What do we know about Complex Regional Pain Syndrome (“CRPS”) and Systemic CRPS?

Without summarizing the following decision, I am simply going to quote stated facts regarding the condition of Complex Regional Pain Syndrome (“CRPS”) and Systemic CRPS, together with excepts from the medical experts that have commented on these conditions and the Court’s comments as it relates to the medical evidence.

As a note:  CRPS is sometimes referred to as “Chronic Regional Pain Syndrome” which is a common error.  The correct name of the syndrome is “Complex Regional Pain Syndrome”.

CRPS is a rare disorder, and this is a great case that provides insight on both Complex Regional Pain Syndrome and Systemic CRPS.

This action is a request by the Petitioner Houston for a Judicial Review from a WCAT ruling dealing with the issue of CRPS and Systemic CRPS. The Petitioner was successful in this Judicial Review.

Houston v. British Columbia (Workers’ Compensation Appeal Tribunal), 2015 BCSC 2447 (CanLII)

Complex Regional Pain Syndrome & Systemic CRPS

A minor injury can result in Comples Regional Pain Syndrome. When the symptoms spread to other parts of the body it is known as “Systemic CRPS”

[8]           Ms. Houston sustained a soft tissue injury to her left shoulder in 1999 while moving boxes in the course of her employment with BC Hydro. At that time, she was employed as an electrician. Subsequently, she developed CRPS in the region of her left shoulder girdle.

[9]           CRPS is rare. It has only fairly recently been recognized as a medical condition. Much of the difficulty faced by the parties in this case arose from the lack of a clear medical consensus as to the symptoms and diagnostic criteria of CRPS.

[10]        The syndrome generally describes a constellation of symptoms that arise following what is often a relatively minor injury. The symptoms are out of keeping with the severity of the original injury. They typically include:

  • temperature deregulation,
  • excessive perspiration,
  • marked cold sensitivity,
  • allodynia,
  • hypersensitivity,
  • discolouration of the skin and
  • burning pain or autonomic disturbance.

[11]        The cause of CRPS s unknown. There is little published or peer reviewed literature relating to it. Diagnosis of CRPS is made more difficult by the fact that its symptoms tend to be variable and not all of them may be present all of the time[12]        As indicated above, in certain cases a person who suffers from CRPS in one region of the body may develop the same symptoms in another region, usually following another minor injury. This condition was described by Dr. Hunt and the Board as Systemic CRPS, although that term does not appear to be universally used in the medical literature, as was pointed out by Dr. Waterman, a doctor consulted by WCAT in this case. Another term used to describe the spread of CRPS symptoms is multiple site CRPS.

The Court further states:

At page six of his expert medical opinion of August 26, 2004, Ms. Houston’s expert, Dr. Hunt, described pain that is disproportionate to the inciting injury event as the essential symptom for CRPS.

Medical Evidence opining on CRPS and Systemic CRPS follows:

Dr. Ebrahim dated December 10, 2012, …said as follows:

By definition, the systemic CRPS is diagnosed when the typical symptoms of the condition affect more than one limb and in this case, the evidence would indicate that the appropriate symptoms in the left lower limb were noted by Dr. McDonald on January 17, 2006, when a firm diagnosis of CRPS of the left lower limb was provided, and a sympathetic block given with observed improvement in the worker’s symptoms, which would be consistent with this diagnosis. This would also be consistent with the expected development of CRPS in a limb following a traumatic event, and a non-compensable fifth metatarsal fracture would appear to be the inciting event leading to the left lower limb CRPS diagnosis. Therefore, the medical evidence would suggest that the worker’s generalized CRPS likely began following her fracture of her left fifth metatarsal on December 10, 2006 and was confirmed by a medical specialist, Dr. McDonald, on January 17, 2006

[Emphasis added]

[53]        In the WCAT decision on appeal, the Vice Chair summarized her findings at paragraph 56:

[56]      The Board based its adjudication on the opinion of Board medical advisor, Dr. Ebrahim. Dr. Ebrahim reviewed the medical evidence on the worker’s claim and concluded the worker’s CRPS spread from the left arm/shoulder, following the left foot fracture in December 2006. The doctor noted the medical examination in January 2007 confirming signs of CRPS  including colour variation, swelling, and temperature variation. The doctor also noted an examination in January 2006 did not reveal any of these signs of CRPS in the worker’s left leg. Dr. Ebrahim also noted a medical report from Dr. Hunt of August 2004 referenced an exacerbation of the worker’s CRPS symptoms secondary to the chest tube insertion after Dr. Hunt’s examination in October 2003. The implication of Dr. Ebrahim’s conclusions infers Dr. Hunt’s comments about an exacerbation do not rise to the level of confirming CRPS in a second location – the left chest wall. However, I note Dr. Hunt’s 2004 report cited left chest wall pain and muscle spasms, the worker’s reports of temperature changes in the chest wall, and colour changes (no details whether these were the worker’s self-reported symptoms or Dr. Hunt’s observations). Dr. Hunt did diagnose CRPS in the left hemithorax (chest wall), although he also noted that the diagnostic criteria included pain and one symptom in each of the four categories of sensory changes, vasomotor (colour or temperature changes), sudomotor (sweating), and trophic (range of motion), yet his own observations do not contain these diagnostic criteria. In addition, at page 24 Dr. Hunt appears to group the worker’s left hemithorax symptoms in with those of her left shoulder girdle CRPS as a deterioration of that condition, rather than spread of her CRPS to a second site. In fact, he described the worker’s left shoulder girdle CRPS as not becoming evident until after the chest tube insertion of November 2000. Dr. Hunt did note that CRPS can spread and queried whether the worker was developing symptoms on the right side of her body. Dr. Ebrahim interpreted these ambiguous results as not indicating the worker’s CRPS had spread to a secondary site as of November 2000.

[Emphasis added.]

[54]        Dr. Hunt’s opinion in 2013 was that the procedures following the inadvertent puncturing of Ms. Houston’s lung in November 2002 led to the outbreak of CRPS in her left chest and that this constituted a second site of the condition that met the definition of Systemic CRPS.  At page ten of his Report of August 7, 2013, Dr. Hunt stated as follows:

It is my opinion that the surgical trauma associated with the placing of the chest tube in her intrathoracic region on November 20, 2000 which triggered Ms. Houston’s CRPS symptoms not only in the left lateral chest wall but also into the posterolateral and anterolateral left hemithorax. She experienced almost immediate new symptoms in this region once the local anesthetic had worn off and in fact had such intense pain and CRPS  symptoms that she had to be admitted to hospital and treated with morphine and support. Her other symptoms bronchospasm induced by cold and exercise also developed following this event. She did not have these symptoms prior to the placement of the chest tube. From 2000 on she has required the use of inhalers to remedy respiratory difficulties, particularly when inhaling cold air.

Dystonia, which is severe prolonged muscle spasm of the chest wall muscles, is common in severe longstanding CRPS patients. Dystonia is a major component of the movement disorder associated with CRPS and therefore can involve not only the limbs but also the chest wall musculature.

It is therefore my opinion that it was the surgical trauma associated with the placing of the chest tube in the intrathoracic region in late 2000 which triggered the development of new CRPS signs and symptoms in the lower lateral chest (at the site of the chest tube placement). The CRPS symptoms and signs spread to involve the left hemithorax and the CRPS symptoms from the lower chest wall became continguous with the CRPS signs and symptoms of the left upper arm, left shoulder and upper left shoulder girdle. This provides substantial clinical information to meet the clinical definition for systemic CRPS in 2000. In short, Ms. Houston developed systemic CRPS in late 2000 following placement of the chest tube.

The Court’s comments regarding the medical evidence:

The Vice Chair arrived at her decision by preferring the opinion of Dr. Ebrahim to that of Dr. Hunt. Ordinarily this would be a decision that could not be said to be patently unreasonable. However, in my view the Vice Chair’s conclusion is based on a fundamental misconception of Dr. Ebrahim’s opinion.

The Court’s conclusion:

[62]     I find that Dr. Ebrahim did not give any consideration to the critical question of whether the symptoms described by Dr. Hunt as an outbreak of CRPS in the left chest area constituted Systemic CRPS because he was of this opinion that to be systemic the CRPS must manifest itself in a second limb.

[63]        I conclude that the Vice Chair’s decision was based on the assumption that Dr. Ebrahim and Dr. Hunt were using the same definition of Systemic CRPS.  That assumption is critical to her conclusion but is unsupported by the evidence. The evidence in fact clearly establishes that the two doctors were using different definitions of CRPS.  Because of her erroneous assumption the Vice Chair did not make any finding on this critical issue.

[64]        In the absence of such a finding, I am forced to conclude that the Vice Chair erroneously concluded that Dr. Ebrahim used the same definition for Systemic CRPS as Dr. Hunt, and in particular that he directed his mind to the question of whether there was evidence of CRPS in Ms. Houston’s chest, when he clearly did not.


[83]        I find the decision of WCAT that Ms. Houston’s CRPS did not become systemic until January 2007 to be patently unreasonable and order that it be remitted to WCAT for reconsideration in accordance with these reasons.

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