The latest news from my MedWorm CRPS-related feeds addresses the diagnostic criteria established by the International Association for the Study of Pain (IASP). The longheld general opinion is that these criteria have "high sensitivity," but "poor specificity," with the resultant complaint of overdiagnosis of CRPS.
It's a good dialogue to have at this time, and one that needs to be renewed periodically, as the hard science attempts to catch up with the clinical expressions of the disease. The summary conclusion of this round of talks is a clear preference for the Budapest CRPS Criteria over the IASP recommendations most widely in force. For an excellent summary (and yes, it will seem repetitive to some of you) see Dr. Bruehl's power point presentation here, on CRPS taxonomy. The IASP criteria are sometimes shorthanded as "the Bruehl criteria," remember!
All three of the following studies were published in the online version of PAIN: The journal of the IASP.*
I have to say that the words "unproven etiology" fairly jump off the page, even though I understand that determining the larger cause-and-effect relationships -- generally noxious events and nerve injuries -- is not equivalent to establishing useful, science-supported proven etiologies, being more in the nature of events. (Leave my sentence alone!) What is especially important is to reiterate that hanging everything from the nail of sympathetically-maintained pain [SMP], and diagnosis by sympathetic block, is definitively outmoded, and usually just plain wrong.
The necessity for regionally-based (or nation-based) diagnostic criteria makes enormous sense, particularly given the rigarmarole above of unproven etiologies. It is gratifying, though, that the five (or the Budapest 4!) basic subgroupings for CRPS symptoms hold "true." The practicing medical world dearly loves a checklist.
Modifying diagnostic criteria for Complex Regional Pain Syndrome by Stephen Bruehl, Ph.D. appears in the same issue (Volume 150, Issue 2, August 2010). Dr. Bruehl, of Vanderbilt, is a clinical psychologist, specializing in "Endogenous Pain Regulatory Systems and the Psychobiology of Emotions":
Dr. Bruehl figures in the [Budapest] group publishing the third article in this PAIN "series" on CRPS, as well:
* PAIN® is the official journal of the International Association for the Study of Pain® (IASP).
It's a good dialogue to have at this time, and one that needs to be renewed periodically, as the hard science attempts to catch up with the clinical expressions of the disease. The summary conclusion of this round of talks is a clear preference for the Budapest CRPS Criteria over the IASP recommendations most widely in force. For an excellent summary (and yes, it will seem repetitive to some of you) see Dr. Bruehl's power point presentation here, on CRPS taxonomy. The IASP criteria are sometimes shorthanded as "the Bruehl criteria," remember!
All three of the following studies were published in the online version of PAIN: The journal of the IASP.*
Development of comprehensive diagnostic criteria for complex regional pain syndrome in the Japanese population
Masahiko Sumitani, Masahiko Shibat, Gaku Sakaue, Takashi Mashimo, Japanese CRPS Research Group
Received 31 July 2009; received in revised form 21 January 2010; accepted 23 March 2010. published online 07 May 2010
Abstract
Complex regional pain syndrome (CRPS) is a syndrome that describes a broad spectrum of sensory, motor and autonomic-like features with unproven etiology. The International Association for the Study of Pain (IASP) diagnostic criteria of CRPS shows high sensitivity but poor specificity. Using statistical-pattern-recognition methods, American researchers have suggested a new set of criteria offering acceptable sensitivity and high specificity. However, non-American CRPS patients present distinct subsets of CRPS-related signs/symptoms from those of American patients. Here, we followed a series of American studies to develop a set of CRPS diagnostic criteria that would be most suitable for the Japanese population. A standardized sign/symptom checklist was used in patient evaluations to obtain data on CRPS-related signs/symptoms in 195 participants meeting the IASP criteria. Using factor analysis, we grouped CRPS-related signs/symptoms into five distinct subgroups (trophic change, motor dysfunction, abnormal pain processing, asymmetric sudomotor activity and asymmetric edema). Discriminant function analysis of these subgroups, regarding their ability to discriminate between CRPS and non-CRPS etiology, indicated that modifying the IASP criteria could increase clinical diagnostic accuracy in the Japanese population. Our diagnostic criteria are not exactly the same as the American criteria, indicating a need for more regionally based CRPS diagnostic criteria. Different sets of CRPS diagnostic criteria could lead to dissimilar patients being diagnosed as CRPS, however, presenting problems for translation of therapeutic effects found in various studies. Therefore, we further recognize a need for a global set of common CRPS diagnostic criteria.
I have to say that the words "unproven etiology" fairly jump off the page, even though I understand that determining the larger cause-and-effect relationships -- generally noxious events and nerve injuries -- is not equivalent to establishing useful, science-supported proven etiologies, being more in the nature of events. (Leave my sentence alone!) What is especially important is to reiterate that hanging everything from the nail of sympathetically-maintained pain [SMP], and diagnosis by sympathetic block, is definitively outmoded, and usually just plain wrong.
The necessity for regionally-based (or nation-based) diagnostic criteria makes enormous sense, particularly given the rigarmarole above of unproven etiologies. It is gratifying, though, that the five (or the Budapest 4!) basic subgroupings for CRPS symptoms hold "true." The practicing medical world dearly loves a checklist.
Modifying diagnostic criteria for Complex Regional Pain Syndrome by Stephen Bruehl, Ph.D. appears in the same issue (Volume 150, Issue 2, August 2010). Dr. Bruehl, of Vanderbilt, is a clinical psychologist, specializing in "Endogenous Pain Regulatory Systems and the Psychobiology of Emotions":
The general focus of Dr. Bruehl’s work is on understanding the functioning of endogenous pain regulatory systems in healthy individuals, and possible dysfunction in these systems associated with chronic pain. Endogenous pain regulatory systems are complex, involving descending pain inhibitory pathways mediated in part by both endogenous opioid and alpha-2 adrenergic mechanisms. Moreover, there appear to be adaptive functional interactions between the cardiovascular and pain regulatory systems that serve to maintain homeostasis in the presence of painful stimuli. Dr. Bruehl’s work focuses on the interface between these areas, and how chronically painful conditions alter the normal functioning of these interacting systems.
Dr. Bruehl figures in the [Budapest] group publishing the third article in this PAIN "series" on CRPS, as well:
Validation of proposed diagnostic criteria (the “Budapest Criteria”) for Complex Regional Pain Syndrome
R. Norman Harden, Stephen Bruehl, Roberto S.G.M. Perez, Frank Birklein, Johan Marinus, Christian Maihofner, Timothy Lubenow, Asokumar Buvanendran, Sean Mackey, Joseph Graciosa, Mila Mogilevski, Christopher Ramsden, Melissa Chont, Jean-Jacques Vatin
Received 18 November 2009; Received in revised form 19 March 2010; Accepted 20 April 2010. Published online 21 May 2010.
Abstract
Current IASP diagnostic criteria for CRPS have low specificity, potentially leading to overdiagnosis. This validation study compared current IASP diagnostic criteria for CRPS to proposed new diagnostic criteria (the “Budapest Criteria”) regarding diagnostic accuracy. Structured evaluations of CRPS-related signs and symptoms were conducted in 113 CRPS-I and 47 non-CRPS neuropathic pain patients. Discriminating between diagnostic groups based on presence of signs or symptoms meeting IASP criteria showed high diagnostic sensitivity (1.00), but poor specificity (0.41), replicating prior work. In comparison, the Budapest clinical criteria retained the exceptional sensitivity of the IASP criteria (0.99), but greatly improved upon the specificity (0.68). As designed, the Budapest research criteria resulted in the highest specificity (0.79), again replicating prior work. Analyses indicated that inclusion of four distinct CRPS components in the Budapest Criteria contributed to enhanced specificity. Overall, results corroborate the validity of the Budapest Criteria and suggest they improve upon existing IASP diagnostic criteria for CRPS.
* PAIN® is the official journal of the International Association for the Study of Pain® (IASP).
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