Background:
Complex regional pain syndrome (CRPS) is defined as continuing chronic regional pain which can be spontaneous and/or evoked and disproportionate to the severity of the inciting event that lasts beyond the normal time frame expected. CRPS is a neurologic disorder of an unpredictable clinical course. It is characterized by extreme regional pain, allodynia (non-painful stimulus provokes pain), and abnormal sensory symptoms (extreme sensitivity to non-painful things and touch), vasomotor (changes in skin temperature, sweating), dystonia (involuntary muscle contractions), and hyperalgesia (increased sensitivity to pain). The progression of the symptoms over time is variable. CRPS is classified in two different forms namely-CRPS type I which is without obvious nerve lesion while the type II CRPS has a verifiable nerve lesion. CRPS is often at issue in personal injury cases. In those cases, a CRPS Expert Witness is typically needed to offer an opinion regarding causation, diagnosis and treatment.
Diagnosis:
There are no blood tests, MRIs, bone scans or other objective diagnostics tests for CRPS. In contrast, a diagnosis of Complex Regional Pain Syndrome requires the rigorous application of the Budapest Criteria. These criteria are widely used throughout the practice of pain medicine and represent the current standard of care in the diagnosis of Complex Regional Pain Syndrome. The Budapest criteria are a validated, statistically derived combination of symptoms and signs. Symptoms are those features as reported and described by the patient, while signs are physical exam observations that are noted by the clinician at the time of the examination.
The Budapest Criteria necessitate that all 4 criteria as outlined below are satisfied in order to conclude that a patient has Complex Regional Pain Syndrome. If the patient fails to satisfy one criteria, there is no need to further apply any of the other criteria as a diagnosis of Complex Regional Pain Syndrome cannot be made if any one of the 4 criteria is not satisfied.
- Continuing pain, which is disproportionate to any inciting event.
- Must report at least one symptom in three of the four following categories:
a. Sensory: Reports of hyperalgesia and/or allodynia
b. Vasomotor: Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
c. Sudomotor/Edema: Reports of edema and/or sweating changes and/or sweating asymmetry
d. Motor/Trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin) - Must Display at least one sign at the time of evaluation in two or more of the following categories
a. Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement)
b. Vasomotor: Evidence of temperature asymmetry and/or skin color changes and/or asymmetry
c. Sudomotor/Edema: Evidence of edema and/or sweating changes and/or sweating asymmetry
d. Motor/Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin). - There is no other diagnosis that better explains the signs and symptoms.
Whether or not a treating physician has evaluated and correctly applied the Budapest Criterion can be an issue requiring evaluation by a CRPS Expert Witness.
Symptoms:
The classic symptoms of CRPS include neurological perturbations in several categories, namely; Sensory, Vasomotor, Sudomotor and Motor changes. Such symptoms can include, unprovoked and spontaneous pain, changes in skin temperature, color, texture, swelling and sweating, abnormal hair and nail growth, joint stiffness, muscle wasting, diminished bone density and impaired muscle strength and coordination.
Complex Regional Pain Syndrome (CRPS) is the great imitator1,2. The current medical literature is clear that severe CRPS, particularly CRPS that has been present for several years, is a systemic disease which can manifest in literally any organ system throughout the body. In fact, there is not a single organ system that is known to be immune from the spread of CRPS. CRPS can spread from one limb to another and from one organ system to another through interactions between the somatic and sympathetic nervous systems.
In a personal injury lawsuit, a CRPS Expert Witness may be called upon to determine if the individual was experiencing symptoms of CRPS.
Treatment:
The treatment of CRPS involves multimodal therapy including early physical therapy and rehabilitation to prevent limb deconditioning and atrophy, medication management (NSAIDS, Neuropathic Agents, Antidepressants, Topical Analgesics, Opioids, Steroids), Injections (Sympathetic blocks, Botox), Spinal Cord Stimulation and Psychotherapy / Behavioral Therapy.
Conclusion:
CRPS is a diagnosis of exclusion and requires the rigorous application of the Budapest criteria by an experienced physician who understands the requisite signs and symptoms. CRPS is a vexing neurological disorder with an unpredictable clinical course. A CRPS Expert Witness may be needed to evaluate the presence of the disorder, it’s cause and the potential need for treatment.
Dr. Carinci is Chief of Pain Medicine at University of Rochester Medical Center. He is a pain management thought leader, a University of Rochester faculty member and former Harvard Faculty member. He is well-published and has significant teaching experience. Dr. Carinci trained at both Johns Hopkins and Harvard. He is the winner of multiple awards for clinical excellence.
Dr. Carinci has been an expert witness in numerous cases involving CRPS litigation for both plaintiff and defense. He has qualified as an expert witness in federal court and has testified at both deposition and trial. Dr. Carinci has evaluated, diagnosed and treated over 1000 patients with Complex Regional Pain Syndrome. Dr. Carinci has published and spoke nationally on the topic of CRPS.
Dr. Carinci can be contacted at adam.carinci@gmail.com or 845-797-2305.
References:
- Borchers AT, Gershwin ME. Complex regional pain syndrome: a comprehensive and critical review. Autoimmun Rev. 2014 Mar;13(3):242-65.
- Bussa M, Guttilla D, Lucia M, Mascaro A, Rinaldi S. Complex regional pain syndrome type I: a comprehensive review. Acta Anaesthesiol Scand. 2015 Jul;59(6):685-97.
