Complex regional pain syndrome underdiagnosed

,; ,; ,

Applied Evidence

Complex regional pain syndrome underdiagnosed

J Fam Pract. 2005 June;54(6):524-532

PDF Download

References

1. Allen G, Galer BS, Schwartz L. Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain 1999;80:539-544.

2. Birklein F, Kunzel W, Sieweke N. Despite clinical similarities there are significant differences between acute limb trauma and complex regional pain syndrome I (CRPS I). Pain 2001;93:165-171.

3. Schurmann M, Gradl G, Andress HJ, Furst H, Schildberg FW. Assessment of peripheral sympathetic nervous function for diagnosing early posttraumatic complex regional pain syndrome type I. Pain 1999;80:149-159.

4. Stanton-Hicks M, Janig W, Hassenbusch S, Haddox JD, Boas R, Wilson P. Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain 1995;63:127-133.

5. Lynch ME. Psychological aspects of reflex sympathetic dystrophy: a review of the adult and paediatric literature. Pain 1992;49:337-347.

6. Field J, Atkins R. Algodystrophy is an early complication of Colles’ fracture: What are the implications. J Hand Surg Br 1997;22B(2):178-182.

7. Reinders MF, Geertzen JH, Dijkstra PU. Complex regional pain syndrome type I: use of the International Association for the Study of Pain diagnostic criteria defined in 1994. Clin J Pain 2002;18:207-215.

8. Atkins R, Duckworth T, Kanis JA. Algodystrophy following Colles’ fracture. J Hand Surg Br 1989;14:161-164.

9. Baron R, Fields HL, Janig W, Kitt C, Levine JD. National Institutes of Health Workshop: reflex sympathetic dystrophy/complex regional pain syndromes— state-of-the-science. Anesth Analg 2002;95:1812-1816.

10. van de Beek WJ, Schwartzman RJ, van Nes SI, Delhaas EM, van Hilten JJ. Diagnostic criteria used in studies of reflex sympathetic dystrophy. Neurology 2002;58:522-526.

11. Bruehl S, Harden RN, Galer BS, et al. External validation of IASP diagnostic criteria for Complex Regional Pain Syndrome and proposed research diagnostic criteria. International Association for the Study of Pain. Pain 1999;81:147-154.

12. Galer BS, Bruehl S, Harden RN. IASP diagnostic criteria for complex regional pain syndrome: a preliminary empirical validation study. Clin J Pain 1998;14:48-54.

13. Veldman PH, Reynen HM, Arntz IE, Goris RJ. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet 1993;342:1012-1016.

14. Oerlemans HM, Oostendorp RA, de Boo T, Perez RS, Goris RJ. Signs and symptoms in complex regional pain syndrome type I/reflex sympathetic dystrophy: judgment of the physician versus objective measurement. Clin J Pain 1999;15:224-232.

15. van de Vusse AC, Stomp-van den Berg SG, de Vet HC, Weber WE. Interobserver reliability of diagnosis in patients with complex regional pain syndrome. Eur J Pain 2003;7:259-265.

16. Perez RS, Burm PE, Zuurmond WW, et al. Interrater reliability of diagnosing complex regional pain syndrome type I. Acta Anaesthesiologica Scandinavica 2002;46:447-450.

17. Harden RN, Bruehl S, Galer BS, et al. Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive? Pain 1999;83:211-219.

18. Wasner G, Schattschneider J, Baron R. Skin temperature side differences—a diagnostic tool for CRPS? Pain 2002;98:19-26.

19. Sandroni P, Low PA, Ferrer T, Opfer-Gehrking TL, Willner CL, Wilson PR. Complex regional pain syndrome I (CRPS I): prospective study and laboratory evaluation. Clin J Pain 1998;14:282-289.

20. Kingery WS. A critical review of controlled clinical trials for peripheral neuropathic pain and complex regional pain syndromes. Pain 1997;73:123-139.

21. Perez RS, Kwakkel G, Zuurmond WW, de Lange JJ. Treatment of reflex sympathetic dystrophy (CRPS type 1). a research synthesis of 21 randomized clinical trials. J Pain Symptom Manage 2001;21:511-526.

22. Cepeda MS, Lau J, Carr DB. Defining the therapeutic role of local anesthetic sympathetic blockade in complex regional pain syndrome: a narrative and systematic review. Clin J Pain 2002;18:216-233.

23. Demangeat JL, Constantinesco A, Brunot B, Foucher G, Farcot JM. Three-phase bone scanning in reflex sympathetic dystrophy of the hand. J Nucl Med 1988;29:26-32.

24. Lee GW, Weeks PM. The role of bone scintigraphy in diagnosing reflex sympathetic dystrophy [comment]. J Hand Surg Amer 1995;20:458-463.

25. Schiepers C, Bormans I, De Roo M. Three-phase bone scan and dynamic vascular scintigraphy in algoneurodystrophy of the upper extremity. Acta Orthop Belg 1998;64:322-327.

26. Todorovic-Tirnanic M, Obradovic V, Han R, et al. Diagnostic approach to reflex sympathetic dystrophy after fracture: radiography or bone scintigraphy? Eur J Nuclear Med 1995;22:1187-1193.

27. Zyluk A. The usefulness of quantitative evaluation of three-phase scintigraphy in the diagnosis of posttraumatic reflex sympathetic dystrophy. J Hand Surg 1999;24:16-21.

28. Chapurlat RD, Duboeuf FP, Liens D, Meunier PJ. Dual energy x-ray absorptiometry in patients with low limb reflex sympathetic dystrophy syndrome. J Rheumatol 1996;23:1557-1559.

29. Murray CS, Cohen A, Perkins T, Davidson JE, Sills JA. Morbidity in reflex sympathetic dystrophy. Arch Dis Child 2000;82:231-233.

30. Wesdock KA, Stanton RP, Singsen BH. Reflex sympathetic dystrophy in children. A physical therapy approach. Arthritis Care Res 1991;4:32-38.

31. Sandroni P, Benrud-Larson LM, McClelland RL, Low PA. Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study. Pain 2003;103:199-207.

32. Hove LM. Nerve entrapment and reflex sympathetic dystrophy after fractures of the distal radius. Scan J. Plast Resconstr Surg Hand Surg 1995;29:53-58.

33. Schurmann M, Gradl G, Zaspel J, Kayser M, Lohr P, Andress HJ. Peripheral sympathetic function as a predictor of complex regional pain syndrome type I (CRPS I) in patients with radial fracture. Auton Neurosci 2000;86:127-134.

34. Bickerstaff DR, Kanis JA. Algodystrophy: an underrecognized complication of minor trauma. Br J Rheumatol 1994;33:240-248.

35. Sarangi PP, Ward AJ, Smith EJ, Staddon GE, Atkins RM. Algodystrophy and osteoporosis after tibial fractures. J Bone Joint Surg Br 1993;75:450-452.

36. Greyson ND, Tepperman PS. Three-phase bone studies in hemiplegia with reflex sympathetic dystrophy and the effect of disuse. J Nucl Med 1984;25:423-429.

37. Wang YL, Tsau JC, Huang MH, Lee BH, Li CH. Reflex sympathetic dystrophy syndrome in stroke patients with hemiplegia-three phase bone scintigraphy and clinical characteristics. Kaohsiung J Med Sci 1998;14:40-47.

38. Petchkrua W, Weiss DJ, Patel RR. Reassessment of the incidence of complex regional pain syndrome type 1 following stroke. Neurorehabil Neural Repair 2000;14:59-63.

39. Geertzen JH, Dijkstra PU, van Sonderen EL, Groothoff JW, ten Duis HJ, Eisma WH. Relationship between impairments, disability and handicap in reflex sympathetic dystrophy patients: a long-term follow up study. Clin Rehabil 1998;12:402-412.

40. van de Beek WJ, Roep BO, van der Slik AR, Giphart MJ, van Hilten BJ. Susceptibility loci for complex regional pain syndrome. Pain 2003;103:93-97.

41. Commentary on RSD focus article Bandolier 2002. Available at: www.jr2.ox.ac.uk/bandolier/booth/ painpag/wisdom/RSD.html. Accessed on May 17, 2005.

42. Alvarez-Lario B, Aretxabala-Alcibar I, Alegre-Lopez J, Alonso-Valdivielso JL. Acceptance of the different denominations for reflex sympathetic dystrophy. Ann Rheum Dis 2001;60:77-79.

FAST TRACK

No single test identifies all persons with CRPS type 1; there is no objective gold standard for diagnosis

The absence of an objective gold standard does not mean CRPS type 1 is not a “real” disorder.¹² In developing diagnostic criteria for CRPS, the IASP turned to models developed for other conditions without objectively measurable findings: the International Headache Society (IHS) classification and the Diagnostic and Statistical Manual of Mental Disorders (DSM). These descriptive systems are based largely on history and self-reported symptoms rather than on clinical signs and laboratory tests. The accuracy of these types of diagnostic criteria is refined over time, through repeated, controlled validation studies using the best means available.¹¹

Specificity of criteria. Specificity has been tested using controls with neuro-pathic conditions.^11,12 In these studies, nonblinded clinicians applied CRPS type 1 diagnostic criteria, except the exclusion criterion, to patients who had either CRPS type 1 or neuropathic pain from other causes. Many persons with peripheral neuropathy met criteria for CRPS type 1. However, as stated in the IASP criteria, the diagnosis of CRPS type 1 is not considered until common causes of neuropathic pain and post-traumatic limb pain have been excluded.⁴ As long as the primary care provider considers and rules out other causes of pain, the clinically relevant specificity of these criteria is likely much higher.

Sensitivity of criteria varies.The sensitivity in these studies is based on a non-independent reference standard. Patients with CRPS type 1 were chosen for these studies using clinical criteria, and these criteria were reapplied by study clinicians to determine sensitivity.^11,12 This method does not allow any determination of whether cases of CRPS type 1 might be missed by the criteria. Sensitivity measured in this way more closely resembles interobserver reliability—the likelihood that different clinicians using the same diagnostic criteria will reach the same diagnosis— and it appears quite good, especially for IASP criteria, in these 2 studies.^11,12

However, when interobserver reliability has been directly studied, albeit in small studies of 3 and 6 observers, only Veldman’s criteria achieve good reliability; IASP and Bruehl’s criteria appear unreliable ( TABLE 3).^15,16 However, IASP and Bruehl’s criteria do fall within the range of reliability of other clinical assessments including medical fitness for a job and shoulder disorders.¹⁵

TABLE 1
Diagnostic criteria for CRPS type 1*

NAME	CRITERIA
IASP 1994 consensus criteria⁴	Criteria 2, 3 and 4 are necessary for a diagnosis of CRPS type 1.¹⁰ Type 1 is a syndrome that develops after an initiating noxious event. Spontaneous occurrence of pain in the absence of an external stimulus, allodynia (pain due to a mechanical or thermal stimulus that normally does not provoke pain), or hyperalgesia (exaggerated response to a stimulus that is normally painful) that is not limited to the territory of a single peripheral nerve, and is disproportionate to the inciting event. There is or has been evidence of edema, skin blood flow abnormality, or abnormal sudomotor (sweating) activity in the region of the pain since the inciting event. This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction.
Bruehl’s criteria: IASP-family¹¹	Continuing pain disproportionate to any inciting event. Patient must report at least 1 symptom in each of the 4 following categories: a) sensory: reports of hyperesthesia b) vasomotor: reports of temperature asymmetry or skin color changes or skin color asymmetry c) sudomotor/edema: reports of edema or sweating changes or sweating asymmetry d) motor/trophic: reports of decreased range of motion or motor ysfunction (weakness, tremor, dystonia) or trophic changes (hair, nail, skin) Must display at least 1 sign in 2 or more of the following categories: e) sensory: evidence of hyperalgesia (to pinprick) or allodynia (to light touch) f) vasomotor: evidence of temperature asymmetry or skin color changes or asymmetry g) sudomotor/edema: evidence of edema or sweating changes or sweating asymmetry h) motor/trophic: evidence of decreased range of motion or motor dysfunction (weakness, tremor, dystomia) or trophic changes (hair, nail, skin)
Veldman’s criteria¹³	Presence of 4 out of 5 symptoms: a) Diffuse pain during exercise b) Temperature differences between affected and unaffected extremity c) Color differences between affected and unaffected extremity d) Volume differences between affected and unaffected extremity e) Limitations in active range of movement of the affected extremity Occurrence or increase of symptoms during or after use Symptoms in an area larger than the area of the primary injury
*IASP definition of CRSP 1: A variety of painful conditions following injury which appears regionally having a distal predominance of abnormal findings, exceeding in both magnitude and duration the expected clinical course of the inciting event and often resulting in significant impairment of motor function, and showing variable progression over time. (All 3 criteria sets use this definition.)