The Budapest Criteria: diagnosing CRPS (Part 1)

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Many conditions are diagnosed based on the results of one or more medical tests; some are invasive, and others are not. Unfortunately, we’re still waiting for a test for CRPS [but see: Is there a blood test for CRPS?]. Instead, the condition remains largely a diagnosis of exclusion, i.e. discount everything else and what’s left?

The Budapest Criteria

In 2004, the International Association for the Study of Pain (IASP) held their annual conference in Budapest. Its lasting legacy was adopting a new set of diagnostic criteria for CRPS, rather unimaginatively labelled the Budapest Criteria.

The Budapest Criteria differentiate between:

• ‘signs’ seen or felt by the clinician carrying out the examination and
• ‘symptoms’ reported by the patient.

If the clinician can record a minimum number of signs and symptoms – AND no other diagnosis can explain them – the patient probably has CRPS.

What are the signs and symptoms of CRPS?

Symptoms of CRPS

For a diagnosis of CRPS, the person must have at least one symptom in three of the following four categories:

• Sensory: hyperaesthesia (an abnormal increase in sensitivity) and/or allodynia (pain caused by usually non-painful stimuli).
• Vasomotor: skin colour changes or temperature and/or skin colour changes between the limbs.
• Sudomotor/oedema: oedema (swelling) and/or sweating changes and/or sweating differences between the limbs.
• Motor/trophic: decreased range of motion and/or motor dysfunction (weakness, tremor, muscular spasm (dystonia)) and/or trophic changes (changes to the hair and/or nail and/or skin on the limb).

Signs of CRPS

At the time of clinical examination, at least one sign must be present in two or more of the following categories:

• Sensory: hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic (physical) pressure and/or joint movement).
• Vasomotor: temperature differences between the limb and/or skin colour changes and/or skin colour changes between the limbs.
• Sudomotor/oedema: oedema and/or sweating changes and/or sweating differences between the limbs.
• Motor/trophic: decreased range of motion and/or motor dysfunction (i.e. weakness, tremor or muscle spasm) and/or trophic changes (hair and/or nail and/or skin changes).

Budapest Criteria: The Valencia consensus-based adaptation

Over the following fifteen years, advances in medical science meant that by 2019, the Budapest Criteria were due an overhaul. So, in 2019, IASP’s CRPS Special Interest Group held a workshop in Valencia “to review perceived ambiguities in the diagnostic text and issues identified in applying these criteria in both the research and clinical contexts.”

As a result of this review, members reached a consensus on updates to the assessment guidelines and associated text. But crucially, “the wording of the diagnostic criteria themselves was not altered so as to avoid invalidating the criteria.” So, in short, the Budapest Criteria survived, but now as the catchily-titled “Valencia consensus-based adaptation of the IASP complex regional pain syndrome diagnostic criteria“.