Complex Regional Pain Syndrome (CRPS): Challenges of diagnosis and building a medico legal case

Dr Ivan Ramos-Galvez, Consultant in Pain Medicine, explores the condition of CRPS in more detail and explains the challenges of diagnosis and proving causation, as well as discussing the subjectivity of assessment.  Find out more about his expertise here.

What are the diagnostic critera?

The Budapest Criteria are used to measure pain.  They involve the report by the patient of severe pain, together with changes in blood flow that manifest themselves as temperature asymmetry, changes in the colour of the skin, lack of growth of finger/toe nails, loss of hair in the affected area, swelling of the affected area, stiffness of the affected area, skin atrophy with waxy/mottled/flaky appearance and muscle-wasting. These changes have to be corroborated by the person making the diagnosis and cannot be attributable to anything else. Common triggers are trauma and surgery, although rarely, CRPS can occur spontaneously.

What are the medicolegal challenges associated with CRPS?

The medicolegal challenges are directly related to the condition itself, in as much as there are no tests to confirm the diagnosis. This is complicated by the fact that CRPS can create, in itself, some maladaptative behaviours and feelings of rejection  towards the affected part of the body (normally a limb) for which again, there is no “test” to prove or disprove their existence. Therefore the medical expert relies entirely on a set of clinical parameters and feedback from the patient as well as their own “experience” (or perhaps astuteness) that makes them scrutinise the symptoms in order to exclude other causes.

An additional medicolegal challenge comes from a widespread philosophy that makes the general population and also, sadly, a significant proportion of medical professionals, disbelieve any diagnosis that does not show in blood tests/imaging. This has led to a new diagnosis called “pain syndrome” that slowly evolved into “complex pain syndrome” and by its similarity has been wrongly linked to CRPS. The meaning of a “pain syndrome” is pain for which a cause cannot be found. It is often used by surgeons who fail to explain continuation of pain despite satisfactory surgery as far as correcting an abnormal anatomy. CRPS is a completely different entity.

What are the challenges of establishing a cause?

Causation can be challenging because previous life experiences can determine how an individual will deal with adversity. Pain, particularly when it limits quality of life, challenges an individual’s social and professional structure and has the potential of jeopardising an individual’s earnings and finances, can be considered adversity. Human beings learn how to behave from those around. This includes how to deal with the unknown and uncertainty about the future, how to deal with frustration and how to deal with fear. Our emotional background and past experiences have an important role to play in how we deal with our lives. Because of the emotional maladaptation that CRPS brings to patients, there has been a suggested psychosomatic origin to it based on learned and past experiences and behaviours.

The challenge of establishing causation relies on careful understanding of the psychological background of the claimant and being able to establish the onset of symptoms only after the index injury. Careful and thorough review of historic medical records is crucial. Close cooperation with psychiatric and psychology experts is paramount to establishing this link. The more “organic” signs and symptoms, including the pain, abnormal sensations and changes in blood flow are more clear cut in as much as they either were or were not present before the index event.

Subjectivity of assessment

The assessment of CRPS relies on both a subjective report from the patient and, very importantly, objective assessment by an expert as an independent assessor. It is paramount that the expert remains impartial and is mindful throughout the process that their duty is to the Court rather than the claimant or the instructing party. This ensures impartiality and objectivity when assessing a condition that does not show in laboratory tests but rather in self-reporting questionnaires. Covert surveillance may be crucial in establishing the subjectivity of the symptoms if the claimant is observed to display the same level of claimed disability in their daily life as they report in the answers to the questionnaires. However, some caution is required here that those claimants who “carry on regardless” are not penalised for trying their best to regain some normality.

Why is it crucial to engage a pain expert on cases involving CRPS?

An expert in pain medicine has been trained in assessing and treating CRPS. We have experience in the diagnosis and management of the condition. We have diagnostic skills that only clinical exposure to the condition allow us to develop. CRPS cannot be diagnosed or managed using knowledge gained from a textbook. Its diagnosis requires suspicion and indepth investigation. Its management requires the knowledge of what is available and more importantly what can help a specific patient at that specific point in their lives. The array of treatments available rely upon being able to offer a full rehabilitative approach. As treating physicians, we have access to these tools and our clinical background gives us the clinical acumen that enables us to provide recommendations that will guide the instructing solicitors in the process of securing appropriate treatment and to quantify the value of the claim.

About Medicolegal Associates

We have two pain experts available for instruction on cases involving CRPS or other pain conditions:

Dr C Jenner

Dr I Ramos-Galvez

Click on the links for more detail on their expertise and get in touch to discuss your case in more detail.