Wonderful Competency

This is a pleased-as-punch pass-along of a report published yesterday in Consultant for Pediatricians, as part of their "photoclinic" --

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• VOLUME 13 - ISSUE 7 - JULY 2014
• PHOTOCLINIC
• COMPLEX REGIONAL PAIN SYNDROME
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    [Citation: CFP. 2014;13(7):330-331]

There's not one thing remarkable about it.

Except it shows evidence of prompt response to a new case of CRPS, an awareness of IASP "Budapest criteria," and a complete absence of NeuroStupidity.

Way to go, Mfon Ekong, MD; Anissa Meher-Homji, BS; and Lynnette Mazur, MD, MPH of the University of Texas Medical School at Houston!


Complex Regional Pain Syndrome

A 10-year-old girl presented with a 3-month history of right knee pain and difficulty walking after her pet German shepherd bumped her leg. She also complained of a 2-week history of hair growth below her right knee.

On physical examination, she had edema, a 12 × 10-cm patch of hair, and decreased range of motion of the right knee. Results of complete blood count, erythrocyte sedimentation rate, complete metabolic profile, creatine kinase tests, and myoglobin tests were normal. Findings on magnetic resonance imaging were unremarkable.

The girl received a diagnosis of complex regional pain syndrome (CRPS) and was hospitalized for inpatient physical therapy. An indwelling catheter was placed for a femoral nerve block. Ropivacaine was continued for 8 days, after which the girl was transferred to a local rehabilitation facility to continue physical therapy, along with continuous passive motion (CPM) of the knee. She was started on gabapentin, fluoxetine, vitamin D, and as-needed diazepam, and was discharged after 1 month to continue her treatment at home.

CRPS, formerly called reflex sympathetic dystrophy, is a painful syndrome accompanied by physical changes in the affected extremity. Dysfunction of local sympathetic and autonomic nerves may be responsible.1-3

Our patient reported 3 of 4 symptoms (allodynia to clothing, edema, and decreased range of motion) and 2 of 3 signs (hyperalgesia to pinprick and allodynia to light touch) meeting the clinical diagnostic criteria for CRPS set forth by the International Association for the Study of Pain (IASP) (Table).4

[read the rest of this wonderful competency HERE]

Free Downloads and More On CRPS Diagnostic Criteria (Woo Hoo!)

In the course of writing one blog post, here I am authoring another.

I just ran across a good article in the newly launched Wiley Online Library -- then discovered the offer of free downloads of most read and most cited articles from the journal Pain Medicine (The Official Journal of the American Academy of Pain Medicine and of the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists and of the International Spine Intervention Society).

Okay, it amounts to just a handful of articles, but some of them are quite good, especially those of the sort I often malign (but always read!) -- the dread review article.

So let us rejoice.
Amen, and amen!

From Volume 8, Number 4, 2007 -- more on diagnostic criteria in CRPS, just in case you haven't realized the importance of this issue by the fact that I have been droning on and on about it at every opportunity.  Anyway, this is a great foundational article about the discussion and helps to put the IASP criteria and the Budapest group's proposals in context.

Proposed New Diagnostic Criteria for Complex Regional Pain Syndrome

R. Norman Harden, MD, Stephen Bruehl, PhD, Michael Stanton-Hicks, MB, BS, DMSc, FRCA, ABPM, and Peter R. Wilson, MB, BS

Rehabilitation Institute of Chicago, Northwestern University, Chicago, Illinois;  Vanderbilt University School of Medicine, Nashville, Tennessee; Cleveland Clinic, Cleveland, Ohio; Mayo Clinic, Rochester, Minnesota, USA


ABSTRACT:  This topical update reports recent progress in the international effort to develop a more accurate and valid diagnostic criteria for complex regional pain syndrome (CRPS). The diagnostic entity of CRPS (published in the International Association for the Study of Pain’s Taxonomy monograph in 1994; International Association for the Study of Pain [IASP]) was intended to be descriptive, general, and not imply etiopathology, and had the potential to lead to improved clinical communication and greater generalizability across research samples. Unfortunately, realization of this potential has been limited by the fact that these criteria were based solely on consensus and utilization of the criteria in the literature has been sporadic at best. As a consequence, the full potential benefits of the IASP criteria have not been realized. Consensus-derived criteria that are not subsequently validated may lead to over- or underdiagnosis, and will reduce the ability to provide timely and optimal treatment. Results of validation studies to date suggest that the IASP/CRPS diagnostic criteria are adequately sensitive; however, both internal and external validation research suggests that utilization of these criteria causes problems of overdiagnosis due to poor specificity. This update summarizes the latest international consensus group’s action in Budapest, Hungary to approve and codify empirically validated, statistically derived revisions of the IASP criteria for CRPS.

Formerly Wiley Interscience, the Wiley Online Library just launched  -- as in *yesterday* -- and it's got some great new features plus a few things in The Realm of The Free (my favorite realm!):

Free access and access information.

Free abstracts and chapter summaries:  All journal abstracts and chapter summaries in books and reference works are free to all users of Wiley Online Library.


Free sample issues:
Each journal has a free sample issue that you can find from the left menu of any journal page.


Free supporting information:
Some articles include extra supporting information and this is available free to all users of the website. You can find supporting information in an extra tab from the abstract or article page.


Access icons:
Shows users in libraries what is free, what you or your institution has subscribed to and you can access.


Access information:
Clearly see why you might not be able to access an article, book, chapter or whole product and find out your options. [Booo!]

CRPS: IASP Diagnostic Criteria Taken to Task

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.*

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).