The guidelines you’re seeing here were crafted by the New York State Workers Compensation Board to aid physicians, podiatrists, and other healthcare professionals in delivering suitable treatment for the Physical Examination of Complex Regional Pain Syndrome.
These guidelines from the Workers Compensation Board are designed to help healthcare professionals make informed decisions about the right level of care for patients dealing with Complex Regional Pain Syndrome.
It’s important to note that these guidelines don’t replace the valuable insights gained from clinical judgment and professional experience. When it comes to deciding on care, the ultimate call should be a collaborative decision between the patient and their healthcare provider.
Physical Examination of Complex Regional Pain Syndrome
When evaluating a patient with well-established Complex Regional Pain Syndrome (CRPS) symptoms, the physical assessment is typically straightforward, especially for an examiner experienced with CRPS. However, in the early stages, the signs can be clinically vague, making the diagnosis less certain.
To prevent dysfunction, primary interventions involve education and specialized physical/occupational treatments focusing on enhancing functional active usage and incorporating aerobic components. Some individuals may also benefit from early psychological interventions, particularly if they already have post-traumatic stress disorder, other psychiatric/behavioral issues, and/or poor coping skills.
Patients with CRPS often exhibit restricted use of extremities, avoiding and protecting the affected limb. This might involve refraining from handshakes or avoiding putting weight on the injured leg.
A key characteristic of this disorder is the notable differences in objective findings between the affected and unaffected extremities. While the affected extremity may feel warmer, the skin temperature can vary, typically being colder. In advanced stages, the flesh may appear smooth, thin, or atrophic. Infrared equipment is recommended for assessing skin temperature, with at least a 1-degree difference considered indicative of CRPS. Changes in skin color, such as mottling, are also common.
Livedo reticularis, a splotchy purplish staining of the skin, may be present, along with swelling of the extremities. Over time, nails may age and become atrophic. Allodynia, the experience of pain from stimuli that most people would not find painful, is a distinctive feature of CRPS.
Examples of CRPS symptoms include discomfort with gentle contact, trembling hands, and even the perceived burden of clothing on the affected area. The injured extremity may show variations in circumference, affected differently in edematous situations (usually early) and differently in chronic situations when disuse dystrophy sets in.
While baseline measurements may not be comparable with the pre-morbid situation, it’s possible to measure water displacement volumes to determine the degree of swelling. Astereognosis, the inability to recognize an item based solely on tactile input, and difficulties in identifying hand laterality with motor imagery are additional findings that have been observed. While occasional assessments may be appropriate, some individuals may become fixated on them, potentially drawing attention.
For evaluating a CRPS patient, a thorough physical examination is recommended. This section doesn’t delve into the detailed components, which should be addressed by the appropriate body part involved (refer to other Healthcare Treatment Protocols).
Patients with somatic symptom disorder or other behavioral/psychological abnormalities may be challenging to differentiate from psychologically healthy individuals during an examination. Referrals for psychological services, including psychometric testing, should have a relatively low barrier.
The focus of the physical examination should be on the patient’s observation. It should commence at the beginning of the appointment, preferably through a summary from the assistant who placed the patient in the examination room.
The examination should assess the patient’s ability to stand up from a correct posture, make positional changes, walk in the hallway (for lower extremity issues, for example), use extremities for tasks, and observe facial expressions during these activities.
It’s crucial to document both synergistic and inconsistent observations from the history and physical exam. Clinicians should look for signs that don’t align with typical symptoms, especially in the context of CRPS.
It’s important to note that positive responses to these procedures are sometimes misinterpreted as evidence of a fictitious disease or hoax claims. While this may be true or not, such responses are occasionally considered beneficial when patients in pain subtly express a need for additional attention to the physical ailment or may indicate psychological distress.
These manifestations may be just one aspect of CRPS’s clinical presentation. However, their presence may suggest the necessity for a psychosocial assessment or consultation with other professionals, particularly if several indicators are present amid a significant delay in healing.
Diagnosing CRPS can be exceptionally challenging due to the similarity of symptoms with various treatments and the inconsistency between subjectively reported symptoms and initial objective findings.
The following conditions may be considered in the differential diagnosis of CRPS, although this list is not exhaustive: neuropathic pain syndromes (peripheral [poly] neuropathy, nerve entrapment, radiculopathy, post-herpetic neuralgia, plexopathy, and motor neuron disease); vascular diseases (thrombosis, atherosclerosis, and Raynaud’s phenomenon); inflammatory conditions (erysipelas, hip pain, seronegative arthritis, thyroid disorders, diabetes mellitus); alcoholic polyneuropathy; and psychological or behavioral issues (such as somatoform pain syndromes, Munchausen syndrome, compensatory neurosis, malingering, and factitious disorder).
This list highlights the complexity of the differential diagnosis, and it’s essential to note that the presence of diagnoses like compensatory neurosis, malingering, or factitious disorder does not invalidate the legitimacy of pain symptoms in individuals with CRPS.
To test the patient’s abilities in the context of CRPS, measures can be followed up in later clinic visits where the patient receives rehabilitation therapy. These may include:
1. Walking distance (assess the patient’s ability to cover more distance in the hallway or outside and inquire about their progress).
2. Ability to climb stairs (observe the patient in the closest stairwell).
3. Dynamometer measurements of grip strength.
4. Pinch power.
5. Continual toe elevates (number able to perform).
6. Walking heel distance.
7. The squat (number).
8. Results of the sensory examination (e.g., monofilaments).
9. Movement in the examination room inconsistent with pain or injury.
This approach allows for more informed decision-making regarding physical activity and other benchmarks, facilitating the patient’s recovery. Another recommended strategy is to monitor patient improvement using established functional assessment tools.
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