RSD Score Sheet

Rate the severity of RSD/CRPS

This form provides one of many aids to evaluate the severity of RSD and to follow the results of treatment. We have used this form in our office for about 6 years and have found it consistently useful for these purposes. In most instances, patients on their own and physicians reached the same severity ratings. It has not been reviewed by other offices or pain management societies and we have not compared its value to other rating scales.

Please note that this form and the information given below is no substitute for the advice of a qualified physician who is experienced with RSD/CRPS. Also note that this form was not designed for use in other pain conditions. It is important to discuss the use of this form with your doctor.

Instructions:

For each question, note the comment that best fits your illness. Each represents a score between zero and 3. Write down the point value that applies on a piece of paper. After answering all questions add the points and write down the total. Make a note of the date, and anything else you can think of that might alter the severity of disease. For example, note treatment, exercise, stressful events, independent medical examinations, depositions, family visits and so on. These will be useful to help discover any relationship between events and severity of your condition, if there are any.

As you practice using the form you will develop better consistency in how to understand and rate the best response.

1. Distribution of symptoms: Symptoms of RSD/CRPS usually begin at the site of injury or operation, but can begin anywhere without obvious cause. It often spreads beyond the site of onset. It . In some cases RSD/CRPS becomes a whole body illness becoming difficult to distinguish from Fibromyalgia Syndrome. Distribution can be rated on this form. Disease in one extremity only rates zero points on this scale. All over disease rates 3 points.	Symptoms limited to one limb or trunk	0
	Another limb involved and/or part of trunk	1
	Multiple limbs and/or extensive spread to trunk	2
	Whole body involvement	3

2. Pain level: We know that the pain feels that it has to be over 10/10, but for the purposes of this form, limit your maximum to 10, with zero meaning no pain at all. Note how pain changes if you do an intervention such as an exercise in therapeutic imagery, take a medication or receive a block. Focus on the comfort and note how long it lasts. Make a note of this on the form.	Pain rates 0 - 1 on a scale of 10	0
	Pain rates 2 - 4 on a scale of 10	1
	Pain rates 5 - 7 on a scale of 10	2
	Pain rates 8 - 10 on a scale of 10	3

3. Sensitivity to touch: In RSD/CRPS increased extreme sensitivity to touch is almost univesal. Even a breeze blowing across the skin can cause pain as if tissues were being torn apart. Patients that gain remission lose this sensitivity. This part of the form is a useful tool for monitoring that change. Dysesthesia means an uncomfortable feeling that should not be there.	No increased tenderness to touch or pressure	0
	Deep pressure hurts more than it should	1
	Light stroking or touch causes pain, dysesthesia	2
	Extreme pain with even a breath of air	3

4. Burning sensation: This is the characteristic pain of RSD/CRPS.	No burning sensation	0
	Mild burning sensation	1
	Moderate burning sensation	2
	Severe and intolerable burning	3

5. Swelling: The precise reasons for swelling in RSD/CRPS are not known. Many patients with a high capacity for using hypnosis or therapeutic imagery are able to control swelling using these techniques. Follow the changes as treatment progresses.	No edema	0
	Minimal edema	1
	Moderate pitting edema	2
	Grossly swollen extremity	3

6. Perception of warmth or cold: This question is about how the affected areas feels to you from the inside - not how you or an observer who examines the areas senses or measures temperature from without. Does the limb itself feel warm or cold, and how far from normal does it feel?	No inappropriate sensations of warmth or cold.	0
	Limb perceived as warm or cold	1
	Perception of freezing cold or throbbing heat	2
	Perception of eat or cold causes pain	3

7. Joint Flexibility: In RSD/CRPS, movement is often limited. Muscle spasm is the initial cause for stiffness. Much later, shortening of ligaments and joint capsules can limit movement independant of muscle activity. Stiffness should always be consdidered a reversible condition until proven otherwise.	Unlimited movement in affected joints	0
	Movement is limited by pain and/or stiffness	1
	Movement is restricted by pain and/or stiffness	2
	Joints are fixed by pain and/or stiffness	3

8. Sudomotor change is about sweating: Sympathetic nerves carry the signals that alter blood flow and sweating. Increased sweating is very common in RSD/CRPS and ranges from mild increase in dampness of the hands to severe sweating for which patients carry kitchen roll to mop up. Hypnosis is a way to change sympathetic nerve function, and patients with a high capacity for this can use imagery or medical hypnosis to reduce sweating and restore circulation towards normal.	No abnormal sweating	0
	Occasional or mild increased sweating	1
	Frequent profuse or increased sweating	2
	Constant profuse sweating	3

9. Lability of Perfusion means change in blood flow to the affected area(s). Unhealthy blood flow can cause temperature or color change in the skin. Vasoconstriction reduces blood flow (area is usually cold, white or dusky in color), vasodilation iincreases blood flow (area is hot, red or excessively pink). Mark 0 if the color and temperature is healthy and the same as normal healthy tissue, 3 if the area is very cold, white or dusky (grey) in color. Since sympathetic nerves carry signals that alter blood flow to the skin, and as RSD/CRPS is an illness that is often driven by sympathetic function, you may be able to modify perfusion using medical hypnosis, biofeedback or therapeutic imagery.	Normal skin perfusion	0
	Mild or occasional vasoconstriction or vasodilatation	1
	Marked or constant skin flow changes	2
	Vasospasm threatens viability of tissue	3

10. Tissue atrophy: In RSD/CRPS, tissues atrophy, become thin and weak. In part, this is because tissues and limbs cannot be used and the atrophy is in part, secondary to disuse. Muscles that are weak and thin tend to hurt more than when strong, and this may form a maintaining factor for the disease. Rehabilitative exercises are very important in preventing and reversing atrophy. BUT -- If the exercise is too strong for you it can aggravate the illness and prevent recovery. YOU must lead this process.	No observable atrophy or hypertrophy	0
	Atrophy present but difficult to see	1
	Easily observed or measured atrophy	2
	Limb has the appearance of skin and bone only	3

11. Use of an extremity: As your condition improves, you will notice increased function. Follow it using this part of the form.	Normal gait or use of arm	0
	Dysfunctional gait or arm use difficult	1
	Walking aid required or arms ineffective	2
	Wheelchair use, or arm requires padding & support	3

12. Medications: Sometimes opiates are the only way possible to help with the pain of RSD/CRPS, and patients should receive what they need. If recovery is possible from any form of treatment, opiates have to be withdrawn at some time as part of the recovery process. From this standpoint, the less opiate you use the better. There may be other medications that are more effective at reducing pain than opiates anyway such as Lidocaine. Special care with opiates and sedatives in patients with sleep apnea - see below.	No medications	0
	Mild analgesics NSAIDs relaxants antidepressants	1
	Opiate analgesics	2
	Opiate analgesic dose excessive	3

13. Nicotine: Of all the patients we have seen recover from RSD/CRPS, NONE have been smokers! This suggests that if you smoke or use nicotine in other forms, you will not recover. We believe that you cannot benefit long term from any conservative or invasive treatment for this disease if you smoke. If you find it difficult to quit, consult a professional. Ask your doctor if you should consider Zyban, nicotine patches or gum or any other technique.	None	0
	Up to one pack daily	1
	Equivalent of two packs daily	2
	Equivalent of three packs daily	3

14. Ability to work or function at home: Function is the best measure of recovery from RSD/CRPS. As the illness improves it will become easier to perform mechanical tasks without aggravating the symptoms.	Able or ready to function full time	0
	Able or ready to function part time	1
	Volunteer or self determined scheduled work only	2
	Unable to function in any work related capacity	3

15. Sleep and fatigue: Prolonged insomnia drives people psychotic, even if they are otherwise healthy. Insomnia must receive adequate evaluation and treatment in RSD/CRPS and without this, therapeutic imagery and medical hypnosis are much more difficult. Be especially careful if you have obstructive sleep apnea and take opiates such as morphine or methadone. Powerful opiates can supress the drive to breath against airway obstruction. Prolonged apnea during sleep can result in serious lack of oxygen so that recovery may not be possible. If you snore heavily or have obstructive sleep apnea, you must discuss this possibility with your doctor before considering the use of powerful opiate medications. Methadone is particularly slow in onset, so this caution applies particularly to this medication when taken before sleep.	Sleep well, wake rested	0
	Adequate sleep hours, wake tired	1
	Inadequate sleep hours, disturbed sleep	2
	Total or near total insomnia	3

16. Psychological factors: RSD/CRPS is a physcial illness. It is severely stressful so that anxiety and depression are real issues that need to be addressed. In addition, because the majority of patients with RSD/CRPS have a hight dissociative capacity, the pain and stress of the disease leads many patients to zone out, or dissociate, leading to memory problems, confusion, de-realization and other dissociative symptoms. These are normal in RSD but must be addressed before recovery is likely to occur. Be fearlessly truthful with yourself. Are you depressed, anxious or confused? Does your memory play tricks on you? Rate these on the scale to the right of this text.	None - mild	0
	Moderate but has little affect on function	1
	Intrusive	2
	Incapacitating	3

Results: The relationship between scores and severity of the disease shown below was derived by a physician on staff at this clinic. You will probably rate your own illness differently and so your scores may differ from these at different severity of illness. Follow the trends that result from therapy - the trend is very much more important than an isolated number. As you become familiar with the form, the weight you give each question will stabilize and your observations become reproducible.

Point Score	Severity of RSD/CRPS
0 - 6	Healthy people can score up to 6 points using this instrument
7 - 12	Mild disease, full time work sometimes still possible. Heavy or repetitive work will aggravate RSD
13 - 18	Moderate disease, the demands of a schedule become difficult to meet
19 - 26	Severe disease, few patients are able to work or function in any capacity with this score
Over 26	Extreme problem

Please notice that in our experience:

Autogenic techniques such as hypnosis and therapeutic imagery tools to add to the overall treatment plan. Most patients do not benefit from these modalities alone. If you have a high capacity to use hypnosis and your RSD/CRPS has reached an "intractable" stage, you are more likely to gain symptom relief if autogenic techniques are included with your overall treatment plan.
In our experience we have seen that smoking blocks recovery and prevents other modalities being effective. We recommend avoiding invasive therapy unless you have been nicotine free for about 3 weeks.

We very much want to know if this form was helpful. Please write to Dr. Flemming. with suggestions and comments.

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