Today’s post comes from guest author Todd Bennett from Rehm, Bennett & Moore. Complex Regional Pain Syndrome (CRPS) diagnosis is particularly important in Wisconsin Workers’ Comp, because scheduled injuries stemming from a limb (arm, hands, leg, foot) are valued significantly lower than unscheduled (back, torso, mental) injuries. A hand or foot injury that results in CRPS migrates from the limb to the spinal canal, and thus becomes a “body as a whole “injury. If the permanent restrictions from the CRPS preclude a return to work, then a Loss of Earning Capacity award is possible—which would not be possible for a limb injury itself.
Representing clients with chronic pain is both one of the hardest and most rewarding parts of my job.
The International Association for the Study of Pain sets forth four diagnostic criteria for Complex Regional Pain Syndrome (CRPS):
- an initiating event,
- continuous pain,
- edema, temperature, or color differences affecting a limb, and
- excluding all other causes.
These criteria are vague but, because diagnosis of CRPS is elusive, they are the established criteria for a physician identifying and treating chronic pain that cannot be attributed to any other cause.
When your doctor believes the pain you are experiencing is out of proportion to your examination findings and the severity of your injury, it creates a problem. However, this is quite common when suffering from complex regional pain syndrome. While those who suffer from CRPS are often frurstrated because the exact cause of the pain cannot be proven, the medical literature confirms that this disease, and the resulting pain, is real!
The 3 stages of complex regional pain syndrome, ie. chronic pain, are variable but the descriptions below show how the disease can progress:
Stage 1 (lasts 1 – 3 months):
- Changes in skin temperature, switching between warm or cold
- Faster growth of nails and hair
- Muscle spasms and joint pain
- Severe burning, aching pain that worsens with the slightest touch or breeze
- Skin that slowly becomes blotchy, purple, pale, or red; thin and shiny; swollen; more sweaty
Stage 2 (lasts 3 – 6 months):
- Continued changes in the skin
- Nails that are cracked and break more easily
- Pain that is becoming worse
- Slower hair growth
- Stiff joints and weak muscles
Stage 3 (irreversible changes can be seen)
- Limited movement in limb because of tightened muscles and tendons (contracture)
- Muscle wasting
- Pain in the entire limb
The hallmark symptoms typically involve swelling, redness, spasms or cramps, color of skin changes, mottling, increase in sweating, stiffness, and, of course, pain – severe pain. The presentation of the symptoms is variable as is the intensity and duration of your symptoms.
Diagnosing CRPS becomes a very difficult proposition because there is no diagnostic gold standard for diagnosing the disease. Medical professionals often make a diagnosis through process of elimination based on their training and experience, the condition itself, or the physical impact on the patient’s daily life activities. If it is determined that complex regional pain syndrome, sometimes referred to as chronic pain syndrome, has the presence of permanent, chronic and disabling pain, it is sufficient for a diagnosis of CRPS.
While a diagnosis of CRPS is appropriate for a patient experiencing ongoing severe pain, the disease does not yet have a diagnostic code (for billing purposes). This makes doctors less likely to make a diagnosis of CRPS for both their own and their patients’ financial sake.
Because many physicians are reluctant to provide an early partial or differential diagnosis of CRPS because it cannot be listed on their billing statement, CRPS often goes undiagnosed for long periods of time. Despite the misdiagnosis, whether intentional or unintentional, it is imperative you continue to inform your treating physician of all symptoms you are experiencing so that the proper diagnosis can eventually be made and the condition treated.
Next week we will discuss current treatment options.