The common triggers of CRPS include fractures, sprains, soft tissue injuries such as burns, surgical procedures and limb immobilisation from a cast, splint or brace. It commonly affects a single limb, but other limbs can become involved. CRPS is essentially an abnormal neurological pain response that magnifies the effects of an injury. CRPS is caused by damage or dysfunction of the peripheral and/ or central nervous system and an inappropriate neuroinflammatory response. More than 80% of cases are caused by an accident, injury or surgical intervention and these are the cases where a medico legal claim is often made.
Symptoms of CRPS include severe stabbing or throbbing pain, burning or pins and needles, sensitivity to light touch (allodynia), changes to skin temperature or colour (mottled or discoloured), swelling, stiffness, alteration in hair and nail growth, decreased mobility, contractures and muscle spasms.
There are three important steps to take to simplify CRPS cases. Firstly, ensure you engage appropriate experts; secondly, obtain a clear diagnosis and prognosis; and finally, engage and obtain a report from a consultant in pain medicine who specialises in diagnosing and treating CRPS.
Engaging with the relevant expert witnesses ensures the patient is appropriately assessed and an accurate and authoritative diagnosis is given. Given the complexities of CRPS, the multitude of symptoms and the overlap of medical expertise required, engaging the correct experts will enable the identification of an appropriate multi-modal treatment package. Instructing a multi-disciplinary team is not only best practice, but will also help reach a fair settlement figure.
In CRPS cases these experts may include a:
A fundamental part of any CRPS case is securing a diagnosis from an expert consultant in pain medicine who is a specialist in diagnosing and treating CRPS and who has extensively reviewed both the patient and their medical records.
The Budapest Criteria is the internationally recognised criteria for the diagnosis of CRPS and should be used in the assessment of the claimant. CRPS cases should command the same consideration as other severe injuries such as spinal cord or brain injuries.
If there is any dispute over the diagnosis of CRPS, then the focus should shift from the CRPS diagnosis to the pain itself. Ultimately, pain is pain. What is important is how severe the pain is, how long it will continue, and how it affects the claimant’s life. It is the expert in pain medicine who has the expertise and responsibility to acknowledge these points for the court.
Medico legal cases involving CRPS are complex – the condition is, as its name implies, ‘complex’. Therefore it is essential to use a specialist consultant in pain medicine with proven experience in diagnosing and treating CRPS as a clinician and reporting on it as an expert witness.
The pain expert will consider several points when assessing a claimant:
CRPS cases can be challenging to prove and quantify. Any steps taken to simplify facts and present them to the court in a practical and useful way will benefit a case. A report lost in unnecessary information and medical complexities will not assist the court in reaching a judgement. Presenting succinct information from a multi-disciplinary team of experts improves the potential to achieve a fair settlement for both parties.
This blog has been written by Dr Christopher Jenner MB BS FRCA FFPMRCA, Consultant in Pain Medicine at Medicolegal Associates Ltd and Imperial Healthcare NHS Trust.
Dr Jenner suggests steps to remove complexities from Complex Regional Pain Syndrome (CRPS) cases and has appeared in the May issue of “Your Expert Witness“
Dr Jenner is also speaking at the Burning Nights CRPS Support’s 3rd Annual National CRPS Conference at the Marriott Bexleyheath, Kent on Saturday 4th November.