. The thermal pain thresholds are reset (decreased)
so that non-noxious thermal stimuli are perceived to be pain
van Hilten, JJ MD et al Intrathecal Baclofen for the Treatment
of Dystonia in Patients with Reflex Sympathetic Dystrophy N
England J Med 2000;343;625-30
A benchmark in RSD studies; intrathecal baclofen as a treatment
for dystonia associated with RSD.
van der Beek WJ van Hilten JJ et al HLA-DQ1 associated with
reflex sympathetic dystrophy Neurology 2000 Aug8;55(3) 457-8
No abstract available.
van Hilten JJ MD et al Multifocal or Generalized Tonic Dystonia
of Complex Regional Pain Syndrome: A Distinct Clinical Entity
Associated with HLA-DR13 Ann Neurology 2000;48:113-116
Patients with CRPS-dystonia have a distinct elevation of HLA-DR13
indicating a susceptibility to this phenotype of CRPS.
Verdugo RJ, Ochoa JL, Dept. of Neurology, Faculty of Medicine,
Univ. of Chile, Santiago, Chile. Abnormal movements in CRPS:
assessment of their nature Muscle Nerve 2000 Feb23(2):198-295
Abnormal movements such as dystonic spasms, coarse postural
or action tremor, irregular jerks, and one choreiform case are
a part of the syndrome CRPS. Fifty eight patients were subjected
to clinical and laboratory evaluations to determine the nature
of their neurological problems. No case of CRPS type 2 (Causalgia)
but only cases of CRPS type 1 RSD) showed these abnormal movements.
There was no evidence of structural nerve, spinal cord or intracranial
damage. All type 1 patients showed psuedo-neurological (nonorganic)
signs. This study points to abnormal movements found only in
CRPS type 1 and not in type 2. It also is a symptom of an underlying
Wheeler DS, Vaux KK, Tan DA, Dept. of Pediatrics and Clinical
Investigations Naval Medical Center, San Diego CA.Use of Gabapentin
in the treatment of childhood RSD Pediatric Neurology 2000 Mar
REVIEWS OF SELECTED STUDIES IN 1999, 1998
Galer, BS, Jensen M. USA.Neglect-like symptoms in complex
regional pain syndrome: results of a self-administered survey
Dept. of Pain Medicine and Palliative Care, Beth Israel Medical
Center, NY, NY. 10002 Journal Pain Symptoms Management 1999
Oerlemans HM, Oostendorp RA, de Boo T, Perez Goris RJA. Signs
and symptoms in CRPS type 1:RSD: judgement of the physician
versus objective measurement. Allied Health Services University
Hospital Nijmegen, The Netherlands. Clin Journal of Pain 1999
Diagnostic signs and symptoms of CRPS patients of one upper
extremity of one year's duration, were recorded The aim was
to assess the relationship between subjective assessed patients
and those who were objectively measured and to determine their
severity. Tests included: (a) pain by using visual analog scale
(VAS), McGill Pain Questionnaire (MPG) (b) edema with a hand
volumeter (c)skin temperature with infrared thermometer (d)
active range of motion (AROM) with goniometers. Bedside evaluation
of CRPS type 1 with Veldman's criteria was in agreement with
psychometric or lab test of these criteria. (This study is effective
in that it works towards ways to make a definitive diagnosis
Oerlemans HM, Goris RJA, de Boo T, Oostendorp RA. .Do physical
impairment and occupational therapy reduce the impairment percentage
in RSD?Allied Health Services, University Hospital Njimegen,
The Netherlands Am J Phys Med. Rehabilitation 1999 Nov-Dec;78(6):
Schwartzman RJ, Maleki J Postinjury neuropathic pain syndromes
Department of Neurology, MCP/Hahnemann University, Philadelphia,
PA, USA.Med Clin North Am 1999 May;83(3):597-626.
Pain is clearly one of the most daunting problems of modern
medicine. Posttraumatic neuropathic pain syndromes are a major
component of the clinical problem. Structural lesions affecting
roots, nerves, the plexi, and central structures can be imaged
non-invasively. The molecular biology of the intraneural cascades
that cause sensitization of the central pain-projecting neurons
of the dorsal horn and subsequent allodynia, hyperalgesia, and
hyperpathia is a subject of intense inquiry. The role of the
clinician in identifying and eliminating the source of the pain
is crucial before the effects of excitotoxicity and central
sensitization permanently alter the physiology of the central
pain-projecting neurons and make treatment ineffectual. PMID:
10386117, UI: 99313895
Blair SJ Chinthagada M, Hoppenstedt D, Kirojowski R, Fareed
J. Role of Neuropeptides in pathogenesis of RSD.
Acto Orthop Belg 1998 64: 448-450
NOTE: Each article has a PMID number which
can be used to order the full text of the article or search
for the abstract or review at Pub Med (National Library of Medicine)
on our links page.You may also try: http://paperchase.com or
Treatment and management for RSD/CRPS has been a longstanding
problem because so many of the experts disagree. The articles
below are an effort to come to a consensus about how RSD/CRPS
is recognized, diagnosed, treated and managed. In the last year
several great articles have synthesized the diagnostic procedures
and treatments into a more comprehensive view. It is recommended
that if you are an RSD/CRPS patient, you give copies of these
articles to your doctor. Below are some excellent efforts.
CRPS: GUIDELINES FOR THERAPY
by M Stanton-Hicks MD et al The Clinical Journal of Pain 1998;
A few years ago, leading US and Canadian RSD doctors and researchers
including Canadians Harold Merskey MD and Angela Mailis MD met
to design a treatment protocol that all doctors could clearly
follow. In essence, it states that treating a complicated disease
requires a complex three part approach.The first step is a diagnosis
which includes careful attention to all signs and symptoms.
Then the treatment plan is designed and begun.
Part A is the medical interventions which include drugs, blocks,
surgery or neurmodulation e.g.. TENS, PNS, SCS.Part B begun
at the same time, is activation including physical therapy achieved
by various methods e.g.. desensitization, flexibility, Peripheral
E-stim, and ROM. Part C consists of psychological interventions
such as counselling, cognitive behavior, relaxation techniques,
imagery, hypnosis or coping skills.
The treatment algorithm is designed in these three parts to
facilitate movement through each section and its purpose is
to combine all parts to return function to the patient.
CLINICAL PRACTICE GUIDELINES FOR CRPS
by Anthony Kirkpatrick MD et al
At the RSDSA Conference October 15-16,1999, the RSDSA's Research
Director, Dr. Anthony Kirkpatrick introduced "Clinical
Practice Guidelines" which were written by a committee
of 12 RSD doctors and researchers from the USA. The Guidelines
explain in great detail what RSD/CRPS is and how it is diagnosed.
The most important treatment concept is educating the patient
so that he/she can participate in the treatment plan which is
precisely described for both doctor and patient. Drugs, physical
therapy, and minimizing pain are some of the goals. It also
covers the various problems and effects which RSD/CRPS can have
on a long term basis. Included is a comprehensive list of references
and FAQ's on RSD/CRPS entitled "Fact or Fiction".
It was recommended that the patient take the Guidelines to his/her
doctor to begin the learning process.
To obtain an updated 2010 copy of the Clinical Practice Guidelines,
please contact: RSDSA of America, Tel: 1 203 877 3790 or visit:
http://www.rsds.org. See our links page.
COMPLEX REGIONAL PAIN SYNDROME : DIAGNOSIS AND
A Review of 824 Patients
Hooshmand, H MD and Masood Hashmi MD
Pain Digest 1999; 9: 1-24 Springer-Verlag New York. Inc.
This article is the most comprehensive and precise
paper written about all aspects of CRPS. Dr.Hooshang Hooshmand,
a leading neurologist and RSD researcher in Florida, reviews 824
patients over 5 years. He maintains that RSD/CRPS is caused by
nerve fibers (neurovascular thermoreceptor C fibers) that become
over-sensitized to norepinephrine (a neurotransmitter)and send
unrelenting pain signals to the brain.
Dr Hooshmand reviews current diagnostic and treatment
procedures. The four clinical principles of RSD/CRPS are discussed
in detail: pain, motor dysfunction, inflammation and limbic system
dysfunction. Again, treatment is complex, consisting of physical
therapy, avoiding inactivity and ice, prescribing drugs such as
NSAIDS, anti-depressants, and opiod antagonists such as Burpenex
and Butorphanol. Various types of blocks, e.g.. paravertebral,
regional and brachial plexus block also provide effective pain
relief. Avoidance of surgery, especially amputation, ice and cast
applications are stressed.
NOTE: Please visit one of the most extensive,
valuable, medical CRPS sites available on the Net. Dr Hooshmand's
Puzzles are of particular interest to patients and professionals
alike . Please see our links page or go to: www.rsdrx.com..
UDPATE: May 2001. Dr Hooshmand's newest article
has just been published in Thermology Intermational.
UPDATE: Dr Hooshmand has retired. We commend
him on his excellent work treating CRPS patients and conducting
research. Great work, Dr H!!!!!
If you wish to obtain a copy of these publications, please contact