October 3, 2025 • 56 mins
What Defense Attorneys Need to Know about CRPS with Dr. Jeffrey Summers
In this podcast, we hear a conversation from our live event with Dr. Jeffrey Summers, a pain management physician, regarding complex regional pain syndrome (CRPS). Dr. Summers discusses the making the diagnosis of complex regional pain syndrome under the AMA Guides and the Budapest criteria and the differences in those methods. He discusses his thoughts on how some physicians have over-diagnosed the condition and gives some useful ideas in how to verify or rule out the diagnosis. Listen as Jennifer White, Shane Dawson, and Steve Armstrong interview Dr. Summers with questions posed to him by our live audience.
To learn more about DRI and the Workers' Compensation Committee visit www.DRI.org.
#DRILawyer
#DRICommunity
In this podcast, we hear a conversation from our live event with Dr. Jeffrey Summers, a pain management physician, regarding complex regional pain syndrome (CRPS). Dr. Summers discusses the making the diagnosis of complex regional pain syndrome under the AMA Guides and the Budapest criteria and the differences in those methods. He discusses his thoughts on how some physicians have over-diagnosed the condition and gives some useful ideas in how to verify or rule out the diagnosis. Listen as Jennifer White, Shane Dawson, and Steve Armstrong interview Dr. Summers with questions posed to him by our live audience.
To learn more about DRI and the Workers' Compensation Committee visit www.DRI.org.
#DRILawyer
#DRICommunity
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:18):
Welcome everyone to this live edition of comp Conversations. My
name is Ryan Hathcock. I am the chair of DRIs
Workers Compensation Committee. Tony Tamaso, who may or may not
be logged in yet, is our vice chair, and our
committee is excited to be putting this on today. Our
committee's podcast, which is titled comp Conversations, has a number
(00:41):
of previous episodes that discuss relevant topics related to workers compensation,
and I encourage everyone that is present here today to
take a listen to those. In addition, if any of
our attendees have interest in getting involved with DRI or
our amazing committee, please shoot me a direct chat, a
LinkedIn message, or or an email and I'll make sure
(01:01):
to try to get you connected our podcast team, who
will also be our moderators today, including Steve Armstrong, Jennifer White,
and Shane Dawson. We believe the conversation today with doctor
Summers will be enlightening and a lot of the issues
we have all likely seen with respect to a CRPS diagnosis.
Doctor Summers has agreed to answer any questions our attendeyes
(01:23):
might have, so please enter those in the chat as
they come about in your head, and our moderators will
make sure to pull the questions and ask those of
doctor Sommers at the end of the conversation. So with that,
let me go ahead and introduce our speaker, Doctor Jeffrey Summers.
Doctor Summers is a nationally recognized leader in pain management
and spine intervention. He graduated sumacumlaude from Ole, miss before
(01:46):
earning his medical degree at the University of Mississippi and
completing his residency at Brooke Army Medical Center. He went
on to advance fellowships and pain management both in San
Antonio and in England, and later founded the Pain Manager
Fellowship at UMMC. Since two thousand and nine, he has
practiced at a multi specialty spine and pain center while
(02:08):
also serving as past president of the International Pain and
Spine Intervention Society. Doctor Summers is board certified in both
anesthesiology and pain management and continues to shape the field
through his leadership and clinical expertise. Thank you for being
here with us today, doctor Summers, and Steve, I will
pass the presentation off to you.
Speaker 2 (02:28):
Thank you Ryan, Thank you Ryan again, Doctor Simmers. Thank
you for being this today.
Speaker 3 (02:33):
Thanks for having us so, Doctor Simmers.
Speaker 2 (02:35):
Let's start at the very beginning, Can you tell us
your thoughts on what is complex regional pain syndrome?
Speaker 3 (02:43):
Well, the key word in that is syndrome, which means
it's not a disease, and as is, a syndrome, has
no therefore no known cause specifically, and diagnosis is not
made with any specific tests because as a syndrome, there
isn't one. So the test we use are basically your
physical examination and your history, because I can't do blood
(03:05):
work or anything like that and confirm the diagnosis. And
in order to meet the threshold to diagnose or actually
you can say suspect the syndrome, you have to have
a requisite number of physical examination findings and requisite threshold
of points within the history that are consistent with the diagnosis. Now,
(03:28):
there are some tests that could be suggestive. One in
particular three phase bone scan. A lot of worthspedic physicians
use that, and I think that's probably the most reliable,
but it's neither specific nor particularly sensitive for CRPS. If
(03:48):
it's not done within the first five or six months.
After that time that it's not as reliable. New MRIs
and X rays and CT scans will also show some findings.
There are no laboratory, I think blood work or anything
like that you can do. And the diagnosis again is
basically that of suspicion. But in order to diagnose any syndrome,
(04:10):
the key requisite criteria is that there can't be anything
else that better explains that condition. And that's not just
limited to the condition overall itself. It's any one of
those given symptoms can be better explained by something else,
you're really not supposed to use them as part of
your diagnostic criteria to make that threshold. And unfortunately, CRPS
(04:36):
almost all of the physical examination and test findings can
be mimicked by disuse alone. And there are a lot
of things that can cause issues that aren't related to CRPS,
but they can give a very similar physical appearance but
without the pain. So that is the difference. That's a
distinguishing thing, is it's a pain syndrome and you must
(04:58):
have continuing pain in order to diagnose it.
Speaker 2 (05:02):
And so doctor, you know, back in the nineties when
I first started practicing law, I think we called it RSD.
Is that the same thing.
Speaker 3 (05:10):
RSD is the same thing as CRPS type one algae
is CRPS type two. The reason they dropped the RSD
because of the words sympathetic. There's no they're saying now
that you can have CRIPS without a component of sympathetic pain.
And I most of the time and the pace that
I saw that had confirmed CRPS, where I felt was
(05:33):
the more classic CRPS. They would get relief with the
sympathetic block. Now that doesn't mean that it would be
enduring relief, but they would get some benefit from it.
But they were providers that complained that there are some
people get no response to sympathetic block, they still otherwise
meet the criteria CRPS. So I think that in order
to be more inclusive in terms of who would be
(05:54):
eligible for that diagnosis, they dropped the sympathetic requirement therefore
changed the name.
Speaker 2 (06:00):
Okay, and you mentioned cause algia. You said that was
a CRPS two. Is that right correct? With the major
nerve injury, that's the distinction. And you know when was
the first time that causagia that the term of the
diagnosis caused algia came about.
Speaker 3 (06:15):
It's after the Civil War where they notice a lot
of hyperjectile and very traumatic injuries that caused severe nerve
nervous system injuries, typically to peripheral nerves and those in
my experience, those cases are far more difficult than the
typical CRIPS, which is probably ninety plus percent of the
(06:36):
diagnosis for CRPS, because if you can't get the underlying
nerve problem taken care of, it's sometimes very difficult to
extinguish the other symptoms and signs that go along with it.
Speaker 2 (06:50):
Okay, and you know what is the current medical opinion
on the different types of you know, typeborn versus type two.
What are the distinguishing features of each?
Speaker 3 (07:00):
Well that it's again one involves a major nerve injury.
That's not to say there aren't any nerve injuries and
CRIPS one, but there are any major nerve injuries. I mean,
anytime you get to burn your hand or something, you're
going to get some nerves or you would even be
able to feel pain, So some nerves are injured. But
CRIPS two implies a major nerve injury or larger peripheral
(07:22):
nerve injury. And ideally you get EMG and nerve conduction testing,
but it's sometimes difficult to perform on somebody that has
true cryps. They just don't tolerate the tests. So when
I see people that have had one, it makes me
suspicious that Sometimes with cryps what you see is disuse
plus a nerve injury, but that's not the same thing
(07:44):
as with a peripheral nerve injury. Sometimes they don't move
it because it's painfulward it's often involves a joint it
was also injured at the time. Sometimes they can't move
it because the injury is devastating enough that there arm
become effectively immobile and they can develop a lot of
the issue signs that are consistent with crypts. So you
(08:05):
try to make that distinction.
Speaker 2 (08:08):
And so for lay people like US attorney's claims representatives
in general, and we'll talk about specifics later, but in general,
what are the best treatment methods for complex regional pain
syndrome one and two?
Speaker 3 (08:21):
Well, two, if you can treat the underlying nerve injury
and correct it, that's ideal. Sometimes that's not possible. When
it's a pinched nerve, for example, you can decompress it.
That'll help, but and then the nerve has to regenerate.
There is no specific treatment unless you do a nerve
graft that would treat a damaged nerve. Now, some providers,
(08:44):
and reasonably so, don't like to operate on somebody with
the active cryps they want to as control as possible.
Sometimes the cause of the crypts is a nerve injury
that you're left with, you know, kind of lesser of
two evils type scenarios. If you want me to give
you a scientifically validated, high level of evidence treatment for cryps,
(09:08):
you can. I'll mute my might because there isn't. Mobility
is the only thing that has really been demonstrated to
show any health, and as patients should be moving, mobilizing
to any extent possible, it's also the best way to
prevent crips after a given injury is mobilization. Everything else
(09:28):
final coart stimulation, sympathetic air blocks, ketamine therapy, numerous drug therapies,
all of that, cognitive behavior. All of that's got some
level of evidence to some extent, but in most cases
it's low quality or nonexistent or no quality. But there
are no high level studies that I can give you
(09:50):
for any of those other previous interventions it says that
it's formally successful or highness successful.
Speaker 4 (09:57):
So doctor, let me ask you. So, I mean, we've
heard of different diagnostic criteria, and you mentioned that some
of these can be mimicked perhaps, But with these different
diagnostic criteria, when you're going about making a diagnosis, what
(10:17):
what do you do to make that diagnosis or to
rule it out?
Speaker 3 (10:22):
Well, I pretty much go through the checklist, but I
like to look at the history too, and because sometimes
you suspect that something else in the history might be
causing the problem. Again, a vascular injury by far the
most common, and a lot of homes are not recognized.
People come in with.
Speaker 5 (10:38):
A swollen red foot and they're automatically assuming it's crips
and it's arterial insufficiency, or it's blue foot, it's venus insufficiency,
it's a pale foot and its arterial I mean, there's
you have to rule out a.
Speaker 3 (10:53):
Vascular injury now. If there's no history of that, that
makes that part easy, although with disuse you can then
get you know, a lot of those symptoms back. What
I have to do is, you know, I look at
all the signs of symptoms because unless you have a
certain requisite number of them, it doesn't matter symptoms are historical.
(11:15):
I want to know what their symptoms are at the time.
If I hear it's not that I'm being skeptical or cynical.
But if they tell me it's terribly swollen at home,
it's terribly discolored at home, it's terribly this at home,
and none of that's in my office, it's not very
useful for me because I need that to be present
on physical examination at the time of the exam in
(11:35):
order to make that diagnosis. And you can go back
through other people's records, but when the signs and symptoms
of CRPS disappear, the diagnosis can't be made anymore. Now
there's pushback on that because a lot of people made
a career treating crypts, and so they like to call
that now CRPS nos not otherwise specified. In other words,
(11:59):
they still have the pain, which is entirely subjective, but
they don't meet the diagnostic career the criteria otherwise. And
again I'm not trying to be cynical about that. Maybe
there's some underlying cause of the pain that wasn't diagnosed,
or maybe CRPS causes some kind of changes you can't measure,
you can't test, you can't prove and look normal. But
(12:23):
that's completely speculative because it's a syndrome. There is no
test at all that you've been used to rule in
or out that condition. But when they're trying to I mean,
sometimes you tell to put on a gown and they've
got to. This isn't common, but it happens they've got
something tied around their upper figh and that's very frustrating.
(12:44):
I make them take their shoes and socks off, or
their shirt off and get it so that you can
make sure there's no ligature. And sometimes they'll take it
off right before they come in the room. This hadn't
happened to me, but an orthopedic friend of mine said,
you know they had a ligature. You could tell it
just untied something, and that's gonna make it bright red
(13:05):
when you come in there, just like it would if
you squeeze all the blood out of your hand and
let it go. Your body's gonna try to make catch up.
And I can't really say somebody is faking hypersensitivity because
they get to experience that I don't. But it shouldn't
change dramatically if it's severe. When they're distracted and sometimes
you're looking at another part. But while you say, well,
(13:26):
I'm gonna try to move your knee. Your knee doesn't hurt,
does it? But so I pull up gently. I act
like I'm a gently pull up on their leg, but
I give it a pretty good squeeze, a squeeze that
was causing terrific pain before when I did it on
the so called injured part. And if that's an inconsistency,
that to me again, you've got to have certain signs.
(13:47):
But hyper sensitivity is considered a sign, not a symptom.
So if in a tremor is considered a sign, not
a symptom. But you can manufacture a tremor. You know
it's just not that hard and that, but you know
it's it's harder if you're But if that shouldn't go
away when you're distracted, it's not an intention trip. So
(14:08):
there in weakness is you have to be able to
tell the difference between feigned weakness or give way weakness
or breakaway weakness, and weakness that is actually phusiologic. Sometimes
that part is difficult to test in somebody with true
crips because they're not going to let you pull hard
on their fingers that are painful. That part's difficult, But
that's not the same thing as physiologic weakness and give
(14:31):
way weakness asssiately with pain in my opinion, is not
It's not physiological weakness. It's a it's a reflex response,
similar to if you grabbed a frying pan that was
on a burner and you didn't know it was hot
and dropped it, and you didn't drop it because you're weak.
You drop it because your body told you to not
do that anymore. Some people say I'll step and my
(14:54):
knee gives out, well, and your body senses that that's
going to be painful. It might make your knee buckle,
and that doesn't mean they're faking that. That is a
true physiologic response, but it also has to distinguish from
true physiological weaknesses, which motor injury. You could do that
with a nerve conduction test are an EMG, but it's
(15:16):
not easy to get some of the true crypts to
sit there and let you stick meals in them and
start electrocuting the painful part of the extremity.
Speaker 4 (15:25):
The doctor, what I'm hearing, I mean, what I'm hearing
from you sounds like this is a much more involved
process to properly evaluate somebody and make this diagnosis where
you're looking both at history, you're looking at them in
the exam room, you know, taking time, whether it's the
distraction and things like that, to make sure the symptoms
(15:48):
they're presenting are consistent. And yet sometimes I think those
of us that practice in that area, we see reports
from doctors who are basically just saying, I can eyeball this.
And certainly I've seen folks myself where maybe one leg
looks extremely withered, it's a different color, it's gray, the
(16:10):
skin looks plastic. There's things that look like there's something
going on there. But how likely is it for a
practitioner just to be able to see somebody come into
their office present a body part like that and they're
able to make a proper diagnosis of CRIPS just on
that alone.
Speaker 3 (16:31):
Well, it's easy if they come in there with a hot, swollen, sweaty,
hyper emic hair growth and nails splitting. But I never
see that. I mean, ever, there was a time back
before people really understood the movement disorder part of it,
that the people came in exactly like that, and it
(16:53):
was almost always, in my experience, it started with a
hot and then it just kind of eventually transitioned to
a cold and a trophy kind of the withered hand look.
But it can come in like that. It came in hot,
swollen and sweating, and the uh with all these other
features it would go along with it, and the hypersensivating
like air conditioning blowing on it, and you could tell
(17:14):
with a glance. But even that doesn't diagnose crips. You
have to have nothing else that can it can be.
That's that's the toughest part. You got to make sure
that you're not Everyone hasn't gone in there because it
looks so classic and made a presumptive diagnosis of crypts
without considering anything else it could possibly be. And there
aren't a zillion things on a hot, sweating, swollen hand
(17:37):
like that, but there are, you know, cellulitis would present
like that. But that's not hard to differentiate. You just
have to have considered it. It's not easy to do
sometimes when but if they come in here with a
normal looking hand, the only way they could diagnose it
at that point everything looks normal are with those signs
(17:59):
such as tremor or motor dysfunction or extreme hypersensitivity, all
of which, in my opinion, are subjective. Weakness is definitely
subjective when it's related to paint avoidance.
Speaker 4 (18:15):
So doctor you mentioned about, they're not being like a
single test that we can use to confirm it. There's
not a lab test that we can do that's going
to be definitive. What about on the other side, are
there is there testing you can do to rule out crips.
Speaker 3 (18:36):
If you do it early enough. A bone scan triple
fased bone scan is diagnostic enough that it's considered very,
very sensitive and specific in that regard. If you wait
forever in the leg becomes a trophy, there's too many
things that could mimic. But early on that's a pretty
specific test. I would say, I see almost none that
(18:58):
are truly you know, I'll see one. Sometimes it'll come
in they'll have that late phase pulling, but it's in
the knee and the pains all in the ankle, so
that doesn't really count. That's probably a good one. It's
one you'll see real Now I'm not exactly sure why
if I had anybody coming in with early phase crips,
(19:19):
I would get it unless there was a contraindication, which
you know it's it would be extremely extremely rare allergic response.
Another good test would be a sympathetic block because it's
both diagnostic and therapeutic. It's always nice to have something
that a test you do that actually helps their pain
as well. Again, though they have to be I don't
(19:40):
use a bunch of blocks in lieu of other treatment.
I only do a block to allow them to participate
more aggressively in physical therapy, because at the end of
the day, if you don't get a moving it, you're
never going to beat that condition. Everything else starts to
fall into categories where you would use generically treating neuropathic pains,
(20:02):
which is the gab of anoise like pre gabbling and
gabba pent and different anti depressants, Deloxea team being the
one that's probably the one that's best tolerated, that works
best for neurotath pathic type pain. Now, the tricyclics and
all those are very useful for neuropathic payment. The side
(20:23):
effects and drug interactions are so high that for Ellaville,
for example, Amma tripoline that I remember reading has studied
the average weight game was something on the order of
thirty pounds. I mean, who's going to put up with that?
And so you just have to pick ones that are
tolerated by the patient have the minimum number of side effects.
I'm not a big ketamine fan I'm not sold on that.
(20:46):
Just saw Cocher and you yesterday that came out on
it said that the evidence was very weak and that
especially for the IV and non existent for other forms,
and so I'm not sold on that has a lot
ofential side effects. It's a usable drug for one thing,
but in the control of the environment less likely. I
just not convinced, and no one really has a good
(21:08):
explanation of why that would work. But anything to get
them to mobilize. I mean, we have anesthetized an extremity
before to get it mobilized, so that because once you
get it moving sometimes it makes a big difference. But
it's now I feel your pain. I wish I could
draw the blood and come back and say you're luck
(21:29):
it's not crips. But it just doesn't work like that.
We treat the symptoms of crips. We don't know the cause,
so we can't treat that. We treat the symptoms.
Speaker 6 (21:40):
Doctor, we wanted to talk a little bit about the
Budapest versus the AMA guides. What are the differences in
diagnosing the conditions per the fifth edition or the Sex Edition.
A lot of us used the fifth and six and
the Budapest criteria.
Speaker 3 (21:55):
Well that they all have the same diagnostic criteria. Now,
there was a time when the difference between the fifth
AMA and the sixth AMA is the fifth AMA was
not well received by some of the more strident CRYPTS
proponents in the community. They thought it was too difficult.
We had to have too many of the signs I
(22:15):
went through before to be able to make the diagnosis.
And they thought that was unfair to the patient that
a lot of people were being denied medical care, necessary
medical care by the insurance companies because they didn't meet
the criteria they were used in AMA. So the AMA
Guideline six just dropped that. I want to say. They
(22:36):
went from eight objective findings down to four three even
and all of those, unfortunately under the AMA can be
ones that can be either feigned or subjective. Because I
still hypersensitivity aladinia is not objective. It's not a sign
(22:58):
that is a symptom and a tremor, but you can
make the diagnosis. But they all use the same theso motor,
pseudo motor and motor a trophy background findings which are
just in a list and anyone can look at them.
You just have to meet a certain number of them
in the certain number of categories at the time of
the diagnosis, at time of the examination to make that diagnosis.
(23:22):
But there's not a lot of difference. That AMA decided
instead of trying to say they have it or not,
because you could never prove the habit. You can have
every single sign and symptom and you cannot prove that
that's cryps. You just can suspect it because you can't
think of anything else, but you can make the diagnosis
based on that suspicion. But the AMA felt like there's
(23:44):
a difference between you know, bronchitis and double lung pneumonia.
You know, there's a big difference in the degree of infection,
and they feel like the CRYPTS should be treated the
same way, even though it's not a disease, that there
should be very very mild crips with no impairment and
severe crips with significant impairments. So they decided to realizing
(24:10):
that they have being criticized for telling too many people
that might have been on the borderline of CRYPTS, you
don't have it, you don't meet the criteria, they decide
to say, well, okay, you don't. You may meet the criteria,
but you're not severe enough that somebody would recommend ketyminte therapy,
for example, or a spinal cord stimulator. Impairment's not there
(24:32):
in order to recommend something like that now. Doesn't stop
a provider from doing it anyway. I think it's enough
and the patient agrees with me. There's not a whole
lot you could do about something like that, except for
to say, well, I would not recommend for somebody that's
functional and their only problem is some degree of pain,
but it's not enough to limit it. Functionally, they can sit, stand,
(24:54):
walk and ride without limitation. It just hurts some time
to do it. Those people don't need spinal cord stimulators.
It won't benefit from it in general. So I just
that's the difference in those At the end of the day,
they're all still about the sin in terms of what
you can do to diagnose it.
Speaker 6 (25:15):
Do you feel like the advent of the Budapest criteria
has made any impact on their frequency of CRPS diagnoses?
Speaker 3 (25:23):
Yes, in my experience, I just that you can make
it now with no objective and scant subjective findings. And
again it back in the nineties when nobody mobilized anybody
late nineties, early two thousands. You know, if somebody came
spraying their ankle, they put them in a cast and
if it kept on hurting, it kept the cast on.
(25:45):
And when it kept on hurting, because now they're developing CRPS,
they kept the cast on. Then they finally the patient
said they're swelling so bad. They say, you've got to
take this thing off. It's killing me. And then they
send them to me. And it's this classic awful look
in condition. And once you rule out of infection, there's
just not a whole lot else that there's vascular in
(26:07):
sufficiency because of a too tight cash for too long.
There's not a whole lot else that would mimic that
that you would have to look at. But they made it,
in my opinion, very easy to meet the minimum criteria.
Diagnosis again, I say diagnosis in kind of air quotes,
because again you're just confirming a suspicion. You can make
(26:27):
the diagnosis, but you're really never sure because you can't
prove it or way or another.
Speaker 6 (26:34):
You kind of talked about the history of why they
switched over to this criteria. Do you think there could
be an argument that it was basically self serving to
benefit pay management doctors to make it easier.
Speaker 3 (26:47):
Well, you can make the argument. It's a little cynical,
but you could make it. Some people are just some
physicians are. They look on there and they say that
by making this diagnosis and treating it all out, you're
starting to lose your risk benefit ratio. In other words,
(27:08):
you know, it's the first do no harm, and if
you over treat somebody with a diagnosis it's suspected in
the first place, or that they're not that disabled from it,
you run the risk of some of these treatments like
small where stimulators have the fourth highest incidents of serious
adverse events and over all two thousand, five hundred medically
(27:30):
approved devices that is not a benign device, they have
an extremely high rate and serious adverse events. So when
you put one in somebody, you've got to make sure
that you're not causing more problems than you're helping. And
also there have been studies that state for various diagnosis
(27:50):
it's final courts stimulators. Don't cut back on the amount
of medication, don't cut back on the number of primary
care business, don't cut back on the number of hospitalizations,
don't cut back on the number of injections and don't
cut back on the number of er visits. And so
the question is, what are they then doing. What's the
upside to that except for saving costs for MRIs because
(28:13):
a lot of times now you can't have an MRI
with spinal stil area. Yes, it's self serving to some extent,
but some people say, well, if there's any chance you
can help them, why would you not make it more
easy to make that diagnosis? And I think that if
you look at it, in my opinion, logically, if you're
(28:37):
going to use the same treatment for neuropathic pain, you
could still make a diagnosis of neuropathic pain without without
making a diagnosis of CRIPS. And I don't understand the
schism there as well as I probably should. I think
if you made the diagnostic criteria more difficult, like I
(28:57):
won't see, more difficult, more selective like AMA five, that
it would be more useful because I can give somebody
every single drug I can give them for CRIPS and
still be within the standard of care without a diagnosis
of CRIPS. If I make a diagnosis of suspective neuropathic pain,
(29:18):
the CRIPS has this aura, which I unfortunately think there's
more subjective than I would like, and know it's got
a flare to it. If you've got crips, people almost
act like it's sepsis and you better get in there
and do something soon they're going to lose them and
you end up with expensive care that unfortunately there's not
(29:39):
a lot of evidence for and if you look at
the insurance data on it doesn't seem to be very effective.
That touch your service.
Speaker 2 (29:49):
How long is the typical life span of treatment for crips?
Speaker 3 (29:54):
You know, I couldn't answer that. There are people tell you,
I saw somebody's work the other days that there is
no cure for cryps, which is interesting since we don't
even know what causes it, and by definition as a syndrome,
wants as signs that the syndrome are gone. You don't
have it, so how that's not a cure. But his
opinion was that there are only CRYPTS survivors that no
(30:17):
one's ever cured from it. It's like cancer. At any minute,
it could come back as bad as ever, and so
you're just you're living with it. You have to deal
with it. And they considered a lifelong condition even when
there's no impairment or even symptoms associated with which I
don't agree, but I would say, if you can prevent
it in the first place, which is the best way
(30:37):
to do it, or make it a mild case. In
CRYPTS one where there's no specific or injury, I say,
if he diagnoses early, you know, months at the most.
Now there's a nerve injury that makes it much more difficult.
You've got a radial nerve injury that's led to CRYPTS two.
(30:59):
Sometimes difficult because the patients debate ability to mobilize it
or willingness to mobilize it. Is sometimes caused by the
direct pain from the nerve injury itself, and that gets
you know, that makes it far more difficult to use
the most effective treatment we have, which is to mobilize.
Speaker 2 (31:18):
And is there some consensus on what causes CRYPTS to
develop in some people and not others. They have the
same injury, but you know, some get it and some don't.
Speaker 3 (31:28):
I think that immobilization by far as the key. I
don't think anybody is a proponent that stating that you've
got to mobilize extremity and all other forms of treatment
or allow you to mobilize it better because I think
your body tends to heal it. Whatever problem it is.
You just don't see it nearly as much. I can't
(31:51):
think of a single case that I saw somebody that
didn't come in with an immobilized extremity, and ninety percent
time in the history that was part of the processes immobilization.
Now there is some immobilization. Is it's more difficult to
(32:11):
explain because why, for example, should the workers population have
four hundred to eight hundred percent higher likelihood of developing
CRPS than first injuries that occur outside of the workforce, right,
And that's you know, that's something more difficult. But outside
(32:33):
of the workforce most people, Again it sounds cynical, but
it's also an observed phenomenon, and that is that you know,
no one's going to pay me not to work. And
if I can't work because my arm hurts and I
can't move it, I can get paid for not moving
(32:53):
or I can get a settlement afterwards. It's it's frustrating,
it's a liability issue. A lot of the tongue of
personal injury and workers calm tend to have a significantly
greater not four to eight percent four to eight times
the incidents of injuries that otherwise don't occur in that environment.
Speaker 2 (33:17):
And doctor, have you seen treatment recommendations that go too far,
either in the people who've been injured for with work
injuries or other injuries, or there might be a claim
associated with it.
Speaker 3 (33:30):
Yes, again, it's a matter of opinion. No one's going
to propost something they think doesn't go too far. But
if if somebody doesn't, First of all, if there's any
suspicion of a manufactured exam where they don't meet the
strict criteria, I just don't see any point of going
into highly invasive treatments such as sympathectomies where they go
(33:52):
on there cutout and sympathetic nerves, or spinal cord stimulation
or dorsal root gangling stimulation or peripheral nerve stimulation that
have poor quality evidence but a high incidence of serious
adverse events, that goes to kedymine therapy. Anything that has
a high ins in so side effects but a low
(34:13):
incidence of benefit. I think that's going too far. You know. Again,
some people you can tell they're just miserable and suffering
with it. But you know, I would allow anything all
those if it would allow them to get their movement
back and therefore treat the ender own condition. But unfortunately
(34:35):
you don't see that a lot. I'm not I think,
except for sympathetic blocks, which shouldn't be infinite because you
can't get better forever. At some point it not diminish
to the point where it's irrelevant simply the blocks and
the easy way out if they've effected. But you should
know after the first one or two if they're going
to work. I wish you had a better answer.
Speaker 4 (34:59):
In other words, doctor in Ohio, I know we're generally
seeing an uptick in request for spinal cord stimulators in
your experience. Are you seeing more and more requests recently
for that as a treatment?
Speaker 3 (35:17):
Absolutely, and I'd like to say it's because the technology
keeps advancing and getting better. But there's a great article
and I want to say the British Medical General once
spinal cord stimulators in general, in which they think they
questioned the effectiveness of them for any diagnosis, but crips
among the highest and they they conclusion of this at
(35:42):
the end of this article was that an editorial opinion
was that there's no indication for spinal cord stimulation outside
of a clinical trial to prove once and for all
of it works are not and they think that there's
extremely high industry influence in these studies that are dominated
(36:05):
by industry. I think eighty something percent of all larger studies,
based on how many patients went in it were all
funded by industry. I think it's higher than that ask
Excember ninety percent, and it would be an expensive thing
to do with that industry support. But when I was
a president of International Pain and Spine Society, we couldn't
(36:28):
wait for that high frequency stimulator to come out because
it was you can't feel it. You know, most of
the time when you're doing spintal wor simulation, the patient
has to feel the paraceesus cover the area of painter.
It doesn't electricity gover the painter, it's not going to
be effective. Well, this, you couldn't feel it. It's put
it in works, that's what they claimed, and we couldn't
(36:49):
wait for them to We ran up to the company
and say, hey, would you give us some of the stuff.
We can perform a placebo trial. Now you can't feel it.
Oh no, you'd have to recharge it and this and that.
I said, you can. You could just tell them that's
part of the protocol and you could find out if
they weren't recharging thrown around the study. You know that
I think would be very effective placebo control. The guy absolutely,
(37:12):
I won't give you. The company refused to help. He said,
place ebo has destroyed more great products in my career
than anything else. Just so you know, we don't need
your permission, right, We can just do the same thing
on our own. And there have been placebo controlled trials
and guess what the ones that weren't by industry that
didn't work, but a new technology would come out, So well,
(37:36):
that's that one. We have a new one now and
they get these approval FDA approval through this. I want
to say it's five ten K something like that loop
loophole that allows them to use the previous stimulator technology
to just put a new twist on a new frequency,
a new mechanism for sensing it, et cetera. They allow
(37:58):
them to use that and then them out with the
new device, have their own couple of studies come out,
and the editorial board said they're skating ahead of the
ice as it's cracking behind them because the evidential ice
is just not there.
Speaker 4 (38:13):
So doctor, with the whatever the current technology that we
have for the spinal cord stimulators, how long does this
as a as a piece of technology, you know, how
long does it last if it's if it's taken care
of properly, if it's serviced in the way it may
need to be.
Speaker 3 (38:32):
Do they have to be you know, replaced?
Speaker 4 (38:36):
You know, once you get that installed, how long does
the patient get the benefit of it.
Speaker 3 (38:43):
Well, you might have to replace the battery, but there's
some that get charged through the skin so that you know, eventually,
even rechargeable batteries go bad, but that's not in my experience.
Ninety of them are revised because the lead migrates, and
the lead migration problem is enormous. It's I want to
(39:05):
say that they all migrate, whether they do migrate to
an area that they're not effective or not. And how
that's supposed to happen in one that there's no way
you can feel the parriceesion anyway, I've never understood why
if it doesn't mean when they put those in, you
put it in to a certain spot that for some
(39:26):
reason was preordained. They said, well, this is what we
found was the most effective. So you put it in
this specific area for all the types of pain and
if somehow supposed to work. I've just never quite understood
the parriceesion with systems, you know, the high frequency ones,
(39:46):
how you could ever test that, But lead migration leads
breaking technical problems with it. Those are all the number
one reason you're gonna have to go back in and
maintain that the costs come off that not so much
as replacing the system. Now there's a new replacing the
(40:08):
system push that I see, and that is that you're
replacing the system because we've got a better one. Now
that's ten year old technology, that's five year old, that's
two year old technology, depending on what's coming out. And
it's so called evidence behind that. So they're upgrading all
the time. And you know, it's an extremely lucrative procedure
(40:30):
for the physician. I mean, I mean we put in
in this center here there are what eight neurosurgeons, and
all those patients come down and we put in I
don't know, one a month maybe something like that, and
there's a guy down the street that puts in we'll
do twenty trials in a day, and that cannot be that.
(40:55):
You can't resolve that based on anything whatsoever to do
with the practice of medicine, per se, And I'll just
leave it there.
Speaker 4 (41:05):
Doctor, I wanted to ask you one last question. A
pivots a little bit, but in your experience, what do
you see with the mental component for the patient in
terms of I guess both we're talking about the efficacy
of a spinal cord stimulator, so you know, with regard
to that specifically, but also more generally with regard to
(41:29):
just the diagnosis and treatment outcomes, even if they're not
using a spinal cord stimulator.
Speaker 3 (41:36):
Well, there's there have been several studies that show that
their level of depression and anxiety is high, probably higher
than most other chronic pain syndromes. Now, that's not to
imply or at least the articles did not say that
that was a pre existing coorbidity and that people with
anxiety and depression are more likely to get CRIPS in
(41:58):
somebody that's not. That's a different that's a difficult one
mistake because they showed that the incidence of a significant
psychiatric diagnosis in children pediatric cases they get CRIPS is
extremely hard and they don't know, and it it seems
to have a significant relationship to what type of household
(42:20):
we're brought up in. Now they're saying, well, maybe that
type of household is less compassionate, so they don't get
you a doctor as quickly at all. But they've never
shown that. They just showed this. It hasn't been explored
well enough. But there's extremely high incidence of crypts being
says it with psycheoatric problems in children. And you know,
(42:45):
it's tough to really know, but that better be part
of a treatment, cognitive behavioral therapy, especially if they refuse
to move it. That's our biggest We get psychomolved early
if they refuse to move They move it first of all,
all they seem to do well, doesn't matter if they
don't move it, though, we get psychedball early because they
have to overcome that. They're going to be successfully treated.
(43:10):
But to at your question, can it cause depression etc.
That has to be treated for life? I mean it
could if they don't get better.
Speaker 6 (43:20):
Doctor. Uh. Just kind of bringing it back. Since we
are talking to a lot of defense attorneys here, I
think what should we as defense attorneys be looking for
when we are handling these cases as far as looking
at the diagnoses or impeaching those plaintiff experts.
Speaker 3 (43:37):
Well, the thing I see the most is somebody just
doesn't get better, and so the orthopedic is somebody was
saying earlier, just decides, I don't know, it's swollen all
maybe it's crips and sends it off to a cryps
expert who immediately calls it cribs. But there's been no
other work, extraneous work up to prove it's not something else,
(44:01):
and that you have to do that. That's the way
you're peaches is what other signs and symptoms, what other
conditions could be consistent with that? The most likely, the
most common in my experience, has been vascular. But disuse
alone could do it, and it would be difficult. It's
a difficult question to turn on somebody is prove it's
(44:21):
not disues. If I'm a physician and they come in
with these signs and symptoms, prove it's not disuse, and
the only thing that would be different from disuses the
degree of pain is if you get let your arm
get stiffened, et cetera. But it shouldn't mean to the
point where just light touch causes pain, but then that
makes a diagnosis subjective at that point. So you know,
(44:45):
what I need to see when they come and to
see me is if they've been worked up, has it
been a proper work up for anything else could be
causing this? And the unfortunate reality is that I don't know.
I'd say that even back before it became such a
huge legal thing, I would say that eighty percent involves
(45:07):
some sort of secondary game. And I hate call workers
comp secondary game because you know, an injured worker deserves
compensation and care, but it's still considered secondary game at
the end of the day. You know, it's just tough
to get around that. Why would they have And it's
(45:30):
not because what I would give lectures to a different
you know, to a mixed audience. I'll call it planus
and lawyers mixed audience plants in defense the defense people,
of course, anything you said that they're all faking it,
they would love that. And I don't believe that they're
all faking it. Some of them are exaggerating, though, and
(45:52):
if you exaggerate something enough, you'll end up with more
treatment than you need, and probably treatment that you shouldn't have.
But on the other hand, I was accused of saying, well,
you're just blaming it on them, because I said, well,
you know, well, why do workers, for example, I have
four to eight increase. Well, it's because they're more likely
(46:16):
to get injured. And that's the trap. If they say that,
you goes away immediately because that they're saying that it's
a blue collar. It's a blue collar you know. The
accountants don't get hurt like somebody that works in a
loading dock, etc. But they're almost unheard of in sports injuries,
(46:37):
almost unheard of. I had to look it up the
NFL and I found two cases crips. One of which
wasn't was in an NFL player when he was sixteen
and woke up and couldn't move his legs, and that
sounds incredibly suspicious to me. There was no injury or
anything align with it. He's fine now and he makes
ten million plus a year, but that was part of
something in his history. The other one was the guy
(46:59):
that claimed that the doctor botched his knee surgery, made
him try to rehab around it when it wasn't really
completely done, and he got crips, and he also got
forty three point five million dollars, so you know there
was a secondary gain issue that half of the NFL
players out there. Then it came down with the potential
(47:21):
secondary gain issues. So but I was in the army,
I never saw it. Now, I didn't see necessarily. I
saw some people with injuries. It might have been a
cause algae at some point, but they were fresh enough
that you can't really tell them and everything's messed up
when somebody's got half their arm blown off, But you
never saw it. And the guys that were in basic,
(47:43):
they didn't end up with crips. You don't see it
in professional athletes. You know, I don't care how bad
your job is. It's not like getting out there and
having a three hundred and twenty five pound guy charge
at you fifty or sixty times in one afternoon. You
just know when works like that. But they don't get crips,
(48:03):
And so maybe there maybe I'm a little biased in
that regard, but I'm waiting for someone else to explain
it to me because it's not specifically just that they
get more trauma.
Speaker 6 (48:15):
Well, these are great, These have been great tips, and
thank you for your time on this. I think we
have a little bit of time for questions. We already
have a few. If anyone has any more, please feel
free to send them in the chat. And Doctor, I
wanted to ask you one from Jeff Low saying, from
my experience with RPS claims the diagnosis is the result
(48:39):
of comprehensive battery rule out of alternative causes, which we
did talk about. What's the optimum time frame in which
to accomplish.
Speaker 3 (48:46):
That ruling out everything else? Yes, if everything is coming
back normally, it shouldn't take that long. And you've got
to set up vascular studies. If you suspect a bacscular
can but anytime their color changes one way or another
and you have no other diagnosis for it, the vascular
studies should be something reasonably high on the list if
(49:10):
they're not too painful. EMG and nerve conduction stays months
at the longest. If you wait longer than that, your
outcomes are going to be worse, even if you think
you will. You know it is a legitimate case of CHRIS.
Doesn't mean you can't treat it in the meantime. But
if you're trying to do all these other rule out things,
some of those can be done very quickly. Somebody comes
(49:31):
in and they have no color changes, no temperture differences.
I pretty much ruled out a vascular cause. Those people
are no edeema. I mean a lot of them. I'd
say the majority, significant majority are ruled out the day
I walk in their examiner because they don't meet the criteria.
You know, somebody with feigned weakness and claims they're hypercented
(49:54):
it will have no objective findings. Well, the only objective
finding is that their arm is as small words or
comforts in the other because they don't ever use it,
or they have some restriction and range of motion because
they don't ever use it. Those aren't That's not enough
to make the diagnosis. But if they do have a big, fat,
swollen or cold or hot extremity, you need to jump
(50:17):
on that because the things that are other than crypts
that would cause that are something that probably couldn't wait
forever before your outcomes are going to be worse.
Speaker 4 (50:28):
Doctor, We've got a question here from Stuart King. He's
asking is a stella ganglion or lumbar sympathetic block diagnostic
or unrelated to the diagnosis.
Speaker 3 (50:41):
Well, it can be diagnostic or supported diagnosis. Again, there's
nothing diagnostic. There's no diagnostic test for crypts, but it
can support a diagnosis if they get an improvement not
only in their symptoms of pain, but in their signs.
Other words, they come back in the next visit and
there's less swell. The temperatures are improving a lot of objectifines. Now,
(51:03):
sometimes I think that those improvements are not directly necessarily
from the block itself, but their secondary because the block
improves the pain. And then you've already encouraged them before
they even get out of the recovery room from the
block to try to keep that mobilizing. Even if all
you can do is barely open and close your hand,
just don't ever stop doing that, and then as you
can get more and more movement, you try to encourage
(51:26):
them to do it. Yes, they but that's the reason
they dropped reflect sympathetic history because too many people didn't
fall into that to that category of a sympathetic block.
You can still have crips without a sympathetic component of pain,
but they are considered but diagnostic and therapeutic potentially for
(51:48):
those patients who do have that sympathetic component.
Speaker 6 (51:54):
Doctor you're's one from Tony Tomaso talking about the final
courts emulators. And you might have gone over some of this,
but how how long in your experience do you see
these ses is helping a crypt's patient essence? It is
a long term treatment plan that you find viable and
useful or not.
Speaker 3 (52:16):
I can just tell you that. Again, I'm a very
limited snapshot of that, but I can tell you from
insurance data there there's a very good study out not
long ago. Any CRYPTS is part of the included diagnoses.
They're finding that there's no decrease in utilization of care,
and statistically, somewhere around forty percent of people lose benefit
(52:40):
within the first year. I realize you're not on It
depends some of the some people use it. I see
people come in with spinal courts stimulators and I said,
where do you feel the buzzing right now? I don't
feel it turned on? How often you turn it on
a couple of times a month? I mean, that's I
don't even know why that's in there. It's not worth
(53:01):
the risk of having it. You're going to turn on
a couple of times a month. I just don't understand
why you would want that. And I think some of
that is, you know, and again I don't. I know,
like I'm trying to appune everybody that has crips and
I'm not. But I do see a significant psychological component
(53:24):
to it in people that it's a crutch. It's like
people that come in and they're using their cane in
the wrong hand. You're like, you don't really even need that,
but you want that. And that's not the vast majority
by any means, but that's a subset of it. When
you get questions like that, it's unfortunately my mind tends
(53:45):
to drift in that direction because it's otherwise very difficult
to explain it.
Speaker 4 (53:52):
Doctor Tony had a follow up to that and this.
I know we're coming up on the end of the
hour and time, but let me ask this because I
think this might be a good place to end. You
mentioned in terms of treatment, I mean repeatedly about how
movement is the key. Movement is important. So in your experience,
(54:12):
what is the best, the best treatment, the best way
that you're getting these patients to start moving and improve
their condition.
Speaker 3 (54:21):
Telling her if you don't, it could turn into the
withered hand and you'll have it forever. That the best
way to stop this is you said you can come
in and get an injection that will last for you know,
physiologic effects overnight. You're lucky. You come in and take
a bunch of medicine that mask your symptoms because it's
not treating underline cause. Or you can start moving it.
(54:44):
You can go to therapy. You can go every day
for an hour. That's one hour in twenty four in
one day, your whole week's worth of therapy. Isn't the
time before you eate breakfast and lunch. And if you
want to beat this, nobody can do more for it
than you can. And I'll do what I have to
do to make your movement less painful, if it means
(55:04):
it's a topical anesthetic, if it means it's a medication.
But if you want to win, you have to set
a goal for yourself. And if if your goal is
just to move it this fart, try to get it
a little further, Try just a little bit of a goal.
And if it starts to get sorted back off a
little bit, that doesn't mean not move it. Do whatever
you can within your movement. Because I've not seen anybody
(55:25):
ever improve that didn't increase the mobility. I've seen plenty
of people deteriorate. That didn't. Doctor, We're about the end
of this.
Speaker 2 (55:34):
We want to thank you again for being with us today,
for everything you've done for us, for all the time
you've spent. And if anybody here wants to reach out
to you, what's the best.
Speaker 3 (55:44):
Way to reach out to you? Through my email Jeff
Summers ninety nine a Gmail sounds good, great, and thank you,
doctor Summers. We appreciate you being here, thank.
Speaker 6 (55:55):
Inviting, thank you, thank you everyone at about
Speaker 5 (56:06):
Singing a bo
Welcome everyone to this live edition of comp Conversations. My
name is Ryan Hathcock. I am the chair of DRIs
Workers Compensation Committee. Tony Tamaso, who may or may not
be logged in yet, is our vice chair, and our
committee is excited to be putting this on today. Our
committee's podcast, which is titled comp Conversations, has a number
(00:41):
of previous episodes that discuss relevant topics related to workers compensation,
and I encourage everyone that is present here today to
take a listen to those. In addition, if any of
our attendees have interest in getting involved with DRI or
our amazing committee, please shoot me a direct chat, a
LinkedIn message, or or an email and I'll make sure
(01:01):
to try to get you connected our podcast team, who
will also be our moderators today, including Steve Armstrong, Jennifer White,
and Shane Dawson. We believe the conversation today with doctor
Summers will be enlightening and a lot of the issues
we have all likely seen with respect to a CRPS diagnosis.
Doctor Summers has agreed to answer any questions our attendeyes
(01:23):
might have, so please enter those in the chat as
they come about in your head, and our moderators will
make sure to pull the questions and ask those of
doctor Sommers at the end of the conversation. So with that,
let me go ahead and introduce our speaker, Doctor Jeffrey Summers.
Doctor Summers is a nationally recognized leader in pain management
and spine intervention. He graduated sumacumlaude from Ole, miss before
(01:46):
earning his medical degree at the University of Mississippi and
completing his residency at Brooke Army Medical Center. He went
on to advance fellowships and pain management both in San
Antonio and in England, and later founded the Pain Manager
Fellowship at UMMC. Since two thousand and nine, he has
practiced at a multi specialty spine and pain center while
(02:08):
also serving as past president of the International Pain and
Spine Intervention Society. Doctor Summers is board certified in both
anesthesiology and pain management and continues to shape the field
through his leadership and clinical expertise. Thank you for being
here with us today, doctor Summers, and Steve, I will
pass the presentation off to you.
Speaker 2 (02:28):
Thank you Ryan, Thank you Ryan again, Doctor Simmers. Thank
you for being this today.
Speaker 3 (02:33):
Thanks for having us so, Doctor Simmers.
Speaker 2 (02:35):
Let's start at the very beginning, Can you tell us
your thoughts on what is complex regional pain syndrome?
Speaker 3 (02:43):
Well, the key word in that is syndrome, which means
it's not a disease, and as is, a syndrome, has
no therefore no known cause specifically, and diagnosis is not
made with any specific tests because as a syndrome, there
isn't one. So the test we use are basically your
physical examination and your history, because I can't do blood
(03:05):
work or anything like that and confirm the diagnosis. And
in order to meet the threshold to diagnose or actually
you can say suspect the syndrome, you have to have
a requisite number of physical examination findings and requisite threshold
of points within the history that are consistent with the diagnosis. Now,
(03:28):
there are some tests that could be suggestive. One in
particular three phase bone scan. A lot of worthspedic physicians
use that, and I think that's probably the most reliable,
but it's neither specific nor particularly sensitive for CRPS. If
(03:48):
it's not done within the first five or six months.
After that time that it's not as reliable. New MRIs
and X rays and CT scans will also show some findings.
There are no laboratory, I think blood work or anything
like that you can do. And the diagnosis again is
basically that of suspicion. But in order to diagnose any syndrome,
(04:10):
the key requisite criteria is that there can't be anything
else that better explains that condition. And that's not just
limited to the condition overall itself. It's any one of
those given symptoms can be better explained by something else,
you're really not supposed to use them as part of
your diagnostic criteria to make that threshold. And unfortunately, CRPS
(04:36):
almost all of the physical examination and test findings can
be mimicked by disuse alone. And there are a lot
of things that can cause issues that aren't related to CRPS,
but they can give a very similar physical appearance but
without the pain. So that is the difference. That's a
distinguishing thing, is it's a pain syndrome and you must
(04:58):
have continuing pain in order to diagnose it.
Speaker 2 (05:02):
And so doctor, you know, back in the nineties when
I first started practicing law, I think we called it RSD.
Is that the same thing.
Speaker 3 (05:10):
RSD is the same thing as CRPS type one algae
is CRPS type two. The reason they dropped the RSD
because of the words sympathetic. There's no they're saying now
that you can have CRIPS without a component of sympathetic pain.
And I most of the time and the pace that
I saw that had confirmed CRPS, where I felt was
(05:33):
the more classic CRPS. They would get relief with the
sympathetic block. Now that doesn't mean that it would be
enduring relief, but they would get some benefit from it.
But they were providers that complained that there are some
people get no response to sympathetic block, they still otherwise
meet the criteria CRPS. So I think that in order
to be more inclusive in terms of who would be
(05:54):
eligible for that diagnosis, they dropped the sympathetic requirement therefore
changed the name.
Speaker 2 (06:00):
Okay, and you mentioned cause algia. You said that was
a CRPS two. Is that right correct? With the major
nerve injury, that's the distinction. And you know when was
the first time that causagia that the term of the
diagnosis caused algia came about.
Speaker 3 (06:15):
It's after the Civil War where they notice a lot
of hyperjectile and very traumatic injuries that caused severe nerve
nervous system injuries, typically to peripheral nerves and those in
my experience, those cases are far more difficult than the
typical CRIPS, which is probably ninety plus percent of the
(06:36):
diagnosis for CRPS, because if you can't get the underlying
nerve problem taken care of, it's sometimes very difficult to
extinguish the other symptoms and signs that go along with it.
Speaker 2 (06:50):
Okay, and you know what is the current medical opinion
on the different types of you know, typeborn versus type two.
What are the distinguishing features of each?
Speaker 3 (07:00):
Well that it's again one involves a major nerve injury.
That's not to say there aren't any nerve injuries and
CRIPS one, but there are any major nerve injuries. I mean,
anytime you get to burn your hand or something, you're
going to get some nerves or you would even be
able to feel pain, So some nerves are injured. But
CRIPS two implies a major nerve injury or larger peripheral
(07:22):
nerve injury. And ideally you get EMG and nerve conduction testing,
but it's sometimes difficult to perform on somebody that has
true cryps. They just don't tolerate the tests. So when
I see people that have had one, it makes me
suspicious that Sometimes with cryps what you see is disuse
plus a nerve injury, but that's not the same thing
(07:44):
as with a peripheral nerve injury. Sometimes they don't move
it because it's painfulward it's often involves a joint it
was also injured at the time. Sometimes they can't move
it because the injury is devastating enough that there arm
become effectively immobile and they can develop a lot of
the issue signs that are consistent with crypts. So you
(08:05):
try to make that distinction.
Speaker 2 (08:08):
And so for lay people like US attorney's claims representatives
in general, and we'll talk about specifics later, but in general,
what are the best treatment methods for complex regional pain
syndrome one and two?
Speaker 3 (08:21):
Well, two, if you can treat the underlying nerve injury
and correct it, that's ideal. Sometimes that's not possible. When
it's a pinched nerve, for example, you can decompress it.
That'll help, but and then the nerve has to regenerate.
There is no specific treatment unless you do a nerve
graft that would treat a damaged nerve. Now, some providers,
(08:44):
and reasonably so, don't like to operate on somebody with
the active cryps they want to as control as possible.
Sometimes the cause of the crypts is a nerve injury
that you're left with, you know, kind of lesser of
two evils type scenarios. If you want me to give
you a scientifically validated, high level of evidence treatment for cryps,
(09:08):
you can. I'll mute my might because there isn't. Mobility
is the only thing that has really been demonstrated to
show any health, and as patients should be moving, mobilizing
to any extent possible, it's also the best way to
prevent crips after a given injury is mobilization. Everything else
(09:28):
final coart stimulation, sympathetic air blocks, ketamine therapy, numerous drug therapies,
all of that, cognitive behavior. All of that's got some
level of evidence to some extent, but in most cases
it's low quality or nonexistent or no quality. But there
are no high level studies that I can give you
(09:50):
for any of those other previous interventions it says that
it's formally successful or highness successful.
Speaker 4 (09:57):
So doctor, let me ask you. So, I mean, we've
heard of different diagnostic criteria, and you mentioned that some
of these can be mimicked perhaps, But with these different
diagnostic criteria, when you're going about making a diagnosis, what
(10:17):
what do you do to make that diagnosis or to
rule it out?
Speaker 3 (10:22):
Well, I pretty much go through the checklist, but I
like to look at the history too, and because sometimes
you suspect that something else in the history might be
causing the problem. Again, a vascular injury by far the
most common, and a lot of homes are not recognized.
People come in with.
Speaker 5 (10:38):
A swollen red foot and they're automatically assuming it's crips
and it's arterial insufficiency, or it's blue foot, it's venus insufficiency,
it's a pale foot and its arterial I mean, there's
you have to rule out a.
Speaker 3 (10:53):
Vascular injury now. If there's no history of that, that
makes that part easy, although with disuse you can then
get you know, a lot of those symptoms back. What
I have to do is, you know, I look at
all the signs of symptoms because unless you have a
certain requisite number of them, it doesn't matter symptoms are historical.
(11:15):
I want to know what their symptoms are at the time.
If I hear it's not that I'm being skeptical or cynical.
But if they tell me it's terribly swollen at home,
it's terribly discolored at home, it's terribly this at home,
and none of that's in my office, it's not very
useful for me because I need that to be present
on physical examination at the time of the exam in
(11:35):
order to make that diagnosis. And you can go back
through other people's records, but when the signs and symptoms
of CRPS disappear, the diagnosis can't be made anymore. Now
there's pushback on that because a lot of people made
a career treating crypts, and so they like to call
that now CRPS nos not otherwise specified. In other words,
(11:59):
they still have the pain, which is entirely subjective, but
they don't meet the diagnostic career the criteria otherwise. And
again I'm not trying to be cynical about that. Maybe
there's some underlying cause of the pain that wasn't diagnosed,
or maybe CRPS causes some kind of changes you can't measure,
you can't test, you can't prove and look normal. But
(12:23):
that's completely speculative because it's a syndrome. There is no
test at all that you've been used to rule in
or out that condition. But when they're trying to I mean,
sometimes you tell to put on a gown and they've
got to. This isn't common, but it happens they've got
something tied around their upper figh and that's very frustrating.
(12:44):
I make them take their shoes and socks off, or
their shirt off and get it so that you can
make sure there's no ligature. And sometimes they'll take it
off right before they come in the room. This hadn't
happened to me, but an orthopedic friend of mine said,
you know they had a ligature. You could tell it
just untied something, and that's gonna make it bright red
(13:05):
when you come in there, just like it would if
you squeeze all the blood out of your hand and
let it go. Your body's gonna try to make catch up.
And I can't really say somebody is faking hypersensitivity because
they get to experience that I don't. But it shouldn't
change dramatically if it's severe. When they're distracted and sometimes
you're looking at another part. But while you say, well,
(13:26):
I'm gonna try to move your knee. Your knee doesn't hurt,
does it? But so I pull up gently. I act
like I'm a gently pull up on their leg, but
I give it a pretty good squeeze, a squeeze that
was causing terrific pain before when I did it on
the so called injured part. And if that's an inconsistency,
that to me again, you've got to have certain signs.
(13:47):
But hyper sensitivity is considered a sign, not a symptom.
So if in a tremor is considered a sign, not
a symptom. But you can manufacture a tremor. You know
it's just not that hard and that, but you know
it's it's harder if you're But if that shouldn't go
away when you're distracted, it's not an intention trip. So
(14:08):
there in weakness is you have to be able to
tell the difference between feigned weakness or give way weakness
or breakaway weakness, and weakness that is actually phusiologic. Sometimes
that part is difficult to test in somebody with true
crips because they're not going to let you pull hard
on their fingers that are painful. That part's difficult, But
that's not the same thing as physiologic weakness and give
(14:31):
way weakness asssiately with pain in my opinion, is not
It's not physiological weakness. It's a it's a reflex response,
similar to if you grabbed a frying pan that was
on a burner and you didn't know it was hot
and dropped it, and you didn't drop it because you're weak.
You drop it because your body told you to not
do that anymore. Some people say I'll step and my
(14:54):
knee gives out, well, and your body senses that that's
going to be painful. It might make your knee buckle,
and that doesn't mean they're faking that. That is a
true physiologic response, but it also has to distinguish from
true physiological weaknesses, which motor injury. You could do that
with a nerve conduction test are an EMG, but it's
(15:16):
not easy to get some of the true crypts to
sit there and let you stick meals in them and
start electrocuting the painful part of the extremity.
Speaker 4 (15:25):
The doctor, what I'm hearing, I mean, what I'm hearing
from you sounds like this is a much more involved
process to properly evaluate somebody and make this diagnosis where
you're looking both at history, you're looking at them in
the exam room, you know, taking time, whether it's the
distraction and things like that, to make sure the symptoms
(15:48):
they're presenting are consistent. And yet sometimes I think those
of us that practice in that area, we see reports
from doctors who are basically just saying, I can eyeball this.
And certainly I've seen folks myself where maybe one leg
looks extremely withered, it's a different color, it's gray, the
(16:10):
skin looks plastic. There's things that look like there's something
going on there. But how likely is it for a
practitioner just to be able to see somebody come into
their office present a body part like that and they're
able to make a proper diagnosis of CRIPS just on
that alone.
Speaker 3 (16:31):
Well, it's easy if they come in there with a hot, swollen, sweaty,
hyper emic hair growth and nails splitting. But I never
see that. I mean, ever, there was a time back
before people really understood the movement disorder part of it,
that the people came in exactly like that, and it
(16:53):
was almost always, in my experience, it started with a
hot and then it just kind of eventually transitioned to
a cold and a trophy kind of the withered hand look.
But it can come in like that. It came in hot,
swollen and sweating, and the uh with all these other
features it would go along with it, and the hypersensivating
like air conditioning blowing on it, and you could tell
(17:14):
with a glance. But even that doesn't diagnose crips. You
have to have nothing else that can it can be.
That's that's the toughest part. You got to make sure
that you're not Everyone hasn't gone in there because it
looks so classic and made a presumptive diagnosis of crypts
without considering anything else it could possibly be. And there
aren't a zillion things on a hot, sweating, swollen hand
(17:37):
like that, but there are, you know, cellulitis would present
like that. But that's not hard to differentiate. You just
have to have considered it. It's not easy to do
sometimes when but if they come in here with a
normal looking hand, the only way they could diagnose it
at that point everything looks normal are with those signs
(17:59):
such as tremor or motor dysfunction or extreme hypersensitivity, all
of which, in my opinion, are subjective. Weakness is definitely
subjective when it's related to paint avoidance.
Speaker 4 (18:15):
So doctor you mentioned about, they're not being like a
single test that we can use to confirm it. There's
not a lab test that we can do that's going
to be definitive. What about on the other side, are
there is there testing you can do to rule out crips.
Speaker 3 (18:36):
If you do it early enough. A bone scan triple
fased bone scan is diagnostic enough that it's considered very,
very sensitive and specific in that regard. If you wait
forever in the leg becomes a trophy, there's too many
things that could mimic. But early on that's a pretty
specific test. I would say, I see almost none that
(18:58):
are truly you know, I'll see one. Sometimes it'll come
in they'll have that late phase pulling, but it's in
the knee and the pains all in the ankle, so
that doesn't really count. That's probably a good one. It's
one you'll see real Now I'm not exactly sure why
if I had anybody coming in with early phase crips,
(19:19):
I would get it unless there was a contraindication, which
you know it's it would be extremely extremely rare allergic response.
Another good test would be a sympathetic block because it's
both diagnostic and therapeutic. It's always nice to have something
that a test you do that actually helps their pain
as well. Again, though they have to be I don't
(19:40):
use a bunch of blocks in lieu of other treatment.
I only do a block to allow them to participate
more aggressively in physical therapy, because at the end of
the day, if you don't get a moving it, you're
never going to beat that condition. Everything else starts to
fall into categories where you would use generically treating neuropathic pains,
(20:02):
which is the gab of anoise like pre gabbling and
gabba pent and different anti depressants, Deloxea team being the
one that's probably the one that's best tolerated, that works
best for neurotath pathic type pain. Now, the tricyclics and
all those are very useful for neuropathic payment. The side
(20:23):
effects and drug interactions are so high that for Ellaville,
for example, Amma tripoline that I remember reading has studied
the average weight game was something on the order of
thirty pounds. I mean, who's going to put up with that?
And so you just have to pick ones that are
tolerated by the patient have the minimum number of side effects.
I'm not a big ketamine fan I'm not sold on that.
(20:46):
Just saw Cocher and you yesterday that came out on
it said that the evidence was very weak and that
especially for the IV and non existent for other forms,
and so I'm not sold on that has a lot
ofential side effects. It's a usable drug for one thing,
but in the control of the environment less likely. I
just not convinced, and no one really has a good
(21:08):
explanation of why that would work. But anything to get
them to mobilize. I mean, we have anesthetized an extremity
before to get it mobilized, so that because once you
get it moving sometimes it makes a big difference. But
it's now I feel your pain. I wish I could
draw the blood and come back and say you're luck
(21:29):
it's not crips. But it just doesn't work like that.
We treat the symptoms of crips. We don't know the cause,
so we can't treat that. We treat the symptoms.
Speaker 6 (21:40):
Doctor, we wanted to talk a little bit about the
Budapest versus the AMA guides. What are the differences in
diagnosing the conditions per the fifth edition or the Sex Edition.
A lot of us used the fifth and six and
the Budapest criteria.
Speaker 3 (21:55):
Well that they all have the same diagnostic criteria. Now,
there was a time when the difference between the fifth
AMA and the sixth AMA is the fifth AMA was
not well received by some of the more strident CRYPTS
proponents in the community. They thought it was too difficult.
We had to have too many of the signs I
(22:15):
went through before to be able to make the diagnosis.
And they thought that was unfair to the patient that
a lot of people were being denied medical care, necessary
medical care by the insurance companies because they didn't meet
the criteria they were used in AMA. So the AMA
Guideline six just dropped that. I want to say. They
(22:36):
went from eight objective findings down to four three even
and all of those, unfortunately under the AMA can be
ones that can be either feigned or subjective. Because I
still hypersensitivity aladinia is not objective. It's not a sign
(22:58):
that is a symptom and a tremor, but you can
make the diagnosis. But they all use the same theso motor,
pseudo motor and motor a trophy background findings which are
just in a list and anyone can look at them.
You just have to meet a certain number of them
in the certain number of categories at the time of
the diagnosis, at time of the examination to make that diagnosis.
(23:22):
But there's not a lot of difference. That AMA decided
instead of trying to say they have it or not,
because you could never prove the habit. You can have
every single sign and symptom and you cannot prove that
that's cryps. You just can suspect it because you can't
think of anything else, but you can make the diagnosis
based on that suspicion. But the AMA felt like there's
(23:44):
a difference between you know, bronchitis and double lung pneumonia.
You know, there's a big difference in the degree of infection,
and they feel like the CRYPTS should be treated the
same way, even though it's not a disease, that there
should be very very mild crips with no impairment and
severe crips with significant impairments. So they decided to realizing
(24:10):
that they have being criticized for telling too many people
that might have been on the borderline of CRYPTS, you
don't have it, you don't meet the criteria, they decide
to say, well, okay, you don't. You may meet the criteria,
but you're not severe enough that somebody would recommend ketyminte therapy,
for example, or a spinal cord stimulator. Impairment's not there
(24:32):
in order to recommend something like that now. Doesn't stop
a provider from doing it anyway. I think it's enough
and the patient agrees with me. There's not a whole
lot you could do about something like that, except for
to say, well, I would not recommend for somebody that's
functional and their only problem is some degree of pain,
but it's not enough to limit it. Functionally, they can sit, stand,
(24:54):
walk and ride without limitation. It just hurts some time
to do it. Those people don't need spinal cord stimulators.
It won't benefit from it in general. So I just
that's the difference in those At the end of the day,
they're all still about the sin in terms of what
you can do to diagnose it.
Speaker 6 (25:15):
Do you feel like the advent of the Budapest criteria
has made any impact on their frequency of CRPS diagnoses?
Speaker 3 (25:23):
Yes, in my experience, I just that you can make
it now with no objective and scant subjective findings. And
again it back in the nineties when nobody mobilized anybody
late nineties, early two thousands. You know, if somebody came
spraying their ankle, they put them in a cast and
if it kept on hurting, it kept the cast on.
(25:45):
And when it kept on hurting, because now they're developing CRPS,
they kept the cast on. Then they finally the patient
said they're swelling so bad. They say, you've got to
take this thing off. It's killing me. And then they
send them to me. And it's this classic awful look
in condition. And once you rule out of infection, there's
just not a whole lot else that there's vascular in
(26:07):
sufficiency because of a too tight cash for too long.
There's not a whole lot else that would mimic that
that you would have to look at. But they made it,
in my opinion, very easy to meet the minimum criteria.
Diagnosis again, I say diagnosis in kind of air quotes,
because again you're just confirming a suspicion. You can make
(26:27):
the diagnosis, but you're really never sure because you can't
prove it or way or another.
Speaker 6 (26:34):
You kind of talked about the history of why they
switched over to this criteria. Do you think there could
be an argument that it was basically self serving to
benefit pay management doctors to make it easier.
Speaker 3 (26:47):
Well, you can make the argument. It's a little cynical,
but you could make it. Some people are just some
physicians are. They look on there and they say that
by making this diagnosis and treating it all out, you're
starting to lose your risk benefit ratio. In other words,
(27:08):
you know, it's the first do no harm, and if
you over treat somebody with a diagnosis it's suspected in
the first place, or that they're not that disabled from it,
you run the risk of some of these treatments like
small where stimulators have the fourth highest incidents of serious
adverse events and over all two thousand, five hundred medically
(27:30):
approved devices that is not a benign device, they have
an extremely high rate and serious adverse events. So when
you put one in somebody, you've got to make sure
that you're not causing more problems than you're helping. And
also there have been studies that state for various diagnosis
(27:50):
it's final courts stimulators. Don't cut back on the amount
of medication, don't cut back on the number of primary
care business, don't cut back on the number of hospitalizations,
don't cut back on the number of injections and don't
cut back on the number of er visits. And so
the question is, what are they then doing. What's the
upside to that except for saving costs for MRIs because
(28:13):
a lot of times now you can't have an MRI
with spinal stil area. Yes, it's self serving to some extent,
but some people say, well, if there's any chance you
can help them, why would you not make it more
easy to make that diagnosis? And I think that if
you look at it, in my opinion, logically, if you're
(28:37):
going to use the same treatment for neuropathic pain, you
could still make a diagnosis of neuropathic pain without without
making a diagnosis of CRIPS. And I don't understand the
schism there as well as I probably should. I think
if you made the diagnostic criteria more difficult, like I
(28:57):
won't see, more difficult, more selective like AMA five, that
it would be more useful because I can give somebody
every single drug I can give them for CRIPS and
still be within the standard of care without a diagnosis
of CRIPS. If I make a diagnosis of suspective neuropathic pain,
(29:18):
the CRIPS has this aura, which I unfortunately think there's
more subjective than I would like, and know it's got
a flare to it. If you've got crips, people almost
act like it's sepsis and you better get in there
and do something soon they're going to lose them and
you end up with expensive care that unfortunately there's not
(29:39):
a lot of evidence for and if you look at
the insurance data on it doesn't seem to be very effective.
That touch your service.
Speaker 2 (29:49):
How long is the typical life span of treatment for crips?
Speaker 3 (29:54):
You know, I couldn't answer that. There are people tell you,
I saw somebody's work the other days that there is
no cure for cryps, which is interesting since we don't
even know what causes it, and by definition as a syndrome,
wants as signs that the syndrome are gone. You don't
have it, so how that's not a cure. But his
opinion was that there are only CRYPTS survivors that no
(30:17):
one's ever cured from it. It's like cancer. At any minute,
it could come back as bad as ever, and so
you're just you're living with it. You have to deal
with it. And they considered a lifelong condition even when
there's no impairment or even symptoms associated with which I
don't agree, but I would say, if you can prevent
it in the first place, which is the best way
(30:37):
to do it, or make it a mild case. In
CRYPTS one where there's no specific or injury, I say,
if he diagnoses early, you know, months at the most.
Now there's a nerve injury that makes it much more difficult.
You've got a radial nerve injury that's led to CRYPTS two.
(30:59):
Sometimes difficult because the patients debate ability to mobilize it
or willingness to mobilize it. Is sometimes caused by the
direct pain from the nerve injury itself, and that gets
you know, that makes it far more difficult to use
the most effective treatment we have, which is to mobilize.
Speaker 2 (31:18):
And is there some consensus on what causes CRYPTS to
develop in some people and not others. They have the
same injury, but you know, some get it and some don't.
Speaker 3 (31:28):
I think that immobilization by far as the key. I
don't think anybody is a proponent that stating that you've
got to mobilize extremity and all other forms of treatment
or allow you to mobilize it better because I think
your body tends to heal it. Whatever problem it is.
You just don't see it nearly as much. I can't
(31:51):
think of a single case that I saw somebody that
didn't come in with an immobilized extremity, and ninety percent
time in the history that was part of the processes immobilization.
Now there is some immobilization. Is it's more difficult to
(32:11):
explain because why, for example, should the workers population have
four hundred to eight hundred percent higher likelihood of developing
CRPS than first injuries that occur outside of the workforce, right,
And that's you know, that's something more difficult. But outside
(32:33):
of the workforce most people, Again it sounds cynical, but
it's also an observed phenomenon, and that is that you know,
no one's going to pay me not to work. And
if I can't work because my arm hurts and I
can't move it, I can get paid for not moving
(32:53):
or I can get a settlement afterwards. It's it's frustrating,
it's a liability issue. A lot of the tongue of
personal injury and workers calm tend to have a significantly
greater not four to eight percent four to eight times
the incidents of injuries that otherwise don't occur in that environment.
Speaker 2 (33:17):
And doctor, have you seen treatment recommendations that go too far,
either in the people who've been injured for with work
injuries or other injuries, or there might be a claim
associated with it.
Speaker 3 (33:30):
Yes, again, it's a matter of opinion. No one's going
to propost something they think doesn't go too far. But
if if somebody doesn't, First of all, if there's any
suspicion of a manufactured exam where they don't meet the
strict criteria, I just don't see any point of going
into highly invasive treatments such as sympathectomies where they go
(33:52):
on there cutout and sympathetic nerves, or spinal cord stimulation
or dorsal root gangling stimulation or peripheral nerve stimulation that
have poor quality evidence but a high incidence of serious
adverse events, that goes to kedymine therapy. Anything that has
a high ins in so side effects but a low
(34:13):
incidence of benefit. I think that's going too far. You know. Again,
some people you can tell they're just miserable and suffering
with it. But you know, I would allow anything all
those if it would allow them to get their movement
back and therefore treat the ender own condition. But unfortunately
(34:35):
you don't see that a lot. I'm not I think,
except for sympathetic blocks, which shouldn't be infinite because you
can't get better forever. At some point it not diminish
to the point where it's irrelevant simply the blocks and
the easy way out if they've effected. But you should
know after the first one or two if they're going
to work. I wish you had a better answer.
Speaker 4 (34:59):
In other words, doctor in Ohio, I know we're generally
seeing an uptick in request for spinal cord stimulators in
your experience. Are you seeing more and more requests recently
for that as a treatment?
Speaker 3 (35:17):
Absolutely, and I'd like to say it's because the technology
keeps advancing and getting better. But there's a great article
and I want to say the British Medical General once
spinal cord stimulators in general, in which they think they
questioned the effectiveness of them for any diagnosis, but crips
among the highest and they they conclusion of this at
(35:42):
the end of this article was that an editorial opinion
was that there's no indication for spinal cord stimulation outside
of a clinical trial to prove once and for all
of it works are not and they think that there's
extremely high industry influence in these studies that are dominated
(36:05):
by industry. I think eighty something percent of all larger studies,
based on how many patients went in it were all
funded by industry. I think it's higher than that ask
Excember ninety percent, and it would be an expensive thing
to do with that industry support. But when I was
a president of International Pain and Spine Society, we couldn't
(36:28):
wait for that high frequency stimulator to come out because
it was you can't feel it. You know, most of
the time when you're doing spintal wor simulation, the patient
has to feel the paraceesus cover the area of painter.
It doesn't electricity gover the painter, it's not going to
be effective. Well, this, you couldn't feel it. It's put
it in works, that's what they claimed, and we couldn't
(36:49):
wait for them to We ran up to the company
and say, hey, would you give us some of the stuff.
We can perform a placebo trial. Now you can't feel it.
Oh no, you'd have to recharge it and this and that.
I said, you can. You could just tell them that's
part of the protocol and you could find out if
they weren't recharging thrown around the study. You know that
I think would be very effective placebo control. The guy absolutely,
(37:12):
I won't give you. The company refused to help. He said,
place ebo has destroyed more great products in my career
than anything else. Just so you know, we don't need
your permission, right, We can just do the same thing
on our own. And there have been placebo controlled trials
and guess what the ones that weren't by industry that
didn't work, but a new technology would come out, So well,
(37:36):
that's that one. We have a new one now and
they get these approval FDA approval through this. I want
to say it's five ten K something like that loop
loophole that allows them to use the previous stimulator technology
to just put a new twist on a new frequency,
a new mechanism for sensing it, et cetera. They allow
(37:58):
them to use that and then them out with the
new device, have their own couple of studies come out,
and the editorial board said they're skating ahead of the
ice as it's cracking behind them because the evidential ice
is just not there.
Speaker 4 (38:13):
So doctor, with the whatever the current technology that we
have for the spinal cord stimulators, how long does this
as a as a piece of technology, you know, how
long does it last if it's if it's taken care
of properly, if it's serviced in the way it may
need to be.
Speaker 3 (38:32):
Do they have to be you know, replaced?
Speaker 4 (38:36):
You know, once you get that installed, how long does
the patient get the benefit of it.
Speaker 3 (38:43):
Well, you might have to replace the battery, but there's
some that get charged through the skin so that you know, eventually,
even rechargeable batteries go bad, but that's not in my experience.
Ninety of them are revised because the lead migrates, and
the lead migration problem is enormous. It's I want to
(39:05):
say that they all migrate, whether they do migrate to
an area that they're not effective or not. And how
that's supposed to happen in one that there's no way
you can feel the parriceesion anyway, I've never understood why
if it doesn't mean when they put those in, you
put it in to a certain spot that for some
(39:26):
reason was preordained. They said, well, this is what we
found was the most effective. So you put it in
this specific area for all the types of pain and
if somehow supposed to work. I've just never quite understood
the parriceesion with systems, you know, the high frequency ones,
(39:46):
how you could ever test that, But lead migration leads
breaking technical problems with it. Those are all the number
one reason you're gonna have to go back in and
maintain that the costs come off that not so much
as replacing the system. Now there's a new replacing the
(40:08):
system push that I see, and that is that you're
replacing the system because we've got a better one. Now
that's ten year old technology, that's five year old, that's
two year old technology, depending on what's coming out. And
it's so called evidence behind that. So they're upgrading all
the time. And you know, it's an extremely lucrative procedure
(40:30):
for the physician. I mean, I mean we put in
in this center here there are what eight neurosurgeons, and
all those patients come down and we put in I
don't know, one a month maybe something like that, and
there's a guy down the street that puts in we'll
do twenty trials in a day, and that cannot be that.
(40:55):
You can't resolve that based on anything whatsoever to do
with the practice of medicine, per se, And I'll just
leave it there.
Speaker 4 (41:05):
Doctor, I wanted to ask you one last question. A
pivots a little bit, but in your experience, what do
you see with the mental component for the patient in
terms of I guess both we're talking about the efficacy
of a spinal cord stimulator, so you know, with regard
to that specifically, but also more generally with regard to
(41:29):
just the diagnosis and treatment outcomes, even if they're not
using a spinal cord stimulator.
Speaker 3 (41:36):
Well, there's there have been several studies that show that
their level of depression and anxiety is high, probably higher
than most other chronic pain syndromes. Now, that's not to
imply or at least the articles did not say that
that was a pre existing coorbidity and that people with
anxiety and depression are more likely to get CRIPS in
(41:58):
somebody that's not. That's a different that's a difficult one
mistake because they showed that the incidence of a significant
psychiatric diagnosis in children pediatric cases they get CRIPS is
extremely hard and they don't know, and it it seems
to have a significant relationship to what type of household
(42:20):
we're brought up in. Now they're saying, well, maybe that
type of household is less compassionate, so they don't get
you a doctor as quickly at all. But they've never
shown that. They just showed this. It hasn't been explored
well enough. But there's extremely high incidence of crypts being
says it with psycheoatric problems in children. And you know,
(42:45):
it's tough to really know, but that better be part
of a treatment, cognitive behavioral therapy, especially if they refuse
to move it. That's our biggest We get psychomolved early
if they refuse to move They move it first of all,
all they seem to do well, doesn't matter if they
don't move it, though, we get psychedball early because they
have to overcome that. They're going to be successfully treated.
(43:10):
But to at your question, can it cause depression etc.
That has to be treated for life? I mean it
could if they don't get better.
Speaker 6 (43:20):
Doctor. Uh. Just kind of bringing it back. Since we
are talking to a lot of defense attorneys here, I
think what should we as defense attorneys be looking for
when we are handling these cases as far as looking
at the diagnoses or impeaching those plaintiff experts.
Speaker 3 (43:37):
Well, the thing I see the most is somebody just
doesn't get better, and so the orthopedic is somebody was
saying earlier, just decides, I don't know, it's swollen all
maybe it's crips and sends it off to a cryps
expert who immediately calls it cribs. But there's been no
other work, extraneous work up to prove it's not something else,
(44:01):
and that you have to do that. That's the way
you're peaches is what other signs and symptoms, what other
conditions could be consistent with that? The most likely, the
most common in my experience, has been vascular. But disuse
alone could do it, and it would be difficult. It's
a difficult question to turn on somebody is prove it's
(44:21):
not disues. If I'm a physician and they come in
with these signs and symptoms, prove it's not disuse, and
the only thing that would be different from disuses the
degree of pain is if you get let your arm
get stiffened, et cetera. But it shouldn't mean to the
point where just light touch causes pain, but then that
makes a diagnosis subjective at that point. So you know,
(44:45):
what I need to see when they come and to
see me is if they've been worked up, has it
been a proper work up for anything else could be
causing this? And the unfortunate reality is that I don't know.
I'd say that even back before it became such a
huge legal thing, I would say that eighty percent involves
(45:07):
some sort of secondary game. And I hate call workers
comp secondary game because you know, an injured worker deserves
compensation and care, but it's still considered secondary game at
the end of the day. You know, it's just tough
to get around that. Why would they have And it's
(45:30):
not because what I would give lectures to a different
you know, to a mixed audience. I'll call it planus
and lawyers mixed audience plants in defense the defense people,
of course, anything you said that they're all faking it,
they would love that. And I don't believe that they're
all faking it. Some of them are exaggerating, though, and
(45:52):
if you exaggerate something enough, you'll end up with more
treatment than you need, and probably treatment that you shouldn't have.
But on the other hand, I was accused of saying, well,
you're just blaming it on them, because I said, well,
you know, well, why do workers, for example, I have
four to eight increase. Well, it's because they're more likely
(46:16):
to get injured. And that's the trap. If they say that,
you goes away immediately because that they're saying that it's
a blue collar. It's a blue collar you know. The
accountants don't get hurt like somebody that works in a
loading dock, etc. But they're almost unheard of in sports injuries,
(46:37):
almost unheard of. I had to look it up the
NFL and I found two cases crips. One of which
wasn't was in an NFL player when he was sixteen
and woke up and couldn't move his legs, and that
sounds incredibly suspicious to me. There was no injury or
anything align with it. He's fine now and he makes
ten million plus a year, but that was part of
something in his history. The other one was the guy
(46:59):
that claimed that the doctor botched his knee surgery, made
him try to rehab around it when it wasn't really
completely done, and he got crips, and he also got
forty three point five million dollars, so you know there
was a secondary gain issue that half of the NFL
players out there. Then it came down with the potential
(47:21):
secondary gain issues. So but I was in the army,
I never saw it. Now, I didn't see necessarily. I
saw some people with injuries. It might have been a
cause algae at some point, but they were fresh enough
that you can't really tell them and everything's messed up
when somebody's got half their arm blown off, But you
never saw it. And the guys that were in basic,
(47:43):
they didn't end up with crips. You don't see it
in professional athletes. You know, I don't care how bad
your job is. It's not like getting out there and
having a three hundred and twenty five pound guy charge
at you fifty or sixty times in one afternoon. You
just know when works like that. But they don't get crips,
(48:03):
And so maybe there maybe I'm a little biased in
that regard, but I'm waiting for someone else to explain
it to me because it's not specifically just that they
get more trauma.
Speaker 6 (48:15):
Well, these are great, These have been great tips, and
thank you for your time on this. I think we
have a little bit of time for questions. We already
have a few. If anyone has any more, please feel
free to send them in the chat. And Doctor, I
wanted to ask you one from Jeff Low saying, from
my experience with RPS claims the diagnosis is the result
(48:39):
of comprehensive battery rule out of alternative causes, which we
did talk about. What's the optimum time frame in which
to accomplish.
Speaker 3 (48:46):
That ruling out everything else? Yes, if everything is coming
back normally, it shouldn't take that long. And you've got
to set up vascular studies. If you suspect a bacscular
can but anytime their color changes one way or another
and you have no other diagnosis for it, the vascular
studies should be something reasonably high on the list if
(49:10):
they're not too painful. EMG and nerve conduction stays months
at the longest. If you wait longer than that, your
outcomes are going to be worse, even if you think
you will. You know it is a legitimate case of CHRIS.
Doesn't mean you can't treat it in the meantime. But
if you're trying to do all these other rule out things,
some of those can be done very quickly. Somebody comes
(49:31):
in and they have no color changes, no temperture differences.
I pretty much ruled out a vascular cause. Those people
are no edeema. I mean a lot of them. I'd
say the majority, significant majority are ruled out the day
I walk in their examiner because they don't meet the criteria.
You know, somebody with feigned weakness and claims they're hypercented
(49:54):
it will have no objective findings. Well, the only objective
finding is that their arm is as small words or
comforts in the other because they don't ever use it,
or they have some restriction and range of motion because
they don't ever use it. Those aren't That's not enough
to make the diagnosis. But if they do have a big, fat,
swollen or cold or hot extremity, you need to jump
(50:17):
on that because the things that are other than crypts
that would cause that are something that probably couldn't wait
forever before your outcomes are going to be worse.
Speaker 4 (50:28):
Doctor, We've got a question here from Stuart King. He's
asking is a stella ganglion or lumbar sympathetic block diagnostic
or unrelated to the diagnosis.
Speaker 3 (50:41):
Well, it can be diagnostic or supported diagnosis. Again, there's
nothing diagnostic. There's no diagnostic test for crypts, but it
can support a diagnosis if they get an improvement not
only in their symptoms of pain, but in their signs.
Other words, they come back in the next visit and
there's less swell. The temperatures are improving a lot of objectifines. Now,
(51:03):
sometimes I think that those improvements are not directly necessarily
from the block itself, but their secondary because the block
improves the pain. And then you've already encouraged them before
they even get out of the recovery room from the
block to try to keep that mobilizing. Even if all
you can do is barely open and close your hand,
just don't ever stop doing that, and then as you
can get more and more movement, you try to encourage
(51:26):
them to do it. Yes, they but that's the reason
they dropped reflect sympathetic history because too many people didn't
fall into that to that category of a sympathetic block.
You can still have crips without a sympathetic component of pain,
but they are considered but diagnostic and therapeutic potentially for
(51:48):
those patients who do have that sympathetic component.
Speaker 6 (51:54):
Doctor you're's one from Tony Tomaso talking about the final
courts emulators. And you might have gone over some of this,
but how how long in your experience do you see
these ses is helping a crypt's patient essence? It is
a long term treatment plan that you find viable and
useful or not.
Speaker 3 (52:16):
I can just tell you that. Again, I'm a very
limited snapshot of that, but I can tell you from
insurance data there there's a very good study out not
long ago. Any CRYPTS is part of the included diagnoses.
They're finding that there's no decrease in utilization of care,
and statistically, somewhere around forty percent of people lose benefit
(52:40):
within the first year. I realize you're not on It
depends some of the some people use it. I see
people come in with spinal courts stimulators and I said,
where do you feel the buzzing right now? I don't
feel it turned on? How often you turn it on
a couple of times a month? I mean, that's I
don't even know why that's in there. It's not worth
(53:01):
the risk of having it. You're going to turn on
a couple of times a month. I just don't understand
why you would want that. And I think some of
that is, you know, and again I don't. I know,
like I'm trying to appune everybody that has crips and
I'm not. But I do see a significant psychological component
(53:24):
to it in people that it's a crutch. It's like
people that come in and they're using their cane in
the wrong hand. You're like, you don't really even need that,
but you want that. And that's not the vast majority
by any means, but that's a subset of it. When
you get questions like that, it's unfortunately my mind tends
(53:45):
to drift in that direction because it's otherwise very difficult
to explain it.
Speaker 4 (53:52):
Doctor Tony had a follow up to that and this.
I know we're coming up on the end of the
hour and time, but let me ask this because I
think this might be a good place to end. You
mentioned in terms of treatment, I mean repeatedly about how
movement is the key. Movement is important. So in your experience,
(54:12):
what is the best, the best treatment, the best way
that you're getting these patients to start moving and improve
their condition.
Speaker 3 (54:21):
Telling her if you don't, it could turn into the
withered hand and you'll have it forever. That the best
way to stop this is you said you can come
in and get an injection that will last for you know,
physiologic effects overnight. You're lucky. You come in and take
a bunch of medicine that mask your symptoms because it's
not treating underline cause. Or you can start moving it.
(54:44):
You can go to therapy. You can go every day
for an hour. That's one hour in twenty four in
one day, your whole week's worth of therapy. Isn't the
time before you eate breakfast and lunch. And if you
want to beat this, nobody can do more for it
than you can. And I'll do what I have to
do to make your movement less painful, if it means
(55:04):
it's a topical anesthetic, if it means it's a medication.
But if you want to win, you have to set
a goal for yourself. And if if your goal is
just to move it this fart, try to get it
a little further, Try just a little bit of a goal.
And if it starts to get sorted back off a
little bit, that doesn't mean not move it. Do whatever
you can within your movement. Because I've not seen anybody
(55:25):
ever improve that didn't increase the mobility. I've seen plenty
of people deteriorate. That didn't. Doctor, We're about the end
of this.
Speaker 2 (55:34):
We want to thank you again for being with us today,
for everything you've done for us, for all the time
you've spent. And if anybody here wants to reach out
to you, what's the best.
Speaker 3 (55:44):
Way to reach out to you? Through my email Jeff
Summers ninety nine a Gmail sounds good, great, and thank you,
doctor Summers. We appreciate you being here, thank.
Speaker 6 (55:55):
Inviting, thank you, thank you everyone at about
Speaker 5 (56:06):
Singing a bo
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