Instructions for Use of Crps Database Form

CRPS Diagnostic Validation Study Instructions©

I. Forms to be Completed by Subject:

Personal Health History
McGill Pain Questionnaire (MPQ)-Short Form (study coordinator to instruct subject in proper technique)
SF-36
Medication list (study coordinator to confirm data with subject)

II. CRPS Database Form Instructions

*NOTE: The term Affected Side/Area is defined as the side of the body/area that is the most painful and original site of injury (in the case of “spreading” CRPS).

SYMPTOMS (as given by or elicited from patient, either currently or historically)

Baseline Numeric pain Rating Scale (NRS) in affected part: 0=no pain, 100=worst pain imaginable. Subjects should be asked to report current pain level only.

There usually is an initiating noxious event or immobilization identified. This can be trauma, fracture, and/or surgery or the subsequent immobilization. Immobilization alone or minor trauma is sometimes sufficient.

The pain is disproportionate to or continues longer than expected based on the clinician’s experience as to what is usual and customary in this type of injury.

Hyperesthesia (an increase in sensory perception of any kind, including cold) is a hallmark of these diseases; however, hypoesthesia (usually described as numbness) may be present as well, especially in CRPS Type II.

Temperature asymmetry of a noticeable and significant nature.

Color asymmetry of a noticeable and significant nature.

Sweating asymmetry of a noticeable and significant nature.

Edema of a noticeable and significant nature (may be described as swelling).

Dystrophic changes of nails, hair, or skin as described by the patient.

Motor abnormalities such as weakness, tremor, or dystonia (limb locked in unusual position) as described by the patient.

Decreased range of motion as described by the patient.

Other symptoms that are prominent in the patient's report should be listed here or on the back of the form.

SIGNS (as observed by examiner on the exam date)

Hyperalgesia as tested by a single pinprick on the affected side (in center of most affected region) and same site of the contralateral limb using the weighted pin developed by Maihofner or a new safety pin. Hyperalgesia reflects this mildly noxious stimulus being perceived as intensely painful or lasting longer than the duration of the stimulus. Have the subject rate their pain on a 0-100 scale for each limb.

Hypoesthesia (numbness) to light touch using a #1500 camel hair brush.

Allodynia as tested by a #1500 camel hair brush (touch), manual deep joint pressure, 128 Hz tuning fork over bony prominence in affected limb (vibration), cool water in a test tube (cold), and hot water in a test tube (heat). Allodynia reflects normally innocuous stimuli now being interpreted as painful.

Asymmetric edema as observed by the examiner, quantified by objectively measured volumetry (cm3) compared side to side. If a graduated cylinder large enough to hold the lower extremity is unavailable, please just omit the volumetry information, as long as the categorical “yes/no” response is marked.

Obvious sweating asymmetry. If not obvious, this may be checked by running a smooth handled instrument (e.g., turning fork) over the skin and noting if the instrument slides more easily on one side than the other, or by rate/degree of soaking of a facial tissue.

Temperature asymmetry in the affected area compared to the comparable area on the contralateral extremity that is obvious to the touch of the dorsum of the hand of the examiner.

Obvious color asymmetry of a regional nature (i.e. hand, foot, knee or larger region). Please specify the color of the affected side as being red, blue, or pale, as well as being mottled or having a scar. This should be coded even if color difference is solely related to edema or scar tissue. If scar tissue is present and affecting the color of the area (as in a burn), please note this fact.

Dystrophic changes of the affected extremity as noted by the examiner in nails, hair or skin (shiny, thin, or thick) of the affected side. Please describe the nature of these changes.

Motor abnormalities as noted by the examiner such as weakness, tremor, or dystonia on the affected side. Weakness to be rated at most affected joint by the Canadian system, 0-5. (0=no movement, 1=flicker of movement, 2=movement with gravity, 3=movement against gravity, 4=weak, 5=normal power)

Decreased active range of motion as noted by the examiner.

TESTS

Light stroking of the skin with a #1500 camel hair brush (with patient not observing) should be used to assess for deficits in light touch sensations in the following areas bilaterally: face, upper chest, upper arm, hand, thigh, and foot. Please indicate for each area whether the response is hypoesthetic (no or decreased touch sensation reported), normal, or allodynic (touch was painful in the area). Record the results from the areas ipsilateral to the most affected extremity under “Ipsi Side” and those areas contralateral to the affected extremity as “Contra Side”. Hemisensory touch deficits have been described in CRPS patients as a possible indicator of central nervous system changes associated with the syndrome (Rommel et al., 2000).

Active ROM on the ipsilateral side of the affected extremity and the contralateral extremity should be assessed using a goniometer. For upper extremity CRPS, elbow, wrist, and index finger flexion and extension should be recorded, using anatomic position as 0 degrees. For lower extremity CRPS, knee and ankle flexion and extension should be recorded, using anatomic position as 0 degrees. Patients should be instructed to “move the joint as far as possible within your pain tolerance.”

Revised 15Feb2007 Pg 1/1