Complex regional pain syndrome (CRPS) is a poorly understood condition in which a person experiences persistent severe and debilitating pain. It affects about 1 in 4,000 people each year and can affect people at any age but is more common between the ages of 40 and 60. It can also affect children and the number of CRPS cases among teenagers and young adults is increasing. It affects both men and women, however, CRPS is three times more frequent in females than males.
Due to the lack of understanding and awareness of CRPS, personal injury claims involving this condition can be problematic. It is important that any solicitor dealing with a Claimant who has CRPS has a good understanding of the condition and potential issues which can arise in these cases.
What is CRPS
CRPS is a condition in which a person experiences persistent severe and debilitating pain. The pain usually starts as a result of an injury and is a greater than normal reaction of the body to the injury. Therefore, the pain in which the person is experiencing is far greater than the pain expected for the injury, and there is no relationship between the severity of the injury and the degree of CRPS experienced.
Not all cases of CRPS are triggered by injury and can also start after strokes, heart attacks or prolonged bed rest. However, The National Institute of Neurological Disorders and Strokes states that in 90% of cases, CRPS is triggered by a clear history of trauma or injury. This can involve fractures, damaged nerves, soft tissue injuries or surgical and medical procedures.
The pain is usually confined to one limb but can spread to other parts of the body. Despite the cause of CRPS being unknown it is widely considered to be as a result of damage to, or malfunction of the nervous system. The nerves in the affected limb are much more sensitive than other nerves and this causes pain and tenderness in the affected area.
The symptoms of CRPS vary in severity and how long they last. Symptoms usually begin within one month after an injury. The main symptom is pain which is often burning, sharp, stabbing or stinging. There may also be tingling and numbness.
Many sufferers say that their limb ‘feels strange’. It can feel as if it does not belong to the rest of their body and as if it is not their own limb. Sometimes the limb feels bigger or smaller than normal.
As well as pain, the affected area may have other symptoms such as:
- Skin sensitivity: the skin may become oversensitive to light touch.
- Allodynia: this means that pain may be felt even after just a gentle touch, such as clothes brushing the skin or even air blowing on the skin. This may be felt as severe pain.
- Swelling: may occur over the painful region.
- Temperature differences between opposite sides: the affected area may often be warmer or cooler and the temperature may keep changing.
- Abnormal sweating.
- Skin changes:
- Abnormal skin changes may occur, like ‘goosebumps’ and skin rashes.
- There may be changes in the skin colour of the affected limb.
- Skin infections can occur and can be very severe.
- Skin may become shiny, dry or scaly.
- Hair changes: hair may become coarse but then become thin.
- Fingernail or toenail changes: nails in the affected area may become brittle (crumbly or break easily) and grow faster at the beginning and then slower.
What is known as the Budapest Criteria is used to diagnose CRPS and all of points (a) – (d) mentioned below must apply to the person in question in order to diagnose CRPS. Mention of the word ‘sign’ is where the medical practitioner can see or feel a problem and mention of the word ‘symptom’ is where a patient reports a problem. The Budapest criteria is as follows:
- The patient has continuing pain which is disproportionate to the inciting event
- The patient has at least one sign in two or more of the ‘categories’
- The patient reports at least one symptom in three or more of the ‘categories’
- No other diagnosis can better explain the signs and symptoms
The ‘categories’ mentioned in (b) and (c) above are as follows:
Sensory: Allodynia (to light touch and/or temperature sensation and/or deep somatic pressure and/or joint movement) and/or hyperalgesia (to pinprick)
Vasomotor: Temperature asymmetry (more than 1 deg.) and/or skin colour changes and/or skin colour asymmetry
Sudomotor/oedema: Oedema and/or sweating changes and/or sweating asymmetry
Motor/trophic: Decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair/nail/skin)
Types of CRPS
There are two types of CRPS known as Type I and Type II. Type I CRPS is when a nerve injury cannot be indentified and is the most common type of CRPS. Type II is when a distinct “major” nerve injury has occurred.
While there is no cure for CRPS, it is very important to diagnose CRPS as early as possible because early treatment can help prevent the condition progressing further. Initial treatment is often in the form of physiotherapy to help with movement of the limb and help make it less sensitive. Also medicine can be prescribed to help reduce the pain and psychological support can be given in the form of CBT (cognitive behavioural therapy) to help with the psychological difficulties associated with CRPS.
These treatments can assist with alleviating pain or at least assisting the sufferer in understanding the condition which in turn can help them manage the condition. If initial treatment fails, the alternative options are incredibly invasive and include spinal injections, column or spinal cord stimulators or, in severe cases, amputation.
As stated previously, early intervention is vital. Where there is a personal injury claim involving CRPS, it is likely that treatment will be required before the case reaches settlement. In these circumstances it is possible to ask the Defendant to fund the treatment privately by way of an interim payment. This is normally only provided when liability for the accident has been admitted. Nevertheless, it still can be requested and is sometimes still provided when liability has not yet been resolved. At Bolt Burdon Kemp we understand the importance of treating CRPS as early as possible and always endeavour to obtain interim payments for the Claimant so that they can access the treatment they need as soon as possible.
Personal Injury claims involving CRPS
Due to CRPS being widely misunderstood, solicitors can often find themselves in a difficult position. As the causes of the condition are unknown, demonstrating that the negligent act caused the Claimant’s CRPS can be problematic. Also, as it is frequently misunderstood by medical practitioners and has an unpredictable prognosis, it can be difficult to quantify the injury.
As one of the symptoms of CRPS is pain that far exceeds the initial injury, the Defendant solicitor will often try to argue that the Claimant is a “malingerer” or “exaggerator” or will seek to blame the underlying cause on some psychosomatic illness. They will often have a psychiatrist go through the Claimant’s medical records and try to explain the condition by a psychiatric history which is unrelated to the negligent act that is the subject of the claim. Alternatively, they will try to argue that the Claimant was pre-disposed to CRPS and would in any event have gone on to develop it is the absence of the negligent act. However, a review of recent medical thinking on the subject confirms that it is now clear that CRPS is not associated with a history of pain-preceding psychological problems or malingering.
In these cases it is vital that the Claimant’s solicitor has a good understanding of the condition and the potential problems that can be encountered so that the best possible outcome can be achieved. CRPS can be an extremely painful, severe and debilitating condition which has an enormous impact on the sufferer’s life. Evidently there is a real lack of understanding of the condition and clearly more needs to be done to spread awareness.