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CRPS DIAGNOSIS & PROGNOSIS

 

Information on CRPS/RSD diagnosis and prognosis

 

DIAGNOSIS

Currently there is no one particular clinical test that will give a definite positive diagnosis of Complex Regional Pain Syndrome / Reflex Sympathetic Dystrophy (CRPS/RSD). In a study (Shah, H. & Kirchner, J.S. 2011) they said that:

 

“Complex regional pain syndrome (CRPS) is a challenging pain condition for doctors and patients…”  

 

To receive a positive clinical CRPS diagnosis, pain specialists and doctors use the current BUDAPEST CRITERIA, which was brought in during the International Consensus Conference in 2004. This new diagnostic criteria takes over from the one from the International Association for the Study of Pain in 1994 (IASP 1994). The pain specialist or doctor will discuss with you your medical history, symptoms you may be having and any signs or changes. They also may do bones scans, thermal study, nerve conduction studies, EMG, MRI scan and x-rays. The Budapest Criteria does provide a solid diagnosis for established and severe CRPS (Dutton, K. & Littlejohn, G. 2015). In another study Friedman, A. (2015) believes that:

 

“It is critical to follow international criteria on making the diagnosis; overdiagnosis can lead to inappropriate interventions and further disability.”

 

In a research article by Kim, H.J. et al (2015) they investigated the predictive value of Sympathetic Skin Response (SSR) to try and attain a positive CRPS diagnosis from a group of 13 patients who had received a possible Complex Regional Pain Syndrome diagnosis. They compared the SSR to 2 other forms of diagnosis; three-phase bone scans (TPBS) and Thermography. They concluded that SSR may be helpful in trying to ascertain a CRPS diagnosis.

 

Even though there are distinct advantages to having an internationally recognised criteria for diagnosing CRPS, it can lead to problems in over-diagnosing the condition. Dutton, K. & Littlejohn, G. 2015 and Harden, R.N. et al. 2010

 

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If there is no known injury or illness that contributed to the problems then the doctors and specialists would carefully check if there is no other treatable condition that has been missed.

 

The BUDAPEST CRITERIA 2004 states that for there to be a clinical diagnosis of CRPS/RSD certain criteria need to be met. These are:

 

  • There needs to be lasting pain which is disproportionate to the initial injury or illness – The Doctor needs to judge when pain is “disproportionate in time or degree to the usual course of pain after any trauma or other inciting event.” Different traumas or events may have different healing times, and deviation from that should alert the clinician to the possibility to CRPS (Dutton, K. & Littlejohn, G. 2015)

 

  • You need to tell the doctor / specialist that you suffer at least 3 or more from the categories below:

 

1. SENSORY – This means that you describe symptoms of increased sensitivity or hypersensitivity on your limb

2. VASOMOTOR– This is when you describe temperature differences in your limb and / or skin colour changes and / or difference in your skin colour between the limbs

3. SUDOMOTOR / OEDEMA – You describe oedema (see the GLOSSARY) and / or sweating changes and / or sweating asymmetry

4. MOTOR / TROPHIC – Reports of decreased range of limb motion and / or abnormality of a muscle or nerve that effects or produces motion (including tremor, weakness, dystonia..) and / or trophic (see GLOSSARY) changes (includes changes in nails, hair, skin…)

  • You must ALSO show at least one (1) sign observed by the doctor or specialist at your appointment, in 2 or more of the categories below:

 

1. SENSORY– Evidence of hyperalgesia (See GLOSSARY) usually following a pinprick and / or allodynia (proof of pain to a light touch and / or deep somatic pressure and / or joint movement)

2. VASOMOTOR Proof of temperature change in 2 limbs or more and / or skin colour changes

3. SUDOMOTOR / OEDEMAProof of swelling or oedema and / or sweating changes and / or sweating asymmetry

4. MOTOR / TROPHICEvidence of decreased range of motion and / or motor dysfunction (such as tremor, weakness, dystonia) and / or trophic changes (skin, hair, nails…)

  • There is NO other diagnosis that could better explain the symptoms and signs observed during a physical examination

 

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To make the Budapest Criteria easier to see, here is a diagram showing the Budapest Criteria for a Complex Regional Pain Syndrome (CRPS) diagnosis:

 

Diagnosis of CRPS | Budapest Criteria CRPS diagnosis

Diagnosis of CRPS | Budapest Criteria CRPS diagnosis Diagnosis of CRPS | Budapest Criteria CRPS diagnosis

 

It is desirable that early diagnosis of CRPS is attained to allow treatment to begin right away to try and ensure the condition doesn’t become chronic. (Lunden, L.K. et al 2016) However unfortunately in the same research article from the clinical experience of the principal investigator of this piece of research has found that:

“….. it became apparent that CRPS often remained undiagnosed and that the clinical conditions of many patients seemed to be worsened following orthopedic surgery subsequent to the initial eliciting event.”

 

In a recent UK article by Dr. A. Goebel, University Lecturer at University of Liverpool in a project in conjunction with the Liverpool Walton Centre and the Pain Relief Foundation (See full details below), they are aiming to:

 

“reduce the time taken between the onset of CRPS and the right diagnosis”

How are they going to achieve this?

Dr. A. Goebel says in the article entitled “Complex Regional Pain Syndrome – Quicker Diagnosis and a new computer treatment for people with CRPS” that the reduction of taken for diagnosis is going to be achieved by:

 

“Patients with CRPS in the greater Liverpool region will be the first In the UK to receive computer guided brain training”

 

In a recent research study undertaken by Dubuis, E. et al. (2014) they found that:

 

“… patients with longstanding CRPS have serum antibodies to α-1a receptors, and that measurement of these antibodies may be useful in the diagnosis and management of the patients.” 

 

These special auto-antibodies that were found in long standing CRPS sufferers were not found in healthy people or those suffering with fibromyalgia or those with neuropathic pain. However it is interesting to note that it had been known that CRPS sufferers produce these auto-antibodies at the onset of the chronic pain condition but also in CRPS sufferers after many years of having CRPS. (Goebel, A. Body In Mind article 2015)

However, there may be other ideas and beliefs among the CRPS world of research that the condition we know to be Complex Regional Pain Syndrome (CRPS) may be known as something else Goebel, A. & Blaes, F. (2013):

 

” We propose that CRPS constitutes a prototype of a new kind of autoimmunity, which we term ‘IRAM’ (injury-triggered, regionally-restricted autoantibody-mediated autoimmune disorder with minimally-destructive course).” 

 

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PROGNOSIS

In a research study by Carr, E.S. et al. (2016) concerning CRPS diagnosis and prognosis, they stated that:

“Delay in diagnosis leads to prolonged suffering for the patient and, at times, unnecessary invasive debridement procedures. Raising awareness of this entity may help physicians make the correct diagnosis early, as well as initiate a collaborative effort between neurology, anesthesiology, and dermatology to provide the patient the most favorable outcome.”

 

If you receive early treatment following the injury or illness there is some evidence and research that believe that for the CRPS prognosis (Shah & Kirchner 2011):

 

“Early diagnosis and treatment are required to prevent a long-standing or permanent disability.” 

 

The study by Shah & Kirchner (2011) explains that there is a fair chance of recovery or ‘remission’ as CRPS sufferers know it as. It has not yet however been proved during clinical trials and studies concerning early treatment. However the CRPS prognosis will be different for each sufferer as everyone is considered unique and their symptoms although they will have a common trait, will also vary.

 

In the study by Birklein, F. et al (2015) they gave a number of recommendations for treating CRPS both in the acute stages and the chronic stages of the chronic pain condition. They also stated that:

 

“If these recommendations are followed, CRPS prognosis is not as poor as commonly assumed. Whether the patients can return to their previous life depends on particular individual factors.”

 

Occasionally people are left with unrelenting, agonising pain and irreparable changes regardless of what treatment is given to them. Again MORE RESEARCH is definitely require to help understand the actual causes of CRPS, how early treatment affects it, why it progresses in some people and not in others… The list is totally endless as to questions about CRPS – WE NEED TO CHANGE THIS.

 

To understand more about what CRPS treatments are available to you, please visit our TREATMENTS page.

 

A UK research study was recently undertaken (2015) Shenker, N. et al.  concerning the long term prognosis of CRPS sufferers using the CRPS-UK Registry, that is a web-based 35 year project and their aims were:

 

“… to outline the CRPS-UK Registry, assess the validity of the data and to describe the characteristics of a sample of the UK CRPS population.” 

 

 

From the same study (2015) Shenker, N. et al., one of the very interesting key points were that:

“Chronic CRPS appears to occur more frequently in left-handed individuals.”

 

 

In another recent study from 2014, Van Velzen, G.A.J. et al. concerning the quality of life, they concluded:

 

“We conclude that loss of QoL in CRPS patients is due mainly to reduced physical health. A comparison with data available from the literature shows that CRPS patients generally report poorer QoL than patients with other chronic pain conditions, particularly in the physical domains.” 

* QoL = Quality of Life

 

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CHILDREN & TEENAGERS PROGNOSIS

Many children and teenagers who have been diagnosed tend to have a good recovery. According to Edward C.T.H. et al:

 

“the prognosis of childhood-onset CRPS I seems less favourable than usually reported, and is comparable to the prognosis of the adult-onset CRPS I in view of a decreased quality of life and a large relapse percentage (33%) at long-term follow-up.”

 

 

In another study by Finniss, D.G., et al. entitled Complex Regional Pain Syndrome in children and adolescents’,   it was said that:

 

Early diagnosis, referral and appropriate intervention are essential in decreasing pain, suffering and resorting function for children and adolescents with CRPS.” 

 

In a study by Logan, D.E. et al. (2013) they found that children with CRPS reported higher pain intensity and more recent onset of pain at the initial tertiary pain clinic evaluation compared with children with other chronic pain conditions.

 

However, delayed diagnosis for children is also a problem as well as adults. CRPS is often missed in children and adolescents with lengthy delays before appropriate treatment is started. Liossi C., Clinch J. & Howard R. (2015) believe that the reason for this may be:

 

“…. because of clinicians’ lack of awareness or the heterogeneity of the presenting signs and symptoms, although paediatric presentation has several unique features when compared with adults.”

 

Another reason why CRPS diagnosis in children and adolescents could be delayed is due to Saito, Y. et al (2015) :

 

“…. the relatively rare association of childhood CRPS with preceding traumatic events compared with adult CRPS and the under-recognition of this syndrome by pediatricians often result in considerable delay in proper diagnosis.”

 

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So.. to conclude the Diagnosis and Prognosis of CRPS –

  • there is not a test specifically designed to get a proper diagnosis of CRPS, but there is the BUDAPEST CRITERIA 2004 which explains to Doctors what they must look for to confirm Complex Regional Pain Syndrome,
  • there is no full research giving us the prognosis of how long each person has to suffer from this terrible condition, but some paper research evidence has shown that early diagnosis and then early treatment will aid the recovery and subsequent ‘remission,’ but no clinical trials / studies as of yet to prove this.

 

CITED RESEARCH / STUDIES / TRIALS / ARTICLES

  • Berklein, F. et al (2015) ‘Complex regional pain syndrome An optimistic perspective,’ Neurology. 2015. Vol 84(1), pp 89-96. Full Text Available from: <http://s3.amazonaws.com/academia.edu.documents/43208956/Neurology.pdf?AWSAccessKeyId=AKIAJ56TQJRTWSMTNPEA&Expires=1470067711&Signature=wthxdJd3pz8G9p4M2JWEKCVEvIQ%3D&response-content-disposition=inline%3B%20filename%3DVIEWS_and_REVIEWS_Complex_regional_pain.pdf>
  • Carr, E.S. et al. (2016) ‘Complex Regional Pain Syndrome,’ Proc (Bayl Univ Med Cent). July 2016. Vol 29 (3), pp 333-334. Full Text Available from: <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4900790/#!po=7.14286>
  • Finniss, D.G. et al. (2006), ‘Complex Regional Pain Syndrome in children and adolescents,’ Science Direct & European Journal of Pain. November 2006. Vol 10 Issue 8, pp 767-770. Available from: <http://www.sciencedirect.com/science/article/pii/S1090380105001898>  Accepted 13 December 2005. Available online 24 January 2006.
  • Shah, A. & Kirchner, J.S. (2011) ‘Complex Regional Pain Syndrome,’ Foot Ankle Clin & NCBI NIH. June 2011. Vol 16(2). pp 351-366. Available from: < http://www.ncbi.nlm.nih.gov/pubmed/21600455>

 

USEFUL WORLDWIDE GUIDELINES

  • Netherlands Society of Anaesthesiologists and Netherlands Society of Rehabilitation Specialists (2014) ‘Complex Regional Pain Syndrome Type 1,’ November 2014. Available from: <http://pdver.atcomputing.nl/pdf/Executive_summary_updated_guidelines_CRPS_I_2014.pdf>

 

From the research we can see that it appears that there is insufficient evidence in many areas of the condition including CRPS diagnosis and prognosis, that are unknown or understood by the Health profession. This is something that as a CRPS charity would like to alter to give help and support to thousands of sufferers of Complex Regional Pain Syndrome / Reflex Sympathetic Dystrophy, in the UK and also around the world. The Budapest Criteria used for the diagnosis of CRPS is a step in the way forward to trying to eventually treat the condition. However it doesn’t help the prognosis of CRPS for sufferers.

 

Last Updated: 02/06/2017

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