Steven D. Feinberg, MD on Complex Regional Pain Syndrome: Reflex Sympathetic Dystrophy & Causalgia

Steven D. Feinberg, MD on Complex Regional Pain Syndrome: Reflex Sympathetic Dystrophy & Causalgia

Complex regional pain syndromes (CRPS) type I and type II formally known as Reflex Sympathetic Dystrophy (RSD) and Causalgia respectively, are the most complicated chronic neuropathic pain syndromes involving sensory, motor and autonomic changes.

Short of a diagnosis of an incurable terminal disease, there are few diagnoses that cause more patient disability and dysfunction and treating physician and payer frustration, than Complex Regional Pain Syndrome. Considerable controversy still swirls around this diagnosis and how to treat it.

Regardless of the controversy, the common objectives for the CRPS patient is less pain, increased function and return to gainful employment and every day life activities. These objectives are best reached through a careful use of selected medications, psychological and behavioral techniques, physical rehabilitation approaches together with limited invasive procedures in the context of a comprehensive multidisciplinary functional rehabilitation approach.

It is critical to diagnose CRPS early and to begin treatment immediately. One of the difficulties of treating complex regional pain syndromes is correctly diagnosing the condition. Despite causalgia and RSD being identified as specific entities for many years, the syndrome remains poorly understood and often goes unrecognized and undiagnosed for a period of time.

Many physicians are not aware of the presenting symptoms and do not entertain the diagnosis until the condition has progressed to later stages at which point it may be more refractory to treatment. On the other side of the coin, the diagnosis of CRPS is often made absent objective criteria of that diagnosis. Unexplained regional pain may be no more than a non-specific musculoskeletal discomfort, but it may also be related to as yet unrecognized pathology and/or to unrecognized psychiatric comorbidity.

To further complicate matters, even the seasoned pain specialist may miss the diagnosis of CRPS, as the patient may present at that moment in time without objective, hard findings to support such a diagnosis. It creates a diagnostic conundrum when the patient presents with severe limb pain and considerable pain behavior with little or no objective correlates and appears to be magnifying symptoms.

 In this article, Dr. Feinberg explains causation, diagnosis, diagnostic criteria, risk factors, clinical presentation, incidence and duration, evaluation, treatment options, as well as steps for rating CRPS under both the AMA Guides Fifth Edition and the AMA Guides Sixth Edition.

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