A presentation given by Dr. Edwin Perez during his time as a Pain Fellow at the University of Washington, detailing the diagnostics and clinical markers in complex regional pain syndrome (CRPS)

1. Diagnostics and ClinicalDiagnostics and Clinical
Markers in CRPSMarkers in CRPS
Edwin Perez, MDEdwin Perez, MD
Pain FellowPain Fellow
University of WashingtonUniversity of Washington

2. PreamblePreamble
““Whatever the Thinker thinks, theWhatever the Thinker thinks, the
Prover provesProver proves””
-Robert Anton Wilson-Robert Anton Wilson
Prometheus Rising,1983Prometheus Rising,1983

3. GoalsGoals
 Medical History of DiseasesMedical History of Diseases
 Current Diagnostic Criteria in CRPSCurrent Diagnostic Criteria in CRPS
 Current Surrogate Markers in CRPSCurrent Surrogate Markers in CRPS
 Rationale for Non-Practitioner BasedRationale for Non-Practitioner Based
Diagnostic and Prognostic ToolsDiagnostic and Prognostic Tools
 Overview of Recently Used ToolsOverview of Recently Used Tools
 Future DirectionsFuture Directions

4. What Disease Process is This?What Disease Process is This?

5. Gay Related ImmunodeficiencyGay Related Immunodeficiency
SyndromeSyndrome
Identified in 1982Identified in 1982
Diagnostic CriteriaDiagnostic Criteria
1)1) Homosexual PromiscuityHomosexual Promiscuity
2)2) Heterosexual living in proximityHeterosexual living in proximity
3)3) Use of Amyl NitrateUse of Amyl Nitrate
4)4) Haitian DescentHaitian Descent

6. 2008 Diagnosis-AIDS2008 Diagnosis-AIDS
1986 Diagnostic Criteria1986 Diagnostic Criteria
Presence of HIV-1 or HIV-2 byPresence of HIV-1 or HIV-2 by
ELISA/Western BlotELISA/Western Blot

7. What Disease Process is This?What Disease Process is This?

8. Multiple SclerosisMultiple Sclerosis
1960 Diagnostic Criteria1960 Diagnostic Criteria
Age 10-50Age 10-50
History of Neurologic AbnormalitiesHistory of Neurologic Abnormalities
Evidence of changes over time and spaceEvidence of changes over time and space
Exam with Neurological AbnormalitiesExam with Neurological Abnormalities
Neurologic Attacks lasting 24hrs and Spaced 1Neurologic Attacks lasting 24hrs and Spaced 1
month apartmonth apart
No better explanationNo better explanation
Diagnosis made by competent physician-Diagnosis made by competent physician-
neurologistneurologist

9. MRI invented 1977MRI invented 1977
Now Routinely used in Diagnosis of MSNow Routinely used in Diagnosis of MS
AlsoAlso
Now Routinely used as a Marker of MSNow Routinely used as a Marker of MS
progression and Serial MRIs are part ofprogression and Serial MRIs are part of
Standard of CareStandard of Care

10. MRI as a Marker of MSMRI as a Marker of MS
““Unfortunately, however, changes in MRIUnfortunately, however, changes in MRI
behavior have not yet been convincinglybehavior have not yet been convincingly
shown to be sufficiently specific orshown to be sufficiently specific or
predictive of disease progression to allowpredictive of disease progression to allow
clinicians to feel confident that a short-clinicians to feel confident that a short-
term change in MRI behavior willterm change in MRI behavior will
accurately predict and important lateraccurately predict and important later
change in clinically identifiable diseasechange in clinically identifiable disease
progression”progression”

11. Complex Regional Pain SyndromeComplex Regional Pain Syndrome
(CRPS)(CRPS)
Circa 1947Circa 1947
Evans coined the term “reflex sympathetic dystrophy”Evans coined the term “reflex sympathetic dystrophy”

12. 1994 IASP Criteria For CRPS1994 IASP Criteria For CRPS
Type 1Type 1
1)1) Presence of a noxious event (not necessary)Presence of a noxious event (not necessary)
2)2) Continuing pain, allodynia, hyperalgesia, with whichContinuing pain, allodynia, hyperalgesia, with which
the pain is disproportionate to any inciting eventthe pain is disproportionate to any inciting event
3)3) Evidence at some time of edema, changes in skinEvidence at some time of edema, changes in skin
blood flow, or abnormal sudomotor activity in theblood flow, or abnormal sudomotor activity in the
region of the painregion of the pain
4)4) This diagnosis is excluded by the existence ofThis diagnosis is excluded by the existence of
conditions that would otherwise account for the degreeconditions that would otherwise account for the degree
of pain and dysfunctionof pain and dysfunction

13. 1994 IASP Criteria For CRPS1994 IASP Criteria For CRPS
Type 2Type 2
1)1) The presence of continuing pain, allodynia, orThe presence of continuing pain, allodynia, or
hyperalgesia after a nerve injury, nothyperalgesia after a nerve injury, not
necessarily limited to the distribution of thenecessarily limited to the distribution of the
injured nerveinjured nerve
2)2) Evidence at some time of edema, changes inEvidence at some time of edema, changes in
skin blood flow, or abnormal sudomotor activityskin blood flow, or abnormal sudomotor activity
in the region of the painin the region of the pain
3)3) This diagnosis is excluded by the existence ofThis diagnosis is excluded by the existence of
conditions that would otherwise account for theconditions that would otherwise account for the
degree of pain and dysfunctiondegree of pain and dysfunction
(All three criteria must be satisfied)(All three criteria must be satisfied)

14. 2007 Proposed Diagnostic Criteria2007 Proposed Diagnostic Criteria
for CRPSfor CRPS (sensitivity 0.76/specificty 0.83)(sensitivity 0.76/specificty 0.83)
1)Continuing pain, which is disproportionate to any1)Continuing pain, which is disproportionate to any
inciting eventinciting event
2) Must report at least 1 symptom in ¾ categories-2) Must report at least 1 symptom in ¾ categories-
sensory, vasomotor, sudomotor, motor/trophicsensory, vasomotor, sudomotor, motor/trophic
3) One sign at evaluation in 2 or more categories-3) One sign at evaluation in 2 or more categories-
sensory,vasomotor,sudomotor, motor/trophicsensory,vasomotor,sudomotor, motor/trophic
4) There is no other diagnosis that better explains4) There is no other diagnosis that better explains
the signs and symptomsthe signs and symptoms

15. Currently Used MarkersCurrently Used Markers
NONENONE

16. Rationale for CRPS TestsRationale for CRPS Tests
 Stigma associated with diagnosis of CRPSStigma associated with diagnosis of CRPS
 May lead to new modalities of treatmentMay lead to new modalities of treatment
 PrognosticationPrognostication
 Possible increased patient satisfactionPossible increased patient satisfaction
 May lead to new treatment algorithmMay lead to new treatment algorithm
 Patient ValidationPatient Validation

17. StigmaStigma
 “Many CRPS patients are mentally anguished
because physicians misdiagnose their condition
or disregard it as imaginary.”
 “Few physicians are familiar with the disease
and some maintain that the disease is a
psychiatric condition where “patients with this
were often dismissed as being ‘neurotic,’ ‘self-
serving,’ or ‘somatizing”

18. Modalities of TreatmentModalities of Treatment
Designer TreatmentDesigner Treatment
German 5 Day Ketamine Coma-30,000 EuroGerman 5 Day Ketamine Coma-30,000 Euro
Common TreatmentCommon Treatment
Physical Therapy-238,808 USPhysical Therapy-238,808 US
Physical Therapy + Spinal Cord Stimulator-Physical Therapy + Spinal Cord Stimulator-
177,999 US177,999 US
Stellate Ganglion Block Total Cost-1,400 USStellate Ganglion Block Total Cost-1,400 US
Lyrica-1,920 USLyrica-1,920 US

19. Patient Satisfaction And ValidationPatient Satisfaction And Validation
The average CRPS patient sees eight to
ten doctors before a diagnosis is made.
 Medical testing is not available to
diagnose CRPS thus the lack of certainty
for diagnosis “raises doubts in the eyes of
doctors and the people that are looking for
hard lab evidence or good imaging
confirmation.”

20. ImagingImaging
Studies have looked at:Studies have looked at:
1)1) Thermography-8 weeks?Thermography-8 weeks?
2)2) Plain XR-maybe laterPlain XR-maybe later
3)3) MRI with contrast-consequence of trauma or operationsMRI with contrast-consequence of trauma or operations
4)4) Triple phase bone scan-maybe laterTriple phase bone scan-maybe later
One study from 2007 had the following conclusion:One study from 2007 had the following conclusion:
““The poor sensitivity of all tested procedures combined with aThe poor sensitivity of all tested procedures combined with a
reasonable specificity produced a low positive predictive value (17%reasonable specificity produced a low positive predictive value (17%
to 60%) and a moderate negative predictive value (79% to 86%).to 60%) and a moderate negative predictive value (79% to 86%).
These results suggest, that these procedures cannot be used asThese results suggest, that these procedures cannot be used as
screening tests. Clinical findings remain the gold standard for thescreening tests. Clinical findings remain the gold standard for the
diagnosis of CRPS I”diagnosis of CRPS I”

21. Laboratory DataLaboratory Data
 Systemic markers-CRP and IL-6 found toSystemic markers-CRP and IL-6 found to
be not elevated in CRPSbe not elevated in CRPS
 IL-8 was found elevated in one study butIL-8 was found elevated in one study but
not in another studynot in another study
 CSF studies for IL-6 and TNF areCSF studies for IL-6 and TNF are
inconclusiveinconclusive
 Blister analysis shows some increase inBlister analysis shows some increase in
IL-6 and TNF as in CRPS patientsIL-6 and TNF as in CRPS patients
compared to non-CRPS patientscompared to non-CRPS patients

22. Future DirectionsFuture Directions
1) Genetics?1) Genetics?
-Angiotensin gene is not correlated-Angiotensin gene is not correlated
-Twin studies-Twin studies
2) Quantitative sensory pointing to2) Quantitative sensory pointing to
Thalamus?Thalamus?
-like ballism-like ballism
3) Economic Analysis?3) Economic Analysis?

23. In ConclusionIn Conclusion
““-and somewhere within him, a drop of pain-and somewhere within him, a drop of pain
moving briefly and vanishing, like amoving briefly and vanishing, like a
raindrop on the glass of a window, itsraindrop on the glass of a window, its
course in the shape of a question mark”course in the shape of a question mark”
Ayn RandAyn Rand
Atlas ShruggedAtlas Shrugged

24. BibliographyBibliography
 Coyle, Patricia, Progressive Multiple Sclerosis: New Hope, New Challenges, Demos
Medical Publishing 2007
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 Henderson, Robert, AIDS: Public Understanding, Opinion, Response, Simon FraserHenderson, Robert, AIDS: Public Understanding, Opinion, Response, Simon Fraser
University, 1983University, 1983
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examination in patients with complex regional pain syndrome and hemisensory
deficits, Pain, pp279-293, 2001
 Schnkel, Christian, Status of Immune Mediators in Complex Regional Pain Syndrome
Type 1, Current Pain and Headache Reports 12:182-185 2008

25. BilbliographyBilbliography
 Schurmann, Matthias, Imaging in Early Posttraumatic Complex Regional Pain
Syndrome: A Comparison of Diagnostic Methods, Clin J Pain Vol23 Num5 June 2007
 Wikipedia: Origin of AIDSWikipedia: Origin of AIDS
 Williams, Sonia, Bodies in Pain, Drexel University 2008
 www.pbs.org/wnet/brain/scanning/mri.html