HISTORY of RSD/CRPS
"Perhaps few persons who are not physicians
can realize the influence of which long-continued and unendurable
pain pain can have upon both body and mind".
Silas Weir Mitchell "Nerve
The first descriptions of CRPS were documented during the America
Civil War (1861-65) by Silas Weir Mitchell MD, a young US Army contract
physician, who treated soldiers with gunshot wounds. In his book
"Gunshots Wounds and Other Injuries", he described pain
which persisted long after the bullets were removed from the bodies
of soldiers. He noted that the pain was characteristically of a
burning nature, and named it "causalgia"(Greek for burning
pain)which he attributed to the consequences of nerve injury. He
"...a painful swelling of the joints....may attack any
or all articulations of a member. It is distinct from the early
swelling due to the inflammation about the wound itself, although
it may be masked by it for a time:nor is it merely a part of the
general edema....Once fully established, it keeps the joint stiff
and sore for weeks or months. When the acute stage has departed,
the tissues become hard and partial anklyosis results."
Mitchell et al 1864
The following is excerpted from a story which appeared in the
Johns Hopkins Medical Institutions' publication, Brainwaves, and
was written by Janet Worthington. It's an account of causalgia,
a type of neuropathic pain, as described by Dr Mitchell:
"Under such torments, the temper changes, the most
amiable grow irritable, the soldier becomes a coward, and the
strongest man is scarcely less nervous than the most hysterical
Silas Weir Mitchell, M.D., a 19th century neurologist, was as
perplexed by the phenomenon of sympathetically maintained pain
(he called it causalgia), as his modern counterparts. In his 1872
book, "Injuries of Nerves and Their Consequences," he
carefully documented case after case in which injuries resulted
"the most terrible of all the tortures which a
nerve wound may inflict."
Most of his patients were Civil War veterans, otherwise
healthy men whose lives had been forever changed by this peculiar,
burning pain, described by one as a
"red-hot file rasping the skin."
In many, pain was associated with a mysterious
glossiness in the skin.
"The burning comes first, the visible
"Of the special cause which provokes it, we know
nothing, except that it has sometimes followed the transfer
of pathological changes from a wounded nerve to unwounded
nerves, and has then been felt in their distribution, so that
we do not need a direct wound to bring it about."
The pain's location varied from patient to patient, but:
"its favorite site is the foot or hand...the
palm of the hand or palmar face of the fingers, and on the
dorsum of the foot; scarcely ever on the sole of the foot
or the back of the hand. When it first existed in the whole
foot or hand, it always remained last in the parts referred
to...if it lasted long it was finally referred to the skin
alone. The part itself is not alone subject to an intense
burning sensation, but becomes exquisitely hyperaesthetic,
so that a touch or a tap of the finger increases the pain."
Patients took obsessive lengths to avoid exposing the area to
the air, Mitchell wrote.
"Most of the bad cases keep the hand constantly
wet, finding relief in the moisture rather than in the coolness
of the application."
The pain took its toll.
"As the pain increases, the general sympathy becomes
more marked. The temper changes and grows irritable, the
face becomes anxious, and has a look of weariness and suffering.
The sleep is restless, and the onstitutional condition,
reacting on the wounded limb, exasperates the hyperaesthetic
state, so that the rattling of a newspaper, a breath of
air...the vibrations caused by a military band, or the shock
of the feet in walking, gives rise to increase of pain.
At last...the patient walks carefully, carries the limb
with the sound hand, is tremulous, nervous, and has all
kinds of expedients for lessening his pain."
Another military surgeon, Rene Leriche MD, (1879-1955), treated
many WW1 soldiers who also had nerve damage. He documented the classic
signs of CRPS and tried to alleviate the pain with a sympathectomy:
"A few months previously I had unexpectedly encountered
one of these cases. I was struck by the resemblance which the
condition had to that of a sympathetic disorder; the cyanosis,
the sweating, the paroxysmal nature of the pains, the effect on
the general mental state, the reference of painful phenomena to
a distance---all pointed in that direction. And, remembering that
the sympathetic, in its distribution to the limbs, follows the
course of the arteries, I asked myself whether, in those cases
of nerve injury complicated by arterial wounds, it was not the
injury to the sheath of the vessel that determined their painful
and trophic features---the wound of the sympathetic---... Starting
from this point, I asked myself whether, by acting upon the perivascular
sympathetic, I might be able to succeed in modifying the causalgia."
He goes on to discuss a case study:
"I saw the patient on the 20th June; the upper limb
was completely paralyzed---arm, forearm, hand and fingers....dominating
everything, was an intense burning pain, concentrated particularly
in the palm of the hand and on the pulp of the fingertips....On
the 27th August, I exposed the brachial artery, which I found
small and contracted. I removed its adventitia for a distance
of 12 cm....By the next day it was obvious that the patient had
In conclusion, he thought that "novicain infiltrations of
the paravertebral sympathetic chain" was an effective treatment
for causalgia. He was tormented by the pain suffered by the brave
soldiers and in 1937 he wrote "La Chirurgie de la Douleur"
(Surgery of Pain) documenting his experiences.
During WWII, William K. Livingston MD, (1892-1966), a military
doctor, was working at Oakland Naval Hospital where he treated peripheral
nerve injures of soldiers who had chronic pain. He wrote about the
"vicious circle of pain as similar with vasoconstriction and
atrophy". He compared this pain to "circus movements in
the heart muscle." He also talked about "mirror images"
of pain or sympathetic pain in which the limb contra lateral to
the injury becomes sympathetic. Modern research has found interneuron
connections that not only ascend and descend the pain pathways but
result in abnormal neurotransmission also to the contralateral side.
Here follows a soldier's narrative:
"It is as if a rough bar of iron were thrust to and
fro through the knuckles, a red, hot iron placed at the junction
of the palm, and then an eminence with a heavy weight on it and
the skin was being rasped off of my finger ends."
Moreover, Dr Livingston suggests that the concept of receptor specificity
with only four methods of cutaneous sensitivity (touch, pain, heat,cold)
is too inadequate to explain phantom limb pain or CRPS and pain
syndromes. Pain sensations are governed by higher cortical centers
in the brain and emotional factors. He described all pain as psychic
perception with a marked psychological component. This idea has
formed the basis of chronic pain as the multi-faceted process we
are familiar with now.
All three of these physicians contributed a great deal to what
we know about causalgia (CRPS-2) and RSD (CRPS-1) today.
In 1900, Sudeck, a surgeon from Hamburg, discovered
a new twist: "acute patchy osteoporosis" as a complication
of infection in limbs. The radiographic changes started as "patchy
osteoporosis of the small bones of the hand or feet and the distal
metaphysis of forearm or tibial bones".Eventually the osteoporosis
becomes diffuse. Hence the name "Sudeck's atrophy", due
to the patchy osteoporosis findings.
Another German doctor, Keinbock confirmed the osteoporosis
findings and also reported "acute bone atrophy and atrophy
due to inactivity". In 1936, one of Sudeck's students, Reider,
suggested that the disease be named "limb dystrophy" due
to the bone tissues breaking down. The term "reflex" originated
with the observations that the syndrome was caused and maintained
by a reflex , travelling through the nervous system.
Sudeck proposed that RSD could be caused by an "exaggerated
inflammatory response after injury or operation of an extremity".
The signs and symptoms of acute inflammation were rubor, calor,
dolor, tumor and functio laesa. This theory forms the basis of modern
Dutch research and treatment; that RSD begins as inflammation.
In 1890, Charcot observed the disease as "non-pitting
edema, changes in color, changes in skin temperature, tenderness
of the skin and pain". Charcot thought the cause was self suggestion.
Leriche, a neurosurgeon, introduced the name "algodystrophie".
He thought it was caused by an increase of activity in the sympathetic
nervous system and introduced "surgical sympathectomy"
as a treatment. This soon became a popular treatment for CRPS.
AMERICA AFTER WW II
In 1947, Steinbrocker renamed the disease "shoulder-hand
syndrome". He also began using oral corticosteriods as treatment
in 1953. Meanwhile, Serre in France and Kozin in USA, used nuclear
scans e.g. bone scans using technetium labelled methylenediphosphonate
and found diffuse disturbances in peri-articular areas. Later Kozin
implemented the three phase nuclear scan which is still used today.
Hannington-Kiff began using the intravenous regional blockade of
the sympathetic nervous system with guanethidine in 1974. This treatment
is still used today along with physical therapy.
NAMES FOR RSD/CRPS
Following these and other developments, the confusion
over the names of this syndrome increased. Algodystrophie was used
primarily in France, Sudeck's atrophy referred to the osteoporosis
part of the disease. When the disease began as a result of nerve
injury, it was called "causalgia" after Mitchell. If it
began with non-nerve injuries, it could be called "mimocausalgia"
or "minor causalgia." "Posttraumatic dystrophy"
(Dutch term) referred to the specific event which caused RSD.
Other names surfaced in the literature such as "vasospastic",
"neurotrophic" "neurovascular" or "reflex".
The most common was "sympathetic". Roberts introduced
the name "sympathetically maintained pain" in 1986 and
it has become popular with pain researchers. This term is a condition
where pain and hyperalgesia are relieved with a blockade.
Some common names in the literature for RSD/CRPS are:
|atrophie de Sudeck
||pourfour du Petit syndrome
||minor traumatic dystrophy
In 1995, Michael Stanton-Hicks and a committee of
RSD researchers decided to give RSD (Reflex Sympathetic Dystrophy)
a new name:
Complex Regional Pain Syndrome. Why? If one name was decided upon,
then further research could be done and confusion would be eliminated.
Now we have CRPS type 1 which is "RSD" and CRPS type
2 which is "causalgia." What is the difference? As of
her 2006 discovery, both have the same exact symptoms and both are
due to nerve injury (Oaklander 2006). Patients with this disease
still call it "RSD" and the medical community refers to
it as "CRPS". Both names are now used interchangeably.
Source: Am Soc Anesth. Newsletter October 2002
Source: Veldman PHJM MD Clinical Aspects of RSD
Thesis Nijmegen CIP-Data Royal Dutch Library, The Hague ISBN 90-9007712-X