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Complex regional pain syndrome medicalises limb pain

BMJ 2014; 348 doi: (Published 28 April 2014) Cite this as: BMJ 2014;348:g2631

Re: Complex regional pain syndrome medicalises limb pain

It is unfortunate that the excellent points by Bass will be lost in the debate over his call for the abandonment of the term CRPS type 1. He is not alone in making this call (1). CRPS is a condition with uncertain aetiology, no diagnostic test and multiple therapies with limited evidence. It exists and causes morbidity (2). CRPS type 2 (with nerve injury), with almost identical clinical features, was not mentioned.
Any distressing health problem is likely to be medicalised. Iatrogenic harm does exist and is related to the over diagnosis of CRPS (often in the medicolegal context). Using it as a diagnosis of last resort, usually in distressed patients, is lazy medicine. The Budapest criteria are an advance in the diagnosis of CRPS type 1, but they should not be applied with blind faith. They reflect the consensus of a group of experts. Other diagnostic criteria exist and inter observer reliability between all criteria is poor (3). The quoted sensitivity and specificity values of the Budapest criteria should be questioned as they are validated on small populations, rather than against a gold standard. Work has shown that different criteria may apply to Japanese patients (4) and a new diagnostic subset of CRPS has also been proposed (5). Increased psychiatric involvement in pain services is pertinent. Somatisation disorder is also controversial and badly diagnosed. Abandoning the term CRPS type 1 is a retrograde step, tightening the diagnosis is not.

1.Del Pinal, F. "Editorial: I have a dream… reflex sympathetic dystrophy (RSD or Complex Regional Pain Syndrome-CRPS I) does not exist." Journal of Hand Surgery (European Volume) 38.6 (2013): 595-597.

2.van Velzen GA, Perez RS, van Gestel MA, Hyugen FJ, van Kleef M, van Eljs F, Dahan A, van Hilten JJ, Marinus J."Health-related quality of life in 975 patients with complex regional pain syndrome type 1." Pain 155(2014):629-635.

3.Perez RS, Burm PE Zuurmond WW, Giezeman MJ, van Dasselar NT, Vranken J, de Lange JJ. "Interrater reliability of diagnosing complex regional pain syndrome type I." Acta anaesthesiologica scandinavica 46.4 (2002): 447-450.

4.Sumitani M, Shibata M, Sakaue G, Mashimo T. "Development of comprehensive diagnostic criteria for complex regional pain syndrome in the Japanese population." Pain 150.2 (2010): 243-249.

5.Żyluk, Puchalski P. "Complex regional pain syndrome: observations on diagnosis, treatment and definition of a new subgroup." Journal of Hand Surgery (European Volume) 38.6 (2013): 599-606.

Competing interests: No competing interests

03 June 2014
Michael H Basler
Consultant in Anaesthesia and Pain Medicine
Dr Colin Rae, Dr Gordon Stewart
Stobhill Hospital
133 Balornock Road, Glasgow G21 3UW