MAKING COMPLEX REGIONAL PAIN SYNDROME SIMPLE FOR A JURY
A start-to-finish strategy for proving the chronic pain and resultant damages of CRPS
When God was testing the faith of Job, the worst punishment was physical pain…. He lost his lands and property, his family – but it was not until physical pain was inflicted that Job broke. (Job 16:6).
A case dealing with chronic pain can be difficult to prove due to the subjective nature of pain itself. This is especially true for Complex Regional Pain Syndrome cases (“CRPS”). CRPS, formerly known as Reflex Sympathetic Distrophy Syndrome (“RSD”), is an incurable chronic pain condition that is often debilitating. For trial lawyers and their clients, this disorder is especially troubling because of the controversy surrounding its diagnosis and treatment. As its very name implies, the disorder is “complex” in nature, is routinely misdiagnosed, and as such, is difficult to explain and prove to a jury.
Take a recent case that had a mixed diagnosis: Some doctors thought it was CRPS, while some did not. In the end, what mattered was our client had severe pain that would likely afflict him for the rest of his life. This was something the jury understood, whether we called it CRPS or not. The primary purpose of this article is to explain the basics of CRPS, highlight some of the challenges in dealing with a CRPS case, and discuss some useful strategies from a recent trial.
CRPS – WHAT IS IT?
CRPS is a chronic pain condition most often affecting one of the limbs (arms, legs, hands, or feet), in which the pain is out of proportion to thc injury. There are two designations of CRPS: Type I and II. Typc I, which this article will focus on, is a result of trauma. Type II stems from a specific injury to a nerve.
Some researchers have said CRPS is potentially the worst chronic pain disorder a human being could endure. Doctors describe the severe cases of CRPS as being higher on the pain scale than childbirth and amputation. However, over the years, pain management practitioners were overzealous in diagnosing chronic pain patients with CRPS. In the early 1990s, “RSD” cases were popping up everywhere, perhaps in part due to the unclear diagnostic criteria at the time. Now, after the hype has calmed and thorough research has flushed out a more clear understanding of the disorder, CRPS cases can and should command the same attention as other severe injuries such as brain and spinal cord injuries.
To begin with, CRPS arises typically after an injury or trauma to the affected limb. For example, a seemingly simple fracture to the ankle eventually causing a severe pain disorder in that limb. The most frightening aspect of the disease is that it often initially begins in an arm or a leg and often spreads throughout the body. In fact, according to the National Institute of Health, 92 percent of patients state that they have experienced a spread, and 35 percent of patients report symptoms in their whole body.
CRPS is characterized by prolonged or excessive pain and mild or dramatic changes in skin color, temperature, and/or swelling in the affected area. These signs can be subtle in nature, or dramatic, depending on the severity of the CRPS.
CRPS symptoms vary in severity and duration. The key symptom is prolonged pain that may be constant and, in some people, extremely uncomfortable or severe. The pain may feel like a burning or “pins and needles” sensation, or as if someone is squeezing the affected limb. The pain may spread to include the entire arm or leg, even though the precipitating injury might have been only to a finger or toe. Pain can sometimes even travel to the opposite extremity. There is often increased sensitivity in the affected area, such that even light touch or contact is painful (called allodynia).
People with CRPS also experience constant or intermittent changes in temperature, skin color, and swelling of the affected limb. An affected arm or leg may feel warmer or cooler compared to the opposite limb. The skin on the affected limb may change color, becoming blotchy, blue, purple, pale, or red. As discussed in more detail below, due to the complexity of the disorder, CRPS cases are often overlooked, misdiagnosed, and not properly worked up.
VETTING A CRPS CASE
As trial lawyers, we appreciate that many of our clients do not have the type of medical treatment and insurance required to get a complete medical workup and diagnosis. Often, an injury like a brain bleed or spinal fracture might go misdiagnosed. With a disorder such as CRPS, this is truly one of the injuries that often require an attorney’s eye and attention to appreciate the client’s dilemma.
The following are a few points to consider when interviewing a client to determine if he or she potentially has CRPS:
• An injury causing pain which is out of proportion to injury,
• Changes in skin texture on the affected area; it may appear shiny and thin,
• Abnormal sweating pattern in the affected area or surrounding areas,
• Changes in nail and hair growth patterns,
• Stiffness in affected joints,
• Problems coordinating muscle movement, with decreased ability to move the affected body part, and,
• Abnormal movement in the affected limb (most often fixed abnormal posture, or tremors of the affected limb).
For a full CRPS potential case checklist, please contact the author.
Find out more about:
What Causes CRPS?
CRPS Diagnosis and Prognosis
How to Deal with Conflicting CRPS Diagnoses
Voir Dire Tips in a Pain Trial
Experts: Get the Dream Team
Dealing with the Defense “Expert”
Making it Simple
via Making Complex Regional Pain Syndrome Simple For a Jury.
COMPLEX REGIONAL PAIN SYNDROME
THE RELENTLESS PURSUIT OF JUSTICE
Complex Regional Pain Syndrome: The Relentless Pursuit of Justice
Diagnosis and Risk Factors
Prognosis and Treatment
Lawsuits and Damages
Spencer Lucas is a trial lawyer at Panish Shea & Boyle and specializes in complex catastrophic personal injury, products liability and wrongful death cases. He has extensive experience in cases involving traumatic brain injuries, spinal cord injuries, and chronic pain.
Panish Shea & Boyle, LLP
11111 Santa Monica Blvd #700, Los Angeles, CA 90025
If you really want to understand the natural history of this miserable pain problem you have to go back into the archives of medicine. In the 1930-80s there were a lot of chatter about a complex pain problem of unknown origin. Fortunately a few physicians attempted to treat it with profound success.
This is a synopsis of what they discovered:
CRPS is not caused by the brain, nerves, the spinal nerves, pinched nerves, lymphatic systems or we simply do not know. This is not true. We DO know for certain or we did know. Today’s medical business models decided that it was too easy to believe and would interfere with profits. Besides Conventional Medicine was too busy promoting pain pills, joint replacement, fusing the vertebrae and robotic surgeries. All of which probably have the same cause and treatment as CRPS.
The muscle system is the only system in the body that is abused by use that we simply overlook because it is so perfect and efficient. But it does need to be maintained or it will began to act erratic, less efficient, less capable, spasm, contract, lock up, cause contractures and squeeze the life out of other organ systems, blocking blood flow and nerve impulses. These sick muscles will pull the live out of the skeleton and smash the synovial fluids out of the joints.
So, all of the everyday aches, pains, spasms and stiffness everybody will experience must come from muscles. It is the only organ system which can collect stresses, strains, tatters, scars, fibrous bands and knots which will lead to the “activation” of destructive crushing contractile forces. This distress is what triggers alert signals requesting help and assistance.
Myofascial (MF) sickness will drive long-term pain. MF sickness and the erratic contractile forces due to dis-eased muscles will drive dysfunctions. This dis-eased will not only cause intense and miserable pain, the contractile forces will lead to many dozen of the invisible, undetectable signs and symptoms that we can witness as dysfunctions or malfunctions.
All invisible to technology, other people, physicians and it will even be impossible to prove in a court of law. Only until the patient is in the late stages can one began to see the damages from the relentless compression forces of sick muscles onto the flesh, skin and nerves. By then the reversal process in almost impossible.
They applies an ancient set of remedies that have always worked to remove pain from the muscle system. There are only 3 categories of remedies which can remove the stressed-strained sick-tired muscle tissues:
1) Hands-on tissue release. This remedy that must be applied externally to the muscles as in any hands-on therapies with manual labor. Massage. Balls, bars and doohickies. Joint Manipulations. Spinal Manipulations. Deep tissue manipulations. Cupping, scraping and brushing. Traction and inversion.
2) Thin dry needling ie acupuncture
3) Hypodermic wet needling.
The most profound complementary remedy for this pain is a modern iteration of “Acupuncture” are: 1) Dry intramuscular stimulative thin/hypodermic needling. 2) Tendon, ligament, tendon-muscle junction stimulative thin/ hypodermic needling. 3) Bony attachment and periosteal thin/hypodermic stimulative needling.
Thank you for commenting.
While I can agree with Myofascial pain and muscle dysfunction as adding insult to injury, and even Acupressure and ancient remedies being helpful, I’m not sure how we can dismiss all that has been learned about Reflex Sympathetic Dystrophy and Complex Regional Pain Syndrome. I’m not speaking of the “other” complex pain syndromes that are sometimes added to this category now a days.
If we do go back into the natural history of this pain problem, we know that there is much literature from the Civil War era with Silas Weir Mitchell documenting his findings, diagnosis’ when soldiers were shot or injured and the injury took on an abnormal healing path, remaining a constant presence of chronic symptoms with severe burning pain as the main complaint. Thus, the word, Causalgia as it’s definition.
I don’t doubt at all that hands on manipulation of the body, deep massage, wouldn’t benefit a patient, if they could handle it. Most can’t. Just the fact that the muscles could be relieved from tension residing within it would be a great pain reducer, but I can’t see how RSD or CRPS can originate as a muscle problem. I can see how muscles become involved and add to the over all body.
I would be interested in seeing that information you’ve spoke of that refers to –
“CRPS is not caused by the brain, nerves, the spinal nerves, pinched nerves, lymphatic systems or we simply do not know. This is not true. We DO know for certain or we did know.”
I look forward to references or citations.
I wish you well.
A true is just true. It is not possible to prove a truth to someone who wishes not to know. On any account, here are a few rules that I have collected which helps me to discern what is true, what is false, high risk, low risk and no risk.
The human body is perfectly designed by the forces of Perfection.
Nature heals all wounds.
All organs and tissues will heal 100%, 100% of the time or it will need some assistance from man.
Out of all 11 organ systems, which system needs nothing or very little from man? The skeleton.
Which is the system is the one that will bother you in the morning upon awakening after a day of cultivating your garden? Muscles!
Throughout the history of man what is the best remedy to remove muscle pain? The muscle system will always need assistance from man, so the application of the remedy to the muscles is natural. We know for certain that the best remedy for muscles has been and always will be massage, stretching and range of motion exercises. This remedy is 100% effective as long as you apply the remedy correctly. The proper type, amount, frequent, more focus, move globally or add in an additional set of tools.
If hand-on remedy for muscles does not restore then you will need to up the dosage to thin intramuscular needling and hypodermic intramuscular needling.
“Nature heals all injuries.” All injuries; falls, breaks, rips tears will heal over a set amount of time with a little TLC, pampering and support. The vast majority without the need for operative intervention. Any pain that is left after an injury must be assumed to reside in the muscles.
Note: The application of remedy to the skeleton is unnatural.
Note: The human body will accept an unnatural remedy but your illogical act will leave the person with nothing, unrestored, disabled, handicapped or missing a body part.
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You said “A true is just true. It is not possible to prove a truth to someone who wishes not to know.”
I did want to know that is why I asked. Truth is to be taken as fact. Fact needs to be supported and verified.
It is possible to prove a truth to someone by offering references that support a fact.
Again that is why I asked for references or citations on your statement-
““CRPS is not caused by the brain, nerves, the spinal nerves, pinched nerves, lymphatic systems or we simply do not know. This is not true. We DO know for certain or we did know.”
I was most interested to read, what is known for certain (or was) regarding CRPS.
In any event, thank you for sharing what you have.
Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic by C. Chan Gunn MD.
Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual David G. Simons , Janet G. Travell, MDs.
Myofascial Pain and Fibromyalgia: Trigger Point Management, Edward S. Rachlin MD.
Ligament and Tendon Relaxation (Prolotherapy) by George S. Hackett, MD.
Pain Procedures in Clinical Practice, Ted A. Lennard MD, David G Vivian MM BS FAFMM, Stevan DOW Walkowski and Aneesh K. Singla MD MPH.
Backache from Occiput to Coccyx 1964 by Gerald L. Burke.
Intraneural Injections for Rheumatoid Arthritis and Osteoarthritis & Control of Pain in Arthritis of the Knee by DiFabio and Pybus.
Healing through Trigger Point Therapy: A Guide to Fibromyalgia, Myofascial Pain and Dysfunction by Devin J. Starlanyl, John Sharkey and Amanda Williams.
Myofascial Pain and Fibromyalgia Syndromes: A Clinical Guide to Diagnosis and Management, 1e by Peter E. Baldry MB FRCP.
Acupuncture: The Ancient Chinese Art of Healing and How it Works Scientifically Paperback – January 12, 1973, by Felix Mann (Author)
The Subluxation Specific, The Adjustment Specific: B.J. Palmer.
The Chiropractor by D. D. Palmer.
CraigPENS as per William F Craig, M.D.
Myofascial Release by Gokavi, Cynthia N. Gokavi, MBBS.
Fibromyalgia and Chronic Myofascial Pain: Devin J. Starlanyl and Mary Ellen Copeland.
Advanced Soft Tissue Techniques as per Leon Chaitow, ND, DO.
Medical Acupuncture as per French Energetic protocols of Joseph Helms, MD.
Mindfulness meditations by Jon Kabat-Zinn.
Cyriax, J. H., Cyriax’s Illustrated Manual of Orthopaedic Medicine, Butterworth & Heinemann, 1993. http://www.aaomed.org/Cyriax-System-of-Orthopaedic-Medicine
Thank you so very much! Most grateful. If you didn’t realize, I am interested in alternative and complimentary medicine as apposed to western. I’ve read 100’s + of articles and listened to live and archived broadcasts on acupressure, acupuncture, trigger point therapy, muscle relaxation (manual and mental), mindfulness, chinese medicine, alternative healing and so much more.
Many of the broadcasts provided by the Living with HOPE radio show on The Body, Mind and Spirit Network with Host Trudy Thomas since 2007. Archives are still available
So I didn’t doubt you, my thirst for ongoing information, learning and knowledge was my hope in my comments and questions to you.
I’ll reply back with any questions or thoughts as I move through the references.
Thank you for your time.
The first reference Hackett 3rd ed 1958 which mentions one of the most severe complex pain syndromes known to mankind. Once called Causalgia and today called Reflex Sympathetic Dystrophy or Complex Regional Pain Syndrome.
Excellent, thank you!
How do we get around the patients that are unable to participate in Prolotherapy. Those who can’t tolerate injections or manual manipulation?
I personally would be willing to try, but many would not. On a regular basis, I manually manipulate my muscles. Nope, I don’t know what I’m doing really other than making sure I massage them regardless of sensation of added pain while doing so. I feel better after that’s why I do it. I’ve also found over the years that pain itself and stress causes us to tense our muscles without even realizing that we are, which adds to an over all body ache. Several times a day I’m mindful to stop whatever I’m doing, even if I think i’m relaxing, and release any muscles that I might be tightening by using muscle relaxation techniques I learned many years back.
What I find to be most important is that these treatments need to be started or offered right away before the the person’s pain gets out of hand, moves to other parts of the body, bones become brittle, muscular-skeletal pain increases and the diagnosis becomes seemingly un treatable. Once the allodynia and hypersensitivity begins, not too many are interested in being touched, let alone needles or massage.
Thank you again,