A Historical Review of Complex Regional Pain Syndrome in the “Guides Library”

Abstract Complex regional pain syndrome (CRPS) is a controversial, ambiguous, unreliable, and unvalidated concept that, for these very reasons, has been justifiably ignored in the “AMA Guides Library” that includes the AMAGuides to the Evaluation of Permanent Impairment (AMA Guides), the AMA Guides Newsletter, and other publications in this suite. But because of the surge of CRPS-related medicolegal claims and the mission of the AMA Guides to assist those who adjudicate such claims, a discussion of CRPS is warranted, especially because of what some believe to be confusing recommendations regarding causation. In 1994, the International Association for the Study of Pain (IASP) introduced a newly invented concept, CRPS, to replace the concepts of reflex sympathetic dystrophy (replaced by CRPS I) and causalgia (replaced by CRPS II). An article in the November/December 1997 issue of The Guides Newsletter introduced CRPS and presciently recommended that evaluators avoid the IASP protocol in favor of extensive differential diagnosis based on objective findings. A series of articles in The Guides Newsletter in 2006 extensively discussed the shortcomings of CRPS. The AMA Guides, Sixth Edition, notes that the inherent lack of injury-relatedness for the nonvalidated concept of CRPS creates a dilemma for impairment evaluators. Focusing on impairment evaluation and not on injury-relatedness would greatly simplify use of the AMA Guides.

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Differential Diagnosis for Complex Regional Pain Syndrome

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2007.sepoct01 ◽

2007 ◽

Vol 12 (5) ◽

pp. 1-4, 12-16

Author(s):

Robert J. Barth ◽

Robert Haralson

Keyword(s):

Mental Health ◽

Differential Diagnosis ◽

Complex Regional Pain Syndrome ◽

Reflex Sympathetic Dystrophy ◽

International Association ◽

Pain Syndrome ◽

Individual Case ◽

Field Trials ◽

High Error Rate ◽

Diagnostic Protocol

Abstract Complex regional pain syndrome (CRPS) is a controversial, ambiguous, and often unreliable concept that presents significant clinical and rating challenges, to the extent that, for any individual case, many of the differential diagnostic issues provide a far more probable explanation of symptoms than does CRPS. The International Association for the Study of Pain (IASP) introduced CRPS in 1994 specifically to replace “reflex sympathetic dystrophy” [RSD] and “causalgia.” The IASP diagnostic protocol for assessing CRPS has led to overdiagnosis, as well as questions regarding the protocol's reliability, validity, and high error rate during field trials. Using the IASP protocol and the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fifth Edition, the authors discuss the mental health and general medical evaluations that are part of the differential diagnosis of CRPS, which involves both psychological and general medical components. Finally, examiners should be aware that the probability rates for a diagnosis of CRPS following a thorough and extensive differential diagnosis is very small and is further limited by the general lack of scientific credibility for the concept of CRPS. A diagnosis of CRPS in the absence of ruling out all potential differentials is not credible. A sidebar discusses several chapters that are relevant to rating impairment due to causalgia, RSD, and CRPS.

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Peripheral Nerve and Brachial Plexus Impairment, AMA Guides, Sixth Edition

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2017.marapr01 ◽

2017 ◽

Vol 22 (2) ◽

pp. 3-5

Author(s):

James B. Talmage ◽

Jay Blaisdell

Keyword(s):

Peripheral Nerve ◽

Brachial Plexus ◽

Complex Regional Pain Syndrome ◽

Lower Extremities ◽

Pain Syndrome ◽

Upper Extremities ◽

Motor Deficits ◽

Type I ◽

Sixth Edition ◽

Nerve Entrapments

Abstract Physicians use a variety of methodologies within the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, to rate nerve injuries depending on the type of injury and location of the nerve. Traumatic injuries that cause impairment to the peripheral or brachial plexus nerves are rated using Section 15.4e, Peripheral Nerve and Brachial Plexus Impairment, for upper extremities and Section 16.4c, Peripheral Nerve Rating Process, for lower extremities. Verifiable nerve lesions that incite the symptoms of complex regional pain syndrome, type II (similar to the former concept of causalgia), also are rated in these sections. Nerve entrapments, which are not isolated traumatic events, are rated using the methodology in Section 15.4f, Entrapment Neuropathy. Type I complex regional pain syndrome is rated using Section 15.5, Complex Regional Pain Syndrome for upper extremities or Section 16.5, Complex Regional Pain Syndrome for lower extremities. The method for grading the sensory and motor deficits is analogous to the method described in previous editions of AMA Guides. Rating the permanent impairment of the peripheral nerves or brachial plexus is similar to the methodology used in the diagnosis-based impairment scheme with the exceptions that the physical examination grade modifier is never used to adjust the default rating and the names of individual nerves or plexus trunks, as opposed to the names of diagnoses, appear in the far left column of the rating grids.

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Challenges in the Diagnostic Conceptualization of CRPS-1 (Formerly Conceptualized as RSD)

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2006.marapr01 ◽

2006 ◽

Vol 11 (2) ◽

pp. 1-3, 9-12

Author(s):

Robert J. Barth ◽

Tom W. Bohr

Keyword(s):

Clinical Practice ◽

Complex Regional Pain Syndrome ◽

Somatoform Disorders ◽

International Association ◽

Pain Syndrome ◽

Somatoform Disorder ◽

Syndrome Type ◽

Previous Issue

Abstract From the previous issue, this article continues a discussion of the potentially confusing aspects of the diagnostic formulation for complex regional pain syndrome type 1 (CRPS-1) proposed by the International Association for the Study of Pain (IASP), the relevance of these issues for a proposed future protocol, and recommendations for clinical practice. IASP is working to resolve the contradictions in its approach to CRPS-1 diagnosis, but it continues to include the following criterion: “[c]ontinuing pain, which is disproportionate to any inciting event.” This language only perpetuates existing issues with current definitions, specifically the overlap between the IASP criteria for CRPS-1 and somatoform disorders, overlap with the guidelines for malingering, and self-contradiction with respect to the suggestion of injury-relatedness. The authors propose to overcome the last of these by revising the criterion: “[c]omplaints of pain in the absence of any identifiable injury that could credibly account for the complaints.” Similarly, the overlap with somatoform disorders could be reworded: “The possibility of a somatoform disorder has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a somatoform scenario.” The overlap with malingering could be addressed in this manner: “The possibility of malingering has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a malingering scenario.” The article concludes with six recommendations, and a sidebar discusses rating impairment for CRPS-1 (with explicit instructions not to use the pain chapter for this purpose).

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