Nail disorders associated with cast immobilization of the forearm and wrist: report of two cases and review of the literature

Abstract Cast immobilization is used in the management of various injuries of joints and/or limbs. A variety of nail disorders have been reported in association with cast immobilization of the forearm and wrist among a limited number of patients so far. The mechanism was not clearly identified in some of these cases. Here, the authors report two patients with nail disorders appeared after the removal of immobilization cast of forearm and wrist and review the literature.

Nail disorders associated with cast immobilization of the forearm and wrist: report of two cases and review of the literature.

Cast immobilization is used in the management of various injuries of joints and/or limbs. A variety of nail disorders have been reported in association with cast immobilization of the forearm and wrist among a limited number of patients so far. The mechanism was not clearly identified in some of these cases. Here, the authors report two patients with nail disorders appeared after the removal of immobilization cast of forearm and wrist and review the literature.

Effects of photobiomodulation on different application points and different phases of complex regional pain syndrome type I in the experimental model.

BACKGROUND: Complex regional pain syndrome type I (CRPS-I) consists of disorders caused by spontaneous pain or induced by some stimulus. The objective was to verify the effects of photobiomodulation (PBM) using 830 nm wavelength light at the affected paw and involved spinal cord segments during the warm or acute phase. METHODS: Fifty-six mice were randomized into seven groups. Group (G) 1 was the placebo group; G2 and G3 were treated with PBM on the paw in the warm and acute phase, respectively; G4 and G5 treated with PBM on involved spinal cord segments in the warm and acute phase, respectively; G6 and G7 treated with PBM on paw and involved spinal cord segments in the warm and acute phase, respectively. Edema degree, thermal and mechanical hyperalgesia, skin temperature, and functional quality of gait (Sciatic Static Index [SSI] and Sciatic Functional Index [SFI]) were evaluated. RESULTS: Edema was lower in G3 and G7, and these were the only groups to return to baseline values at the end of treatment. For thermal hyperalgesia only G3 and G5 returned to baseline values. Regarding mechanical hyperalgesia, the groups did not show significant differences. Thermography showed increased temperature in all groups on the seventh day. In SSI and SFI assessment, G3 and G7 showed lower values when compared to G1, respectively. CONCLUSIONS: PBM irradiation in the acute phase and in the affected paw showed better results in reducing edema, thermal and mechanical hyperalgesia, and in improving gait quality, demonstrating efficacy in treatment of CRPS-I symptoms.

Síndrome doloroso regional complejo / Regional complex pain syndrome

RESUMEN Fundamento: el síndrome doloroso regional complejo es una condición incapacitante y a menudo crónica, que se ha mantenido como una de las enfermedades más enigmáticas desde su descubrimiento hace 150 años y se presenta entre el dos y el cinco por ciento de la población adulta, y hasta el 20 % de la población pediátrica. Objetivo: profundizar y actualizar los aspectos más importantes del síndrome doloroso regional complejo. Métodos: se realizó una revisión de la literatura en idioma español e inglés disponible en PubMed Central, Hinari y SciELO. Para ello se utilizaron los siguientes descriptores: complex regional pain syndrome, sympathetic reflex dystrophy, Sudeck dystrophy, algodystrophy. A partir de la información obtenida se realizó una revisión bibliográfica de un total de 167 artículos publicados, de ellas se seleccionaron 40 citas para realizar la revisión, 38 de los últimos cinco años. Resultados: se insistió en aquellos tópicos importantes dentro del tema como son: reseña histórica, epidemiología, fisiopatología, presentación clínica, diagnóstico, estudios complementarios y tratamiento. Conclusiones: el síndrome doloroso regional complejo es un trastorno doloroso enigmático y visible. La comprensión de la compleja fisiopatología ha logrado avances significativos, que llevarán a la desmitificación y a la mejoría en las terapias. A pesar de los tratamientos disponibles y los que se encuentran en estudio, no existen protocolos estandarizados que permitan un abordaje multidisciplinario.

ABSTRACT Background: complex regional pain syndrome is a painful disabling and often chronic condition that remains as one of the most enigmatic diseases since its discovery 150 years ago and presents between the 2 % and the 5 % of adult population and up to the 20 % in children. Objective: to update and to deepen in the most important aspects of regional complex pain syndrome. Methods: a revision of the literature was made in English and Spanish, available in PubMed Central, Hinari and SciELO was carried out. The following descriptors were used: complex regional pain syndrome, sympathetic reflex dystrophy, Sudeck dystrophy, algodystrophy. Based on the obtained data, a bibliographic revision was made of 167 publishing articles, including 40 citations selected for the research, 38 of them of the last five years. Results: it was focus in those controversial topics like: history, epidemiology, physiopathology, clinical presentation, diagnosis, complementary studies and treatment. Conclusions: regional complex pain syndrome is a painful enigmatic and visible disorder. The understanding of the complex physiopathology has improved significant advances that will rule out the myth and will perform better therapies. Besides available treatments and which are in study, no standardized protocols are in hand which allows a multidisciplinary approach.

Photobiomodulation Decreases Hyperalgesia in Complex Regional Pain Syndrome: An Experimental Mouse Model Subjected to Nicotine.

BACKGROUND AND OBJECTIVES: Complex regional pain syndrome (CRPS) is defined as an extreme and chronic pain condition, and photobiomodulation has relevance as a complementary treatment for CRPS. The objective of this study was to verify the effects of photobiomodulation (PBMT) therapy protocols at two wavelengths 660 and 830 nm, associated or not to nicotine in complex regional pain syndrome type I (CRPS-I). STUDY DESIGN/MATERIALS AND METHODS: Sixty-four Swiss mice were divided into the following groups: (i) Naive, (ii) Sham, (iii) Control, (iv) 660 nm, (v) 830 nm, (vii) Nicotine, (vii) Nicotine/660 nm, and (viii) Nicotine/830 nm. CRPS-I was induced in an experimental ischemia/reperfusion model by affixing an elastic ring, proximal to the ankle joint of the right hind mouse paw, for 3 hours. Nicotine, in the respective groups was administered for 28 days prior to the induction of CRPS-I. PBMT was applied immediately after the procedure and for 20 consecutive days. The animals were evaluated for mechanical hyperalgesia, thermal hyperalgesia, paw edema at baseline and for 7, 14, and 21 days. Statistical analyses comprised a mixed-effects model, using the Tukey post hoc test (P < 0.05). RESULTS: The PBMT wavelengths in 660 and 830 nm groups had beneficial effects (P < 0.05) in reducing mechanical and thermal hyperalgesia, but the effects at 660 nm were significantly better than 830 nm. At reducing edema, both wavelengths had significant effects statistically, absolutely no difference between them. CONCLUSIONS: The use of PBMT (660 and 830 nm) was effective in reducing mechanical hyperalgesia and thermal hyperalgesia; however, PBMT at 660 nm generated significant results. In reducing edema, both wavelengths had similar effects, which were significant statistically. The deleterious effects of nicotine were evident statistically and were softened when treated with PBMT (P < 0.05). Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Complex regional pain syndrome in the orofacial region. Case report / Síndrome complexa de dor regional em região orofacial. Relato de caso

ABSTRACT BACKGROUND AND OBJECTIVES: The complex regional pain syndrome is characterized by presenting autonomic, sensory and motor difficult to control changes of the chronic evolution. Its pathophysiology and treatment are not fully defined, and the search for an increasingly effective treatment is a subject of medical concern. The involvement of the orofacial region has an even rarer incidence, and the literature reports only 14 cases in five decades. The objective of this report was to warn physicians and researchers about the importance of a correct diagnosis and to show the possibility of controlling this dysfunction with conservative treatment. CASE REPORT: A 68-year-old female patient, who after a facial trauma and three subsequent surgical procedures, developed orofacial complex regional pain syndrome. Several therapeutic regimens were performed, and after the last one she became completely asymptomatic: oxcarbazepine (900mg/day), morphine-controlled liberation (120mg/day), fluoxetine (40mg/day) and clonazepam (2mg/day), electrotherapy and oral rehabilitation. CONCLUSION: The diagnosis criteria for complex regional pain syndrome recommended by the International Association for the Study of Pain, revised in 2007, should be followed. The treatment of this neuropathic syndrome includes anticonvulsants, tricyclics, opioids, electrotherapy and somatic and stellate ganglion block, the latter when the pain is maintained by the sympathetic nervous system. In this report of an orofacial complex regional pain syndrome II, pain control was shown without the need for sympathetic ganglion block, which can be a warning to the medical class to a correct diagnosis and an effective and less invasive treatment.

RESUMO JUSTIFICATIVA E OBJETIVOS: A síndrome complexa de dor regional se caracteriza por apresentar alterações autonômicas, sensitivas e motoras de evolução crônica de difícil controle. Sua fisiopatologia não está totalmente definida e a busca por um tratamento cada vez mais eficaz é objeto de preocupação médica. O comprometimento da região orofacial tem uma incidência ainda mais rara e a literatura relata apenas 14 casos em cinco décadas. O objetivo deste relato foi alertar médicos e pesquisadores para a importância de um diagnóstico correto e mostrar a possibilidade de controle dessa disfunção com o tratamento conservador. RELATO DO CASO: Paciente do sexo feminino, 68 anos, após trauma facial e três intervenções cirúrgicas posteriores, desenvolveu quadro de síndrome complexa de dor regional orofacial. Foram realizados vários esquemas terapêuticos, o último dos quais tornou-a completamente assintomática: oxcarbazepina (900mg/dia), morfina de liberação controlada (120mg/dia), fluoxetina (40mg/dia) e clonazepam (2mg/dia), eletroterapia e reabilitação oral. CONCLUSÃO: Os critérios de diagnóstico para a síndrome complexa de dor regional, preconizados pela International Association for the Study of Pain, revisados em 2007, devem ser seguidos. O tratamento desta síndrome neuropática inclui anticonvulsivantes, tricíclicos e opioides, eletroterapia, bloqueio somático e de gânglio estrelado, este último quando a dor for mantida pelo sistema nervoso simpático. Neste relato de uma síndrome complexa de dor regional II orofacial foi mostrado o controle da dor sem a necessidade de bloqueio do gânglio simpático, o que pode alertar a classe médica para um correto diagnóstico e um tratamento eficaz e menos invasivo.

Spinal cord stimulation in the treatment of complex regional pain syndrome type 1: Is trial truly required?

OBJECTIVE: Spinal cord stimulation has been proven highly effective in the treatment of Complex Regional Pain Syndrome (CRPS). The definitive implantation of a neurostimulator is usually preceded by a therapeutic test (trial), which has the purpose of identifying whether the patient would respond positively to neuromodulation or not. The present study aims to analyze the surgical results of spinal cord stimulation in type 1 CRPS patients who have not undergone trial. PATIENTS AND METHODS: From January 2011 to August 2017, 160 patients underwent implantation of spinal cord neurostimulator. Out of that total number of surgeries, 33 patients were unequivocally diagnosed with type 1 Complex Regional Pain Syndrome and selected for this study. The efficacy of the surgical procedure concerning pain improvement was analyzed through the application of the Pain Disability Index and the Visual Analog Pain Scale. RESULTS: The mean sample age was 48.08 years. The majority of the study subjects were female (66.66%). In respect to the Pain Disability Index, a 65% improvement in disability was observed subsequently to the neurostimulator implantation; in addition, the means of the scores for preoperative and postoperative periods were, respectively, 55 ±â€¯8.69 (p < 0.0001) and 18.90 ±â€¯11.58 (p < 0.0001). Regarding the Visual Analogue Scale, the mean pain in the preoperative period was 9.43 ±â€¯0.77 (p < 0.0001), while the mean in postoperative period was 2.86 ±â€¯2.08 (p < 0.0001). Thus, an average reduction of 70% of painful symptoms was observed after the surgical procedure. CONCLUSION: Implantation of a spinal cord neurostimulator presented significant improvement in pain and disability of patients with type 1 CRPS in all cases. These results were obtained following the criteria: 1) patients presenting unequivocal diagnosis of type 1 CRPS; 2) submitted to constant current spinal cord neurostimulator implant; 3) underwent intraoperative tests for precise location of the spinal cord electrode implantation. Therefore, it is possible to suggest that a trial may be unnecessary in that subgroup of patients. Further studies would be required to confirm these findings.

Aspectos clínicos, radiográficos y rehabilitadores en pacientes con síndrome doloroso regional complejo / Clinical, radiographic and rehabilitative aspects in patients with complex painful regional syndrome

Se efectuó un estudio descriptivo y transversal de 17 pacientes con síndrome doloroso regional complejo, que recibieron rehabilitación en el Departamento de Fisioterapia del Hospital General Docente Dr Juan Bruno Zayas Alfonso de Santiago de Cuba, desde enero 2016 hasta febrero 2017, con vistas a caracterizarles según aspectos clínicos y radiográficos. Entre los principales resultados predominaron el tipo 1 de la enfermedad (64,7 por ciento), la etapa precoz (25,0 por ciento), la localización en el miembro superior (82,4 por ciento) y el sexo femenino (58,8 por ciento), entre otros. La corrección postural y la cinesiterapia fueron necesarias independientemente del estadio clínico de la enfermedad. Se concluye que resulta importante efectuar un diagnóstico clínico y radiográfico oportuno, así como ejecutar medidas rehabilitadoras tempranas para evitar la discapacidad y lograr una recuperación funcional óptima

A descriptive and cross-sectional study of 17 patients with complex painful regional syndrome who received rehabilitation in the Physiotherapy Department of Dr Juan Bruno Zayas Alfonso Teaching General Hospital was carried out in Santiago de Cuba, from January, 2016 to February, 2017, aimed at characterizing them according to clinical and radiographical aspects. Among the main results there was a prevalence of the type 1 of the disease (64.7 percent), early stage (25.0 percent), localization in the upper member (82.4 percent) and the female sex (58.8 percent), among others. The postural correction and kinesiotherapy were necessary independently of the clinical stage of the disease. It was concluded that it is important to make an appropriate clinical and radiographic diagnosis, as well as to implement early rehabilitative measures to avoid disability and achieve a good functional recovery

FACTORS ASSOCIATED WITH COMPLEX REGIONAL PAIN SYNDROME IN SURGICALLY TREATED DISTAL RADIUS FRACTURE.

OBJECTIVE: The aim of this study was to identify factors associated with developing complex regional pain syndrome (CRPS) after surgical treatment for distal radius fracture (DRF). METHODS: This case-control study analyzed patients seen from January 2014 to January 2016. Results: In our sample of 249 patients, 4% developed CRPS. Associated factors were economic compensation via work disability (odds ratio [OR] 14.3), age (OR 9.38), associated fracture (OR 12.94), and level of impact (OR 6.46), as well as psychiatric history (OR 7.21). CONCLUSIONS: Economically-productive aged patients with a history of high-impact trauma and patients with a history of psychiatric disorders have greater risk of developing CRPS after DRF. Level of Evidence III, Case-Control Study.

OBJETIVO: Este estudo tem como objetivo identificar fatores de risco associados ao desenvolvimento de síndrome de dor regional complexa (CRPS) após o tratamento cirúrgico da fratura distal do rádio (DRF). MÉTODOS: Este estudo de caso/controle analisou pacientes atendidos de janeiro de 2014 a janeiro de 2016. Resultados: Em nossa amostra de 249 pacientes, 4% desenvolveram CRPS. Os fatores associados foram compensação econômica (razão de chances [RC] 14,3), idade (RC 9,38), fratura associada (RC 12,94) e nível de impacto (RC 6,46), bem como história psiquiátrica (RC 7,21). CONCLUSÕES: Os pacientes com idade produtiva e história de trauma de alto impacto e os com história de transtornos psiquiátrico têm maior risco de desenvolver CRPS depois de DRF. Nível de Evidência III, Estudo de Caso Controle.

Factors associated with complex regional pain syndrome in surgically treated distal radius fracture / Fatores associados à síndrome de dor regional complexa em fratura do distal do rádio tratada cirurgicamente

ABSTRACT Objective: The aim of this study was to identify factors associated with developing complex regional pain syndrome (CRPS) after surgical treatment for distal radius fracture (DRF). Methods: This case-control study analyzed patients seen from January 2014 to January 2016. Results: In our sample of 249 patients, 4% developed CRPS. Associated factors were economic compensation via work disability (odds ratio [OR] 14.3), age (OR 9.38), associated fracture (OR 12.94), and level of impact (OR 6.46), as well as psychiatric history (OR 7.21). Conclusions: Economically-productive aged patients with a history of high-impact trauma and patients with a history of psychiatric disorders have greater risk of developing CRPS after DRF. Level of Evidence III, Case-Control Study.

RESUMO Objetivo: Este estudo tem como objetivo identificar fatores de risco associados ao desenvolvimento de síndrome de dor regional complexa (CRPS) após o tratamento cirúrgico da fratura distal do rádio (DRF). Métodos: Este estudo de caso/controle analisou pacientes atendidos de janeiro de 2014 a janeiro de 2016. Resultados: Em nossa amostra de 249 pacientes, 4% desenvolveram CRPS. Os fatores associados foram compensação econômica (razão de chances [RC] 14,3), idade (RC 9,38), fratura associada (RC 12,94) e nível de impacto (RC 6,46), bem como história psiquiátrica (RC 7,21). Conclusões: Os pacientes com idade produtiva e história de trauma de alto impacto e os com história de transtornos psiquiátrico têm maior risco de desenvolver CRPS depois de DRF. Nível de Evidência III, Estudo de Caso Controle.

Update on the effects of graded motor imagery and mirror therapy on complex regional pain syndrome type 1: A systematic review.

Graded motor imagery (GMI) and mirror therapy (MT) is thought to improve pain in patients with complex regional pain syndrome (CRPS) types 1 and 2. However, the evidence is limited and analysis are not independent between types of CRPS. The purpose of this review was to analyze the effects of GMI and MT on pain in independent groups of patients with CRPS types 1 and 2. Searches for literature published between 1990 and 2016 were conducted in databases. Randomized controlled trials that compared GMI or MT with other treatments for CRPS types 1 and 2 were included. Six articles met the inclusion criteria and were classified from moderate to high quality. The total sample was composed of 171 participants with CRPS type 1. Three studies presented GMI with 3 components and three studies only used the MT. The studies were heterogeneous in terms of sample size and the disorders that triggered CRPS type 1. There were no trials that included participants with CRPS type 2. GMI and MT can improve pain in patients with CRPS type 1; however, there is not sufficient evidence to recommend these therapies over other treatments given the small size and heterogeneity of the studied population.

Síndrome de dolor regional complejo / Complex regional pain synndrome

El Síndrome de Dolor Regional Complejo (SDRC) es una enfermedad crónica, que se caracteriza por dolor y alteraciones sensitivas, motoras y autonómicas, a menudo sigue a trauma de un miembro, su curso es variable y, tanto su fisiopatología como el tratamiento, no están claramente establecidos. El objetivo de esta revisión es presentar una actualización de los aspectos generales de la enfermedad y mostrar parte de la evidencia existente en relación a las alternativas terapéuticas de la misma, tanto las conservadoras como las intervencionales. Es importante tener en consideración algunos puntos que limitan el objetivo de obtención de evidencia de buena calidad para el tratamiento de este síndrome. Lo primero es que el diagnóstico es clínico y los criterios para realizarlo han variado en el tiempo. Segundo, es la ausencia de criterios estandarizados para medir los resultados al tratamiento. Y, por último, ya que se trata de un síndrome crónico cuya manifestación principal es el dolor, existe respuesta a placebo...

The Regional Pain Syndrome Complex (CRPS ) is a chronic disease, which is characterized by pain and sensory, motor and autonomic disturbances, often follows trauma, the course and the pathophysiology are variable. The aim of this review is to provide an update on the general aspects of the disease and show the evidence in relation to therapeutic alternatives...

Caracterización del perfil cognitivo y funcional motor en pacientes con síndrome doloroso regional complejo y dolor neuropático: serie de casos / Cognitive profile characterization and functional motor in patients with complex regional syndrome painful and nerve pain: case series

El dolor es una experiencia sensorial y emocional desagradable, asociada a daño tisular, real o potencial. Dos causas de dolor neurológico son el Síndrome Doloroso Regional Complejo -SDRC- y dolor neuropático -DNP-. El dolor afecta la función cognitiva y el funcionamiento motor. Es objetivo describir el perfil cognitivo y funcional motor en pacientes con SDRC y DNP. Estudio descriptivo en seis pacientes, tres con SDRC y tres con DNP. Evaluación neuropsicológica y perfil de funcionamiento mediante clasificación internacional del funcionamiento. Los pacientes con SDRC y DNP poseen un déficit estructural y fisiológico en las redes centrales y periféricas del dolor, limitación en las funciones de las extremidades comprometidas y restricciones en las actividades y participación de diferente nivel. El dolor como enfermedad crónica afecta la función cognitiva y emocional de quien lo sufre, debido a que diferentes estructuras cerebrales se ven afectadas ante su presencia.

Pain is an unpleasant sensory and emotional experience associated with tissue damage, actual or potential. Two causes of neuropathic pain include Complex Regional Pain Syndrome, CRPS and neuropathic pain-DNP. Pain affects cognitive function and motor functioning. Describing the functional and cognitive profile in patients with CRPS engine and DNP is the objective of this study. Descriptive study in six patients, three of them suffer from CRPS and the other three cope with DNP. Neuropsychological assessment and performance profile by International Classification of Functioning. Discussion: The SDRC and DNP have a structural and physiological deficit in central and peripheral pain networks, limitation in functions of involved limbs, restrictions in the activities, and participation of different levels. As a chronic disease, pain affects cognitive and emotional function of the sufferer, due to different brain structures are affected because its presence.

Síndrome Dolorosa Regional Complexa: atualização / Complex Regional Pain Syndrome: an update about the subject

A Síndrome Dolorosa Regional Complexa (SDRC) representa acometimento neurológico crônico, engloba várias patologias caracterizadas pela presença de dor espontânea em queimação, hiperalgesia, edema, instabilidade vasomotora, alteração da função motora e anormalidades autonômicas. Há piora evidente da dor com alguns estímulos, como mudanças de temperatura, toque e movimento. Sua incidência é em menos de 2% da população, sendo leve em 30 a 40% após as fraturas e traumas cirúrgicos. A idade média de acometimento é de 41 anos, com predomínio em mulheres (3:1). Associa-se em 65% dos casos ao trauma, 19% no pós-operatório, 2% após processos inflamatórios e 4% após outros fatores, como punção venosa. Não há evidências de que existam fatores de risco que predisponham ao seu desenvolvimento. O diagnóstico é clínico e por exclusão. O tratamento, apesar de difícil e pouco eficaz, deve ser realizado de forma multidisciplinar, instituído em fase precoce da doença, com o objetivo de impedir seu agravamento.

The Complex Regional Pain Syndrome (CRPS) is a chronic neurological syndrome, that encompasses several diseases characterized by the presence of spontaneous burning pain, hyperalgesia, edema, abnormal vasomotor activity, changes in motor function and autonomic abnormalities. There is clear worsening of pain with some stimuli, such as changes in temperature, touch and movement. United States data estimate the incidence of chronic CRPS in less than 2% of the population, and takes into SDRC 30-40% after fractures and surgical trauma. The average age of patients is 41 years, predominantly in females (3:1). About 65% of the cases are related to trauma, 19% in the postoperative period, 2% after inflammatory processes and 4% after other factors, such as venipuncture. There is no evidence that there are risk factors that predispose to its development. The diagnosis is purely clinical and by exclusion. The treatment, although difficult and inefficient, should be accomplished through a multidisciplinary approach and be established at an early stage of the disease in order to prevent its increase.

Síndrome doloroso regional complejo tipo 1: Un diagnóstico elusivo / Complex regional pain syndrome type 1: An elusive diagnosis

El síndrome doloroso regional complejo tipo 1 es una afección que puede complicar traumatismos, en especial de los miembros. Es infradiagnosticado y potencialmente muy incapacitante. El diagnóstico se realiza reuniendo una serie de criterios clínicos. No existe un método de diagnóstico complementario que pueda considerarse patrón de oro. Su tratamiento debe ser multidisciplinario (fármacos, terapia física, terapia psicológica y en casos seleccionados, procedimientos invasivos). Se han comunicado resultados favorables con múltiples tratamientos farmacológicos, siendo la terapia con corticosteroides una de las que han alcanzado altos niveles de evidencia a favor de su utilidad. Presentamos el caso de un paciente masculino de 47 años de edad que fue internado en nuestro servicio por dolor intenso en su extremidad inferior derecha de características neuropáticas de larga evolución. Había realizado múltiples consultas previas y cumplido diversos tratamientos. Se le realizó centellograma óseo de tres fases con 99Tc que resultó compatible con el diagnóstico propuesto. Se trató con metilprednisona 60 mg/día con disminución progresiva hasta completar 15 días, obteniéndose una mejoría significativa de la sintomatología. Se le otorgó el alta hospitalaria para proseguir la rehabilitación ambulatoria.

Complex regional pain syndrome type 1 is a painful disorder that may complicate a traumatic lesion especially in extremities. It is infradiagnosed and potentially very disabling. Its diagnosis consists of a few clinical criteria. It does not exist a complementary diagnostic study which can be considered as gold standard. Its treatment must be multidisciplinary (e.g. medicines, physical therapy, psychological therapy and, in selected cases, invasive procedures). There have been communicated some favorable results using multiple pharmacological treatments in which corticosteroid therapy was among the ones that have reached highest levels of evidence in favor of its utility. Here we present the case of a forty-seven male patient who presented severe pain in his right lower extremity with neuropathic characteristics and a long time of evolution. He had had multiple previous consultations and he had carried out many other treatments. It has been performed a 99Tc three- phase bone scintigraphy that was compatible with the proposed diagnosis. He was treated with methyl prednisone 60 mg q24h with progressive lowering doses during fifteen days with a significant improvement of signs and symptoms. Finally he received hospital discharge for ambulatory rehabilitation treatment.

Distrofia simpática refleja idiopática / No presenta

La distrofia simpática refleja es un síndrome caracterizado por dolor local severo, desproporcionado, asociado a alteraciones de tipo vasomotor y cambios tróficos. Afecta las extremidades, apareciendo de forma relativamente frecuente luego de un trauma o cirugía, incluso aunque fuese menor. La presentación idiopática de este síndrome es mucho menos frecuente. A continuación se describe el caso de una mujer joven con distrofia simpática refleja idiopática y se presenta una revisión de la literatura con énfasis en el diagnóstico y tratamiento de esta entidad.

Reflex sympathetic dystrophy is characterized by intense and disproportionate local pain, associated with vasomotor and trophic changes. Extremities are commonly involved, especially when a trauma or surgery, even minor, has occurred. Likewise, spontaneous or idiopathic presentation of this syndrome is much less frequent. Here we describe the clinical picture of a young woman presenting with idiopathic reflex sympathetic dystrophy. Then we present a brief review, emphasizing on diagnosis and treatment of this disease.

Enfermedad reumatológica y embarazo / Rheumatic diseases and pregnancy

La presencia de enfermedad reumatológica en el embarazo no es infrecuente. Este hecho se favorece por la mayor prevalencia de enfermedades reumáticas en mujeres en edad fértil. El efecto del embarazo en la enfermedad reumatológica varía de acuerdo a la enfermedad; en algunos casos se tiende a exacerbar la patología de base, mientras que en otros tiende a remitir. Independiente de cuál sea la situación, la enfermedad reumática en el embarazo siempre representa un desafío importante para el equipo médico tratante. El tratamiento de cada condición difiere del estándar porque muchos medicamentos poseen efectos adversos para el embarazo y adicionalmente, en los estudios clínicos con frecuencia se excluye a la población obstétrica por lo que muchas de las recomendaciones en este grupo de pacientes provienen de observaciones clínicas. El conocimiento preciso del problema y la inclusión del médico reumatólogo en el equipo de tratamiento son pasos fundamentales para obtener un mejor resultado materno-fetal. En este artículo analizamos las enfermedades reumáticas más frecuentes y su relación con el embarazo.

The association between rheumatic diseases and pregnancy is not uncommon. This is due to the high prevalence of the rheumatic diseases among young women. The effect of pregnancy on any rheumatic disease is unique to each rheumatologic condition; in some cases pregnancy is the trigger for a flare-up, while in other cases the disease tends to go to remission. Independent to the clinical scenario, rheumatic diseases on a pregnant women is always a challenge for the medical team. Treatment for each condition differs from the standard of care, because many drugs may have serious side effects on pregnancy. Besides, obstetric population is commonly excluded from clinical trials, so most recommendations are made by expert opinion and clinical observations. The precise understanding of this situation and the participation of a rheumatologist in the medical team are essential elements to achieve the best outcomes. In this paper we review the most frequents rheumatic diseases and its relation with pregnancies.