Clinical Findings of Post-Stroke Reflex Sympathetic Dystrophy
Post-stroke reflex sympathetic dystrophy (now termed Complex Regional Pain Syndrome Type 1) presents with regional pain in the affected limb accompanied by autonomic dysfunction including skin color changes, temperature alterations, edema, abnormal sweating, and motor abnormalities including weakness and dystonia. 1, 2
Core Clinical Features
The diagnosis is primarily clinical and requires identification of the following characteristic findings 1, 2:
Pain and Sensory Changes
- Excruciating pain that gradually increases in intensity and spreads within the affected limb 1
- Pain characteristically worsened by touch or stimulation (allodynia) 1
- Regional pain following the initial stroke event, often appearing disproportionate to any identifiable injury 1, 2
- Sensory disturbances in the affected region 3
Autonomic Dysfunction
- Skin discoloration (may appear red, blue, or mottled) 1, 2
- Temperature changes in the affected limb (typically cooler or warmer than the contralateral side) 3, 2
- Abnormal sweating patterns (increased or decreased) 3, 2
- Edema of the hand/wrist region 4, 3
Motor Abnormalities
- Functional limb weakness appearing flaccid or disproportionate to the initial stroke 1, 5
- Focal dystonia (abnormal posturing or sustained muscle contractions) 5
- Tremor in the affected limb 5
- Spasms and increased muscle tone 5
- Difficulty initiating movement 5
- Decreased active range of motion, particularly reduced finger flexion and shoulder movement 3, 5
- Altered movement patterns and difficulty with weight-bearing activities 1
Trophic Changes
- Hair growth changes (increased or decreased) 3
- Nail growth abnormalities 3
- Tissue changes at the site of pain 1
Clinical Staging
The clinical course traditionally divides into three stages 2:
- First stage (acute/hyperemic): Predominant pain, warmth, erythema, and edema 2
- Second stage (dystrophic/ischemic): Progressive skin changes, coolness, and increased stiffness 2
- Third stage (atrophic): Tissue atrophy, contractures, and irreversible changes 2
Important Clinical Considerations
The motor manifestations may precede other features by weeks or months, making early diagnosis challenging 5. These movement disorders can occur with or without the classic sudomotor/vasomotor changes and pain 5.
Shoulder pain and decreased passive range of motion of the shoulder are particularly important screening findings in post-stroke patients 4.
The incidence of post-stroke CRPS Type 1 is relatively low (approximately 1.56%) when patients receive early comprehensive rehabilitation with proper positioning and early mobilization 4. This is substantially lower than historically reported rates, emphasizing the protective effect of early intervention 4.
Diagnostic Confirmation
While diagnosis is primarily clinical based on the constellation of findings above 1, three-phase bone scan provides objective confirmation with 78% sensitivity and 88% specificity 6, 7. The scan should be considered when at least three of five key criteria are present: shoulder pain, decreased shoulder range of motion, wrist/hand pain, edema, and skin changes 4.
Plain radiographs should be obtained first to exclude fractures, osteoarthritis, or other osseous pathology 7. MRI without contrast has high specificity (91%) but lower sensitivity (35%) and is particularly useful when nerve injury is suspected 7.