Abstract
Over the past several decades, complex regional pain syndrome (CRPS) has gone through an evolution of its diagnostic criteria. The disorder was initially known as causalgia, then reflex sympathetic dystrophy, and then eventually termed CRPS; it has gone through many name changes to reflect the broader characterization of its symptomology. The Orlando criteria suggested two types of CRPS with four subsets. After further research and debate, the Budapest criteria were developed to classify CRPS with more specificity. This chapter provides a review of these guidelines and diagnostic criteria.
Keywords
Budapest criteria, Complex regional pain syndrome, CRPS, Diagnostic criteria, Orlando criteria
Complex regional pain syndrome (CRPS) has evolved over the years not only in its nomenclature, but also in its diagnostic criteria. It was first described by Dr. Silas Weir Mitchell in the American Civil War as “causalgia,” describing the chronic burning pain soldiers experienced after neurologic injuries following gunshot wounds. It was later described throughout the 20th century as reflex sympathetic dystrophy, as it was thought to be a pain syndrome linked to a sympathetic nervous system disorder. This terminology was eventually thought to be a misrepresentation of the disorder for multiple reasons. First, the term “reflex” implied the involvement of a complex, multisynaptic process, yet this has not been characterized. In addition, the sympathetic nervous system was considered a primary mediator of pain; however, it is not involved in all stages of disease progression. Lastly, “dystrophy” is not present in all cases. Thus, in 1994, the disorder was renamed “complex regional pain syndrome” or CRPS by the International Association for the Study of Pain (IASP).
As described by Harden et al., there had been a trend of “diagnostic chaos,” warranting a clear consensus regarding diagnostic criteria. The IASP held the Schloss Rettershof Conference in 1988, followed by the Orlando Conference in 1994, during which the first definitive diagnostic criteria for CRPS were developed ( Box 5.1 ).
- 1.
The presence of an inciting noxious event or cause of immobilization
- 2.
Continuing pain, allodynia, or hyperalgesia with which the pain is disproportionate to any inciting event
- 3.
Evidence at some time of edema, changes in skin, blood flow, or abnormal sudomotor activity in the region of pain
- 4.
The diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction.
Type I: without evidence of major nerve damage.
Type II: with evidence of major nerve damage.
The IASP/Orlando criteria were based on professional consensus and did not include clinical or systematic validation. These guidelines suggest two different types of CRPS: CRPS type I (without nerve injury) and CRPS type II (with nerve injury). The guidelines also suggest two main subgroups of signs and symptoms: one group of criteria with pain, allodynia, or hyperalgesia and the other group of criteria with edema, skin changes, or sudomotor activity. A subsequent survey of 123 patients showed that the signs and symptoms of CRPS could more accurately be categorized into one of four groups ( Table 5.1 ).
| Factor 1 | Factor 2 | Factor 3 | Factor 4 |
|---|---|---|---|
| Hyperalgesia signs (0.75) | Temperature asymmetry symptoms (0.68) | Edema signs (0.69) | Decreased range of motion signs (0.81) |
| “Hyperesthesia” symptoms (0.78) | Color change signs (0.67) | Sweating asymmetry signs (0.62) | Decreased range of motion symptoms (0.77) |
| Allodynic signs (0.44) | Color change symptoms (0.52) | Edema symptoms (0.61) | Motor dysfunction signs (0.77) Motor dysfunction symptoms (0.61) Trophic symptoms (0.52) Trophic signs (0.51) |
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