Standards for the diagnosis and management of complex regional pain syndrome: Results of a European Pain Federation task force

Abstract

Background: Complex regional pain syndrome is a painful and disabling post-traumatic primary pain disorder. Acute and chronic complex regional pain syndrome (CRPS) are major clinical challenges. In Europe, progress is hampered by significant heterogeneity in clinical practice. We sought to establish standards for the diagnosis and management of CRPS.

Methods: The European Pain Federation established a pan-European task force of experts in CRPS who followed a four-stage consensus challenge process to produce mandatory quality standards worded as grammatically imperative (must-do) statements.

Results: We developed 17 standards in 8 areas of care. There are 2 standards in diagnosis, 1 in multidisciplinary care, 1 in assessment, 3 for care pathways, 1 in information and education, 4 in pain management, 3 in physical rehabilitation and 2 on distress management. The standards are presented and summarized, and their generation and consequences were discussed. Also presented are domains of practice for which no agreement on a standard could be reached. Areas of research needed to improve the validity and uptake of these standards are discussed.

Conclusion: The European Pain Federation task force present 17 standards of the diagnosis and management of CRPS for use in Europe. These are considered achievable for most countries and aspirational for a minority of countries depending on their healthcare resource and structures.

Significance: This position statement summarizes expert opinion on acceptable standards for CRPS care in Europe.

Figure 1

Budapest Diagnostic Criteria for CRPS. Notes: (1) If the patient has a lower number of signs or symptoms, or no signs, but signs and/or symptoms cannot be explained by another diagnosis, “CRPS‐NOS” (not otherwise specified) can be diagnosed. This includes patients who had documented CRPS signs/symptoms in the past. (2) If A, B, C and D above are all ticked, please diagnose CRPS. If in doubt, or for confirmation, please refer to your local specialist. (3) Psychological findings, such as anxiety, depression or psychosis, do not preclude the diagnosis of CRPS (3) Distinction between CRPS type 1 (no nerve injury) and CRPS type 2 (major nerve injury) is possible, but has little relevance for treatment. Explanation of terms: “Hyperalgesia” is when a normally painful sensation (e.g., from a pinprick) is more painful than normal; “allodynia” is when a normally not painful sensation (e.g., from touching the skin) is now painful; and “hyperaesthesia” is when the skin is more sensitive to a sensation than normal. A special feature in CRPS: In category 4, the decreased range of motion/weakness is not always due to pain. It is also not necessarily due to nerve damage or a joint or skin problem. Some patients’ experience of an inability to move their limb may be due to yet poorly understood, disturbed motor coordination which can be reversible. A helpful question to assess this feature is: “If I had a magic wand to take your pain away, could you then move your… (e.g., fingers)?” Many patients will answer with “no” to that question. Unusual CRPS: Around 5% of patients cannot recall a specific trauma or may report that their CRPS developed with an everyday activity such as walking or typewriting. In very few people, CRPS can have a bilateral onset. In some patients, CRPS can spread to involve other limbs. Around 15% of CRPS cases do not improve after 2 years. It is appropriate to make the diagnosis of CRPS in these unusual cases

Figure 2

The European Task Force dynamic diagnostic standard quality framework for CRPS. HP: health professional

Figure 3

Services and competencies. PMP = multidisciplinary pain management programme integrating psychological care and functional rehabilitation; ^&additionally “Hand Therapists” in some European Countries, *note, some pain clinics and rehabilitation facilities do not provide group‐based PMP, whereas others additionally provide “super‐specialized” services; **neuromodulation is listed to highlight the care structure within which it is delivered; some centres will not provide this service