Broken and fractured bones are seen on x-rays. Herniated discs can be visualized on MRIs. Scars and burns can be seen with the naked eye. While often the cause of pain can be readily identified, pain itself is a conundrum. We know it exists. We have all felt it. But there is no battery of tests, no bloodwork, no scan that can show the presence or degree of pain itself.
Enter Complex Regional Pain Syndrome, formerly known in most medical circles as Reflex Sympathetic Dystrophy syndrome (RSD). CRPS is a form of chronic pain that varies significantly in severity and duration. CRPS symptoms can be mild in form but are often utterly incapacitating. Some of the most common symptoms of CRPS include:
- Burning pain, particularly in extremities
- Pins and needle sensation
- Spontaneous/unprovoked pain
- Extreme pain to light touch
- Sharp/shooting pain
- Temperature or color changes of the skin
- Changes in nail and hair growth pattern
Diagnosing CRPS is one of the greatest challenges associated with treating the disease. The recent trend in establishing criteria for diagnosing CRPS has become associated with the names of the conferences in which such accepted criteria was developed and adopted. As a result of the Schloss Rettershof conference in 1988 and the subsequent Orlando conference in 1994, diagnostic criteria for CRPS was adopted by the Committee for Classification of Chronic Pain of the International Association for the Study of Pain (IASP), which included:
- The presence of an inciting noxious event or cause of immobilization.
- Continuing pain, allodynia, or hyperalgesia with which the pain is disproportionate to any inciting event.
- Evidence at some time of edema, changes in skin, blood flow, or abnormal sudomotor activity in the region of pain.
- The diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction.
“Type I” of the disorder was delineated as CRPS without evidence of major nerve damage and “Type II” of the disorder was classified as involving major nerve damage.
A further attempt to focus the criteria for diagnosing CRPS was made during an international consensus meeting in Budapest, Hungry in August 2003. The goal was to eliminate some of the “false positives” that were resulting in application of the Orlando criteria. The resultant criteria (the “Budapest Criteria”) established the following conditions to validate a clinical diagnosis of CRPS:
- Continuing pain, which is disproportionate to any inciting event.
- Must report at least one symptom in all four of the following categories:
- Sensory – reports of hyperaesthesia and/or allodynia
- Vasomotor – reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
- Sudomotor/edema – reports of edema and/or sweating changes and/or sweating asymmetry
- Motor/trophic – reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
- Must display at least one sign at time of evaluation in two or more of the following categories:
- Sensory – evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or temperature sensation and/or deep somatic pressure and/or joint movement)
- Vasomotor – evidence of temperature asymmetry and/or skin color changes and/or asymmetry
- Sudomotor/edema – evidence of edema and/or sweating changes and/or sweating asymmetry
- Motor/trophic – evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
- There is no other diagnosis that better explains the signs and symptoms.
To date, the Budapest Criteria is the most often cited tool used by clinicians for diagnosing Complex Regional Pain Syndrome. Still, however, there is no specific, clear cut diagnostic test for determining whether one suffers from CRPS.
The only aspect of CRPS that may be more amorphous than the clinical diagnosis, are the causes of CRPS. Some of the most commonly known causes of CRPS include:
- Surgery (incision sites, sutures, post-operative scarring)
- Bone fractures
- Limb immobilization (for instance, after casting of an injury)
- Sprains & strains
- Poor nerve health
- Cuts & lacerations
- Poor circulation
Once CRPS is diagnosed, treatment options also vary from patient to patient. In its least invasive form, treatment may include physical/occupational therapy and medications such as Advil, Motrin, and Aleve, which can reduce inflammation and relieve pain. In addition to over-the-counter pain relievers and nonsteroidal anti-inflammatory drugs (NSAIDs), doctors may also use antidepressants and anticonvulsants (e.g., amitriptyline, gabapentin) to treat the pain generated from damaged nerves.
More invasive treatment may be instituted when oral medications and therapy fail. Sympathetic nerve-blocks, such as stellate ganglion blocks, are injections that can help relieve pain and increase blood circulation. Ketamine, an anesthetic drug, can be mixed with fluids in an IV bag and infused intravenously into the arm. Generally, Ketamine infusions are performed as part of a series and can be repeated if and when the effects wear off. More invasive still are spinal cord stimulators, in which electrodes are placed under the skin that send low levels of electricity directly into the spinal cord to relieve pain.
As referenced above, very often CRPS is caused by a traumatic personal injury, such as a fracture, or during recovery from a traumatic injury, such as limb immobilization/casting and scar formation. When that injury is caused by the actions of another person or entity, a personal injury claim may arise. Personal injury cases involving legitimate CRPS cases result in some of the highest value settlements and trial verdicts in New Jersey. But unlike a herniated disc or a broken bone, litigating CRPS cases in New Jersey requires a degree of experience and attention that can easily be overlooked by less attuned trial attorneys.
With limited exception, the very existence of CRPS itself will be challenged in a personal injury case. This flows from the lack of any gold standard test for objectively identifying when a person is suffering from CRPS. Skeptics will always question what they cannot see in black and white. Even if the diagnosis is conceded, inevitably the cause of the condition will be disputed. While traumatic injuries do make up a large portion of CRPS cases, research has also shown that CRPS can be caused by other factors discussed above.
In the face of vigorous challenges to both the CRPS diagnosis itself as well as the causative factor of that diagnosis, it is imperative that practitioners craft and implement a results-oriented litigation plan. This plan necessarily includes a comprehensive approach that cohesively incorporates the client, treating providers, and the most qualified medical experts. Finding the right trial attorney to handle a CRPS personal injury case is crucial to ensuring full and fair compensation for what is a significant and often debilitating disease.