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!]

Three Months Later: José Ochoa, *Still* A Big, Fat Turd

Do you remember the couple of posts wherein I called José Ochoa a turd?  No?  Well, you can read up on this poor excuse for a hackjob doctor here and here. 

Or you can keep reading this post, as I am about to call José Ochoa a turd one more time.  He's co-authored an eight-page article painting people diagnosed with CRPS as malingerers, as suffering from conversion disorder, or -- now isn't this kind of him to allow? -- as harboring "unrecognized pathology (lesions) of the nervous system."

He has built a lucrative career testifying about his [now very lonely] contention that CRPS does not exist. His forensic testimony has less and less influence as hard science advances, but his path remains littered with broken lives -- lives financially ruined, physically and emotionally devastated by his self-enrichment campaign.

Am I questioning the data he reports?  Not at all.

Do I propose canonization of people with CRPS, an affliction that only strikes the angelic, a syndrome often caused by work-related injuries, associated with legal action, and therefore never feigned by lazy dipshits? Nope!

I do protest the authors' simultaneous display of contempt for "the label" CRPS and their ready glee to paint all those diagnosed with CRPS with the same brush as those identified as malingerers.  In lieu of identifying the defects in the diagnosis process, they have assumed a character defect in the vast majority of real sufferers. 

It's tiresome, it's disgusting, and Ochoa needs to find a new way to invent scientific support for his true calling:  his own enrichment.

I am almost completely out of line in writing this blog post, but I really don't care.  I have not read the article I am maligning, would not spend the money to buy it or to subscribe to the journal, and have no basis for attacking the study results.

I am just mad that Ochoa has been published again, that he has found another means of advancing his loathesome small-mindedness and greed.

Don't get me wrong, I know that many doctors and most researchers are fully cognizant of his malicious intent. It's just that his energies would be better used -- and actually appreciated! -- were he to channel them toward, say, working with the IASP and their efforts to produce workable, effective diagnostic criteria for CRPS.  The data he is producing does nothing but make that endeavor even more worthwhile.  The better the diagnostic criteria, the fewer malingerers abusing the justice and health systems.

I am the last person to contest legitimate dissent, no matter the subject matter. But neither am I going to assert the rights of an academic who might, for example, publish work after work about the Holocaust as a fiction, no matter how well-documented. (I am not trying to aggrandize CRPS as a topic, that is just the first instance that came to mind. So let me add that neither would I debate The Texas School Board on textbook choice or history and science curricula!)

In the years 1997-2009, Dr. Ochoa has earned, according to his own testimony, between $300,000 and $400,000 a year -- over a 12-year period, he has made between 3.6 and 4.8 million dollars by denying the existence of CRPS. Given that there is no research that legitimizes his claim, it makes sense that he needs to publish something, periodically, that he can use to maintain his claim to be an expert. There simply is NO currently valid research to which he can point, beyond what he manages to publish.

God help the poor patient with CRPS whose unsuspecting family doctor refers him to The Oregon Nerve Center, to Dr. Ochoa. Hoping for treatment, these patients will instead be subjected to his pre-suppositions about their physical symptoms and psychological makeup.

The worst crime of all?  The delay in treatment -- which can obviate the possibility of a fairly easy cure -- that may result from Dr. Ochoa and his campaign against the existence of CRPS.

ABSTRACT
Neuropathic Pain Syndrome Displayed by Malingerers
José L. Ochoa, M.D., Ph.D., D.Sc. and Renato J. Verdugo, M.D., M.Sc.
J Neuropsychiatry Clin Neurosci.2010; 22: 278-286

Received October 27, 2009; accepted April 1, 2010. The authors are affiliated with The Oregon Nerve Center at Legacy Health Systems and the Departments of Neurology and Neurosurgery at Oregon Health and Science University in Portland, Oregon; Dr. Verdugo is also affiliated with the Department of Neurology, Faculty of Medicine, Universidad de Chile, in Santiago, Chile. Address correspondence to José L. Ochoa, M.D., Ph.D., D.Sc., The Oregon Nerve Center, Good Samaritan Medical Center, 1040 NW 22nd Ave., Suite 600, Portland, OR 97210; jochoa@nervesense.net (e-mail).

Among 237 patients communicating chronic pain, associated with sensory-motor and "autonomic" displays, qualifying taxonomically for neuropathic pain, there were 16 shown through surveillance to be malingerers. When analyzed through neurological methods, their profile was characteristically atypical. There were no objective equivalents of peripheral or central processes impairing nerve impulse transmission. In absence of medical explanation, all 16 had been adjudicated, by default, the label complex regional pain syndrome (CRPS). The authors emphasize that CRPS patients may not only harbor unrecognized pathology ("lesion") of the nervous system (CRPS II), hypothetical central neuronal "dysfunction" (CRPS I), or conversion disorder, but may display a recognizable simulated illness without neuropsychiatric pathology.
[You may read more HERE]








NOTE: The law firm had to take down this illustrious video because Ochoa sued them, saying it cost him revenue.  What a turd.  There's an excellent unbiased summation of the non-board certified Doctor Ochoa by the Third Circuit Louisiana State of Appeals Court HERE. As for what you would have seen in the video -- the patient being examined by The Turd asks him to be aware of the severe allodynia she has in her hand.  He proceeds to blow on it and also to pinch it -- saying, in what can only be the cutest SCOTUS reference of all time, that he was just removing the "pubic hair" that was somehow on her hand.  I say again:  turd, turd, turd.

Posted to YouTube by LawlorWinston | September 21, 2009, with this comment:

Here we see Dr. Jose L. Ochoa, a defense-retained expert, in a portion of his examination of a woman whom six other physicians, including another defense-retained expert have diagnosed with RSD/CRPS-1. The Plaintiff, who suffers from crippling neurological pain, has requested Dr. Ochoa not blow air on her affected extremities.

RSD is an abbreviation for "Relex Sympathetic Dystrophy", also referred to as "Complex Regional Pain Syndrome" (CRPS).

Dr. Ochoa has become one of the foremost experts used by Defendants in lawsuits involving RSD/CRPS by denying that this condition is an actual "diagnosis". His opinions have been stricken or otherwise disallowed as unscientific in at least three States.

[Trust me, I'd much rather be watching a video over at PTZ.  I keep waiting for Ochoa to be featured over there, but I guess Emilbus only has room for so many explosive pilonidal cysts.]

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).