Removing the complexity from Complex Regional Pain Syndrome (CRPS) cases.
By DR CHRISTOPHER JENNER MB BS FRCA FFPMRCA, Consultant in Pain Medicine at Medicolegal Associates Ltd and Imperial Healthcare NHS Trust.
COMPLEX REGIONAL PAIN SYNDROME (CRPS) is one of the most painful types of pain known. Medico legal cases involving chronic pain (pain that lasts for three months or more) is challenging for both the claimant and the defendant to prove or refute because of the subjective nature of pain. This is especially true for cases involving CRPS, partly due to the condition itself but also because the pain that follows the injury is not usually reflective of the original injury sustained and often far worse. Hence the complex disputes that arise regarding causation, liability and prognosis.
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.
Steps to simplify CRPS cases
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.
Engage the appropriate expert witnesses
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:
- Consultant in pain medicine – to diagnose, provide a prognosis, identify and evaluate the effect on the claimant’s life and provide a multidisciplinary treatment plan
- Rheumatologist – to aid in the diagnosis of CRPS
- Orthopaedic consultant – if orthopaedic injuries were sustained prior to onset
- Psychiatrist – to assess the claimant and rule out any psychiatric/psychological issues
- Occupational therapist – to identify care needs
Obtain a clear diagnosis
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.
Engage an expert in pain medicine
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:
- Medical history
- Severity of pain
- Impact of symptoms on claimant’s life, ability to function and need for support
- Effect on claimant’s ability to work
- The requirement to take medication to control symptoms and consideration of how the medications will impact the claimant’s daily functioning
- Multi-modal treatment that has been undertaken or can be in the future
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.