General Guideline Principles for Physical Examination
of Complex Regional Pain Syndrome for
workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Physical Examination of Complex Regional Pain Syndrome.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Physical Examination of Complex Regional Pain Syndrome

The physical assessment of a patient who has CRPS symptoms that are well-established is nearly always simple, especially for the examiner who is experienced with CRPS. Early signs are frequently clinically vague, though, and the diagnosis could be less certain.

To prevent dysfunction, education and specialized physical/occupational treatment with a focus on strengthening functional active usage, and aerobic components continue to be the main interventions. Selected people may also benefit from early psychological interventions, especially if they already have post-traumatic stress disorder, other psychiatric/behavioral issues, and/or poor coping skills.

The patient will frequently be seen restricting the use of the extremities, including avoiding and protecting the limb. This may entail refraining from shaking your hands or placing weight on the injured leg.

The fact that the affected extremity’s objective findings greatly differ from those of the uninfected extremity is a fundamental characteristic of this disorder. Although it can be warmer, the skin temperature can vary, usually being colder in the affected extremities.

If the condition is advanced, the flesh may appear smooth, thinning, or atrophic. Infrared equipment should be used to assess skin temperature, and there ought to be at least a 1-degree difference for CRPS. Additionally common are alterations in skin color, such as mottling.

There could be livedo reticularis, splotchy purplish staining of the skin. The extremities could swell up. The nails may age and atrophic with time. Allodynia, or the feeling of pain from something that most people would not find painful, is a differentiating feature.

Examples include discomfort at gentle contact, trembling hands, and even the burden of garments on the affected area. The injured extremity may vary in circumference. They may be affected differently in edematous situations (usually early) and differently in chronic ones when they have disuse dystrophy.

Although the baseline measurements won’t be comparable with the pre-morbid situation, which is unknown, it is possible to measure water displacement volumes to determine the degrees of swelling.

Astereognoses, the inability to recognize an item simply on tactile input, and the identification of hand laterality with motor imagery are further discoveries that have been made public. While occasional assessments may be okay, some people have a propensity to become fixated on them, which could attract attention.

A thorough physical examination is recommended for evaluating a CRPS patient. This section will not go into detail on the physical examination’s components, which should be done by the appropriate body part involved (see other Healthcare Treatment Protocols).

Individuals with somatic symptom disorder or other behavioral/psychological abnormalities are frequently difficult to tell apart from psychologically healthy people while they are being examined. Referrals for psychological services, including psychometric testing, should have a relatively low barrier.

The focus of the physical examination is thought to be the patient’s observation. It should start at the beginning of the appointment, or even better, through a summary from the assistant who placed the patient in the examination room.

It should assess the patient’s capacity to stand up from a correct posture (as well as other positional changes), stride in the hallway (for any ailments involving the lower extremities, for example), use of extremities for tasks, and facial gestures while carrying out those duties.

It is important to document both synergistic and synergistic observations from the history and physical exam. You should look for signals that don’t match your symptoms, especially if you have CRPS.

It should be emphasized that favorable outcomes from these procedures are occasionally mistakenly interpreted as proof of fictitious disease and/or hoax claims. That might be true or might not. Often, it is thought that these might be advantageous when patients who are in pain subtly display a need for additional attention to the physical disease or occasionally may signify psychological disturbance.

They might only be a component of the clinical manifestations in the context of CRPS. However, their existence may suggest the need for a psychosocial assessment or consultation with other professionals, particularly if several indications are present in the setting of a major healing delay.

Because many treatments can present similarly to CRPS and because the subjectively reported symptoms of CRPS are frequently inconsistent with both the presenting history and initial objective findings, making a correct diagnosis in the context of conceivable CRPS can be very challenging.

The following conditions may be included in the differential diagnosis of CRPS but are not required to be: neuropathic pain syndromes (peripheral [poly] neuropathy, brain entrapment, radiculopathy, post-herpetic neuralgia, plexopathy, and motor neuron disease); vascular diseases (thrombosis, atherosclerosis, and Raynaud’s phenomenon); inflammation (erysipelas, hip pain, seronegative arthritis, thyroid disorders, diabetes mellitus, alcoholic polyneuropathy, or psychological or behavioral issues (such as somatoform pain syndromes, Munchhausen syndrome, compensatory neurosis, malingering, and factitious disorder).

This list only serves to illustrate the intricacy of the differential diagnosis; it is not meant to be comprehensive. Furthermore, it should not be assumed that the presence of diagnoses like compensating neurosis, malingering, or factitious disease invalidates the validity of the pain symptoms of individuals with CRPS.

It is rather to test the patient’s skills in the CRPS setting so that the measures can be followed up on in later clinic visits where the patient receives rehabilitation therapy. These might include the next:

• Walking distance (check the patient’s ability to go farther in the hallway or outside, then ask them about their progress at the same time).

   

• The ability to climb stairs (going with the patient to the closest stairwell and having observational skills).

   

• Dynamometer measurements of grip strength

   

• Pinch power

   

• Continual toe elevates (number able to perform)

   

• Walking heel distance

   

• The squat (number)

   

• Results of the sensory examination (e.g., monofilaments)

   

• Movement in the examination room not consistent with pain or injury problem

This enables more informed decision-making regarding physical activity and other benchmarks and is thought to be very beneficial in accelerating the patient’s recovery. Another suggested strategy is to monitor patient improvement using proven functional assessment tools.

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