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Diagnosing Complex Regional Pain

Syndrome (CRPS)
There is no general agreement on how to make the diagnosis of CRPS
and no single test that represents a "gold standard." Experts generally
agree that the medical experience of the doctor and the clinical history
are the most important factors in making a correct diagnosis, especially
because the patient's symptoms and physical findings can vary greatly
over time and certain tests may or may not be "positive" at any stage of
the disease. For these reasons, doctors often will disagree about
whether a patient has CRPS. This may present problems for patients in
accessing proper care, including getting authorization for tests and
treatment from insurance carriers. .
A doctor should always suspect CRPS when a patient's localized pain
that is associated with an injury or illness begins to spread and seems
to be out of proportion to the original medical problem. The appearance
of autonomic symptoms as discussed above may signal the
appearance of CRPS.

Following are the most common diagnostic tests used to aid in the
diagnosis of CRPS.

Response to sympathetic blockade

In the past, physicians believed that a positive response (reduced pain)
to a sympathetic block was necessary to make the diagnosis of CRPS.
This is no longer considered to be the case. For a more detailed
explanation, read about interventional treatment for CRPS under the My
Treatment section.

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Tests of sudomotor functioning

During any stage of CRPS, patients may have abnormalities in sweat
gland function (called sudomotor function). Patients may have either
excessive or reduced sweating. Special laboratories are able to test
resting sweat output (RSO), thermoregulatory sweating (TST) and
quantitative sudomotor axon reflex testing (QSART). These tests are
helpful if they are positive, but not if they are negative. Sudomotor
functioning tests are difficult to conduct and available in only a few parts
of the country.

Three-phase bone scans

Once the only diagnostic tool available to doctors, this test has proven
to be of limited usefulness. It becomes positive in only approximately
50% of CRPS patients (usually in later stages of the illness) and is,
therefore, not particularly useful in making the diagnosis in earlier
stages.

Nerve conduction testing (NCV) and electromyography (EMG)

Despite the fact that EMG/nerve conduction testing is very common,
there are actually very few studies about their usefulness in patients
with CRPS. Studies that do exist show that there are nerve conduction
abnormalities in almost half of CRPS patients, but the abnormalities
tend to be mild. Some researchers have suggested that the
abnormalities may be due to swelling (called edema) or changes in
blood supply to affected limbs, which then affects nerve functioning. A
specialized test of nerve conduction is called somatosensory evoked
potentials (SEP). Like other nerve conduction tests, there may be
borderline abnormal findings in CRPS patients and the tests may be
misinterpreted. SEP recording is not recommended as a routine method
to diagnosis of CRPS-I. Based on these mild or borderline
abnormalities, some test readers (called electromyographers) may
make the mistake of saying that patients have "peripheral neuropathy,"
which is a different disease process than CRPS. The exception to this is
when a patient does have a definite nerve injury associated with CRPS
(CRPS-II).

Nerve conduction testing uses skin electrodes placed on the surface of

the skin and usually is not painful. Electromyography, on the other
hand, uses needles that are placed within muscle tissue and is painful.
EMG recordings are generally not helpful in CRPS patients and may

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worsen CRPS. Experts generally agree that EMG recordings have no

diagnostic value in CRPS.

Quantitative sensory testing (QST)

QST may be a useful method for a physician to confirm the clinical
findings of abnormalities in sensation. The problem with this test,
however, is that it is not specific for the disease CRPS. It may help,
however, to confirm the doctor's findings, particularly when multiple
physicians have recorded a wide variety of findings on testing
sensation. These tests are available in only a few parts of the country.

Sympathetic skin response (SSR)

These tests may help confirm the doctor's impression that there are
"sympathetic" abnormalities in function, however, it is a very specialized
type of test done in only a few laboratories that conduct other electrical
testing such as electromyography and nerve conduction. So far, it is of
unproven value and not generally recommended for making the
diagnosis of CRPS.

Other radiological imaging studies

Plain x-rays and MRI scans may occasionally be useful, particularly in
later stages of the disease. MRI can demonstrate the presence of soft
tissue changes such as swelling or skin thickening. Plain x-rays may
show demineralization of bone in later stages of CRPS. For these
reasons, imaging tests can be useful in later stages of CRPS but not as
a screening tool earlier on.

**Infrared thermography
Infrared thermography is a diagnostic imaging procedure that records
body surface temperature by detecting the heat (infrared radiation)
emitted from the surface of the skin. An infrared thermogram essentially
is a "heat map" of the surface of the skin. This heat map accurately
records changes in skin blood flow. By evaluating alterations of the
surface skin temperatures, a physician is able to indirectly evaluate the
neurological status of the autonomic nervous system. This information
may be very helpful, as the autonomic nervous system is intimately
involved in both CRPS type I, CRPS type II and other painful conditions
that can mimic CRPS.

In healthy individuals, there are very slight differences in skin

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temperature from one extremity to the other; however, patients with

CRPS may have temperature differences greater than 1 C between
the affected and unaffected extremity.1,2 Subsequent research has
shown that a greater than 1.5 C computer generated side-to-side
temperature difference is helpful in telling if a patient's condition is
post-traumatic (that is, a normal somatoautonomic reflex that follows a
trauma) or an autonomic dysfunction that is present in CRPS.3

Patients undergoing infrared thermographic testing must follow certain

instructions before testing, including special restrictions regarding the
use of nicotine and caffeine, skin lotions, physical therapy the day
before the test, and other diagnostic procedures prior to testing.
Patients may be required to discontinue certain pain medications and
sympathetic blocks. After a patient arrives at a thermographic
laboratory, he or she is equilibrated in a 16-20 C draft free
steady-state room wearing a loose fitting cotton hospital gown for
approximately 20 minutes. The infrared study includes obtaining
infrared images of the affected limbs and the normal limbs as well as
imaging other parts of the body including the face, upper back and
lower back. After capturing the baseline images, some labs will require
the patient to undergo cold-water autonomic functional stress testing to
evaluate the function of the autonomic nervous system peripheral
vasoconstrictor reflex. This is performed by placing a patient's normal
limb in a cold-water bath (approximately 20 C) for five minutes while
collecting images. In a normal-intact functioning autonomic nervous
system, a patient's painful extremity will become colder. Warming of the
painful extremity indicates a disruption of the body's normal thermal
regulatory vasoconstrictor function present in patients with CRPS.4 This
is also known as "vasomotor instability."

Research has shown that patients undergoing infrared thermographic

testing in a controlled cold environment (less than 20 C) who
demonstrate computerized side-to-side temperatures greater than 1
C and show abnormal response to cold water functional stress testing
have a high sensitivity (patients who have the disease) and specificity
(patients who do not have the disease) in the diagnosis of CRPS.4,5
Not all patients with CRPS, however, demonstrate the "vasomotor
instability" changes just discussed, particularly in later stages of the
disease. The results of the thermogram, therefore, must be interpreted

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as part of the disease history by the clinician.

**Written by Timothy D. Conwell, DC, Denver, Colo.

Editor's Note
Dr. Conwell, a leading expert in thermography, nicely shows the great
promise that this diagnostic tool holds for the evaluation of CRPS.
Unfortunately, there are few laboratories in the United States that have
the capability to perform the study as described and thermography is
therefore underappreciated by the medical community. -- R. Stieg, MD,
MHS

Notes
1. Uematsu S, Edwin DH, Jankel WR, Kozikowski J, Trattner M.
Quantification of thermal asymmetry, part 1: normal values and
reproduce stability. J Neurosurg 1988; 69:552-5.
2. Low PA. Laboratory evaluation of autonomic function. In: Low PA
(Ed.). Clinical Autonomic Disorders. Boston: Little, Brown and
Company, 1993, pp 169-192.
3. Birklein F, Kunzel W, Sieweke N, Despite clinical similarities there are
significant differences between acute limb trauma and complex regional
pain syndrome I (CRPS-I). Pain 2001; 93:165-171.
4. Gulevich SJ, Conwell TD, Lane J, et al. Stress Infrared
Telethermography is useful in the diagnosis of complex regional pain
syndrome, type I (formerly reflex sympathetic dystrophy). Clin J Pain
1997; 13:50-59.
5.Wasner G, Schattschneider J, Baron R. Skin temperature side
differences: a diagnostic tool for CRPS? Pain 2002; 98:19-26.

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