MES 2 : ANS Disorders,

Reflex Sympathetic Dystrophy,

Hypertonicity
Ramon Antonio S. Sarmiento ,MD
DLSU-HSC

ANS Disorders
I.
II.

Autonomic Dysreflexia
Central Pain
A. CRPS
B. Reflex Sympathetic Dystrophy
C. Sudecks atrophy

III.

Hypertonicity

Autonomic Dysreflexia
syndrome

of massive
sympathetic discharge
triggered by a noxious stimuli
common in SCI patients with
lesions above T6 level

Clinical Manifestations
1.
2.
3.
4.
5.
6.
7.

Hypertension
Headache
Sweating
Nasal congestion
Facial flushing
Piloerection
Reflex bradycardia

Causes/ Noxious stimuli

Bladder

and bowel distention due to

neurogenic bladder
Pressure sores
Ingrown toenails
Tight clothing and shoes
Urinary tract infections
Uterine contractions
Invasive procedure

Pathophysiology
Interruption

of inhibitory signals
Peripheral and splanchnic vasoconstrictio
Hypertension
Mass sympathetic discharges :
sweating and piloerection
Reflex bradycardia and
vasodilation (facial flushing and
congestion)

Pathophysiology
Noxious stimuli
Impulses
Dorsal column & Spinothalamic tracts
Inhibition of impulses
Sympathetic neurons

Sympathetic response

Complications
Confusion
Visual

disturbance
Loss of consciousness
Encephalopathy
Intracerebral hemorrhage
Seizures
Acute myocardial failure
Pulmonary edema

Treatment
1. Identify and remove the noxious
stimuli
2. Sit the patient up and monitor blood
pressure
3. Medications for hypertension:
Nitrates, nifedipine, hydralazine
4. Prevention of recurrence
5. Patient and family education

Central Pain
Pain

associated with a central nervous

lesion
Examples:
Thalamic pain syndrome
Complex Regional Pain Syndromes
(CRPS)
Causalgia
Reflex Sympathetic Dystrophy
(RSD)

Complex Regional Pain

Syndromes (CRPS)
A

consequence of trauma to the

body with or without nerve lesions
Due to overactivity of the
sympathetic NS
CRPS Type I Reflex Sympathetic
Dystrophy
CRPS Type II Causalgia

CRPS
Clinical

1.
2.
3.
4.

findings:
Pain and sensory abnormalities
Abnormal blood flow and
sweating
Abnormality in motor system
Trophic changes

CRPS Type I:
Reflex Sympathetic Dystrophy
Syndrome

that develops after a

noxious event
not limited to a peripheral nerve
distribution
symptoms disproportionate to
the inciting event
Distal > proximal

Reflex Sympathetic Dystrophy

Etiology:

Unknown
Other terms:
1. Sudecks atrophy
2. Shoulder hand syndrome

Sudecks atrophy
Sympathetic

symptoms associated
with traumatic fractures
Presents with pain, LOM, muscle
atrophy, cyanosis and edema
Diagnostic: x-ray
Involves distal extremities
Lasts weeks to months

Shoulder Hand Syndrome

Associated

with coronary
ischemia and CVA
Painful shoulder, hand and finger
Severity not proportional to
extent of underlying disorder

RSD: Signs and symptoms

pain follows trauma

onset: 1 month after injury
burning and continuous pain
exacerbated by movement,
stimulation and stress
(+) allodynia and hyperalgesia
change in skin temperature and
color, edema

RSD: Signs and Symptoms

increased/ decreased sweating

impairment of motor function
atrophy of skin and nails
alterations in hair growth
loss of joint mobility
weakness and tremor
fluctuating signs and symptoms

3 Stages of RSD
I. Acute stage
Constant burning pain
hyperalgesia, hyperesthesia
hyperpathia
localized edema
increased hair and nail growth
Increase skin temperature
muscle weakness, spasms

Stages of RSD
II. Dystrophic stage
hypersensitivity and
burning pain
lowered skin temperature
cessation of hair/ nail growth
hyperhydrosis
cyanotic skin color
muscle atrophy
spotty osteoporosis

Stages of RSD
III. Atrophic stage
decrease hypersensitivity
normalization of blood flow
and temperature
smooth, glossy skin
severe muscle atrophy
diffuse osteoporosis

RSD: Diagnosis
Difficult to diagnose
Use anatomic/ pharmacologic
nerve blocks
Technetium diphosphonate bone
scans

RSD: Complications

Phlebitis
Inappropriate drug use
Suicide

RSD: Treatment
Therapeutic

exercise
Sympathetic nerve blocks
Psychological counseling
Pharmacological intervention:
analgesics, NSAIDS, narcotics
Surgery: rhizotomies,
cordotomies, sympathectomy

RSD: Treatment
Physical

modalities
- cryotherapy vs. heat therapy
- TENS
- Acupuncture
Behavioral treatment modalities
- Behavior modification/
Relaxation technique
- Biofeedback

Hypertonicity
Increase

in muscle tone
Muscle tone - the resistance of
muscle to passive elongation or
stretch
Abnormalities:
1. Hypertonia
2. Hypotonia
3. Dystonia

Muscle Tone Disorders

Spasticity
Rigidity
Hypotonia/

Flaccidity

Spasticity
Velocity-dependent

increase in
tonic stretch reflexes with
exaggerated phasic stretch
reflexes
Results from dysfunctional spinal
and supraspinal mechanisms
A component of upper motor
neuron syndrome

Conditions presenting
with Spasticity
1.
2.
3.
4.
5.
6.

Spinal cord injury

Demyelinating disease
Stroke
Traumatic brain injury
Decorticate and decerebrate
rigidity
Cerebral palsy

Spasticity: symptoms

abnormal reflex behavior

loss of autonomic control
impaired muscle activation
paresis
decreased dexterity
fatigability

Spasticity: Clinical Evaluation

Clinical

history
Reflex examination
Passive and active motion
examination
Functional examination
Determine whether spasticity is
beneficial or detrimental

Benefits from spasticity

Aid

to standing and walking

Maintained muscle mass
Maintained bone mineralization
Reduced dependent edema
Reduced risk of deep venous
thrombosis

Detrimental effects of spasticity

Impaired

standing balance
Impaired swing phase of gait
Slow voluntary movements
Risk of contracture
Impaired sleep, perineal hygiene
Pain

Spasticity: Treatment
Eliminate

nociception
Provide patient education and
adaptive equipment
Range of motion exercises
Proper seating and positioning

Spasticity: Treatment
Daily

ROM and static stretch

Bracing, splinting
Biofeedback, ES
Icing
Surgery: Tendon lengthening,
selective dorsal rhizotomy,
tenotomy

Spasticity: Treatment
Oral:

Baclofen, Clonidine,
Diazepam, Tizanidine,
Dantrolene
Intrathecal Baclofen
Chemical nerve blocks: BOTOX
injection, Phenol block

Rigidity
Resistance

is increased in both
agonist and antagonist muscles
Body parts become stiff and
immovable
Seen in lesions of basal ganglia
e.g. Parkinsons disease
Due to excessive supraspinal
mechanism

Rigidity
Associated

with:
bradykinesia
tremor
loss of postural stability

Types of Rigidity
Cogwheel

rigidity - rachetlike
response to passive movement ;
alternating letting go and
increasing resistance to
movement
Leadpipe rigidity rigidity
constant throughout the
movement

Hypotonia and Flaccidity

Decreased

or absent muscular

tone
Diminished resistance to passive
movement
Impaired movements

Hypotonia and Flaccidity

Seen

in the following conditions:

1. UMN lesions affecting
cerebellum or pyramidal tracts
2. Spinal or cerebral shock
3. LMN lesions affecting PNS