Complex regional pain syndrome type I in children

Complex Regional Pain Syndrome: Evidence-Based Advances in Concepts and Treatments

PURPOSE OF REVIEW

This review presents the most current information about the epidemiology of complex regional pain syndrome (CRPS), classification and diagnostic criteria, childhood CRPS, subtypes, pathophysiology, conventional and less conventional treatments, and preventive strategies.

RECENT FINDINGS

CRPS is a painful disorder with multifactorial pathophysiology. The data describe sensitization of the central and peripheral nervous systems, inflammation, possible genetic factors, sympatho-afferent coupling, autoimmunity, and mental health factors as contributors to the syndrome. In addition to conventional subtypes (type I and type II), cluster analyses have uncovered other proposed subtypes. Prevalence of CRPS is approximately 1.2%, female gender is consistently associated with a higher risk of development, and substantial physical, emotional, and financial costs can result from the syndrome. Children with CRPS seem to benefit from multifaceted physical therapy leading to a high percentage of symptom-free patients. The best available evidence along with standard clinical practice supports pharmacological agents, physical and occupational therapy, sympathetic blocks for engaging physical restoration, steroids for acute CRPS, neuromodulation, ketamine, and intrathecal baclofen as therapeutic approaches. There are many emerging treatments that can be considered as a part of individualized, patient-centered care. Vitamin C may be preventive. CRPS can lead to progressively painful sensory and vascular changes, edema, limb weakness, and trophic disturbances, all of which substantially erode healthy living. Despite some progress in research, more comprehensive basic science investigation is needed to clarify the molecular mechanisms of the disease so that targeted treatments can be developed for better outcomes. Incorporating a variety of standard therapies with different modes of action may offer the most effective analgesia. Introducing less conventional approaches may also be helpful when traditional treatments fail to provide sufficient improvement.

Pediatric Complex Regional Pain Syndrome With and Without a History of Prior Physical Trauma at Onset

OBJECTIVE

To determine whether differences exist between children with complex regional pain syndrome (CRPS) who identify an inciting physical traumatic event (group T) versus those without such history (group NT).

METHODS

We performed a single-center, retrospective study of children diagnosed with CRPS, 18 years old or younger, presenting between April 2008 and March 2021 and enrolled in a patient registry. Abstracted data included clinical characteristics, pain symptoms, Functional Disability Inventory, psychological history, and Pain Catastrophizing scale for children. Charts were reviewed for outcome data.

RESULTS

We identified 301 children with CRPS, 95 (64%) reported prior physical trauma. There was no difference between the groups regarding age, sex, duration, pain level, function, psychological symptoms, and scores on the Pain Catastrophizing Scale for Children. However, those in group T were more likely to have had a cast (43% vs 23%, P < 0.001). Those in group T were less likely to experience complete resolution of symptoms (64% vs 76%, P = 0.036). There were no other outcome differences between the groups.

DISCUSSION

We found minimal differences in children with CRPS who report a prior history of physical trauma to those who do not. Physical trauma may not play as significant a role as immobility, such as casting. The groups mostly had similar psychological backgrounds and outcomes.

Sex and gender differences in pain

Chronic pain affects 20% of adults and is one of the leading causes of disability worldwide. Women and girls are disproportionally affected by chronic pain. About half of chronic pain conditions are more common in women, with only 20% having a higher prevalence in men. There are also sex and gender differences in acute pain sensitivity. Pain is a subjective experience made up of sensory, cognitive, and emotional components. Consequently, there are multiple dimensions through which sex and gender can influence the pain experience. Historically, most preclinical pain research was conducted exclusively in male animals. However, recent studies that included females have revealed significant sex differences in the physiological mechanisms underlying pain, including sex specific involvement of different genes and proteins as well as distinct interactions between hormones and the immune system that influence the transmission of pain signals. Human neuroimaging has revealed sex and gender differences in the neural circuitry associated with pain, including sex specific brain alterations in chronic pain conditions. Clinical pain research suggests that gender can affect how an individual contextualizes and copes with pain. Gender may also influence the susceptibility to develop chronic pain. Sex and gender biases can impact how pain is perceived and treated clinically. Furthermore, the efficacy and side effects associated with different pain treatments can vary according to sex and gender. Therefore, preclinical and clinical research must include sex and gender analyses to understand basic mechanisms of pain and its relief, and to develop personalized pain treatment.

Long-term biopsychosocial issues and health-related quality of life in young adolescents and adults treated for childhood Complex Regional Pain Syndrome, type 1

OBJECTIVES

Treatment for childhood Complex Regional Pain Syndrome (CRPS) is associated with long-term recovery. The present study aimed to investigate the long-term biopsychosocial status and quality of life in young adolescents and adults after the treatment of childhood CRPS.

METHODS

A 4 year follow-up of individuals with childhood-CRPS, type 1 (n=22; age:12 years (years) [median] at treatment and 17 years at follow-up) was completed. Biopsychosocial status and quality of life were assessed with structured interviews, using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the Strengths and Difficulties Questionnaire (SDQ), the Pediatric Pain Coping Inventory (PPCI), and the Pediatric Quality of Life Inventory (PedsQL). Comparisons were made with normative samples of age-matched controls.

RESULTS

CRPS at follow-up was still present in seven out of 22, and non-CRPS pain symptoms were found in 12 out of 22 individuals. Signs of mental health pain-related problems, including phobias and obsessive-compulsive disorder, were observed in ten out of 19 individuals. Mental well-being, social functioning, and quality of life (SDQ and PedsQL) were independent of pain status (p>0.05). Adaptive pain coping strategies were utilized regardless of pain status (PPCI). Social functioning (p<0.01) and the quality of life (p=0.01) were attenuated and statistically significantly poorer than healthy age-matched young adults but better than for fibromyalgia subjects.

CONCLUSIONS

A subset of individuals treated for childhood-CRPS, type 1 experiences long-term consequences of persistent pain, a decrease in quality of life indicators, and demonstrates significant psychosocial issues. Childhood-CRPS is suggested to be associated with long-term psychosocial consequences and poorer quality of life than found in age-related healthy peers. Subjects treated for childhood CRPS may need a longer clinical follow-up attempting to preclude relapse of CRPS and non-CRPS pain.

A lateralized model of the pain-depression dyad

Chronic pain and depression are two frequently co-occurring and debilitating conditions. Even though the former is treated as a physical affliction, and the latter as a mental illness, both disorders closely share neural substrates. Here, we review the association of pain with depression, especially when symptoms are lateralized on either side of the body. We also explore the overlapping regions in the forebrain implicated in these conditions. Finally, we synthesize these findings into a model, which addresses gaps in our understanding of comorbid pain and depression. Our lateralized pain-depression dyad model suggests that individuals diagnosed with depression should be closely monitored for pain symptoms in the left hemibody. Conversely, for patients in pain, with the exception of acute pain with a known source, referrals in today's pain centers for psychological evaluation should be part of standard practice, within the framework of an interdisciplinary approach to pain treatment.

Team Approach: Complex Regional Pain Syndrome in Children and Adolescents

Children and adolescents with chronic pain are best managed by an interdisciplinary team. In cases of complex regional pain syndrome (CRPS), the interdisciplinary team consists of a pain management specialist, such as an anesthesiologist or physiatrist, a physical therapist, an occupational therapist, a pain psychologist, and an orthopaedist. It may also include other professions, such as a gastroenterologist, psychiatrist, nurse practitioner, nutritionist, endocrinologist, acupuncturist, or social worker. Key factors include rapid recognition of CRPS and the initiation of appropriate treatment, both for the pain syndrome as well as for the orthopaedic injury. Intensive therapies have been shown to be effective in treating CRPS in children. Children often are more responsive to noninvasive treatments than adults.

Utility of Electrical Neuromodulation for Treating Chronic Pain Syndromes in the Pediatric Setting: A Systematic Review

OBJECTIVES

Chronic pain syndromes in children can carry significant threats to psychological well-being, opioid overuse, functional impairments, and severe disability. While several high-level studies, almost exclusively in adults, have demonstrated the utility of implantable electrical neuromodulation systems for treating various chronic pain syndromes, there exists a paucity of pediatric-specific evidence. Unfortunately, evidence and practice patterns established from adults may not be fully translatable to children given differences in disease manifestations and anatomical variances.

MATERIALS AND METHODS

We performed a systematic review using conventional PRISMA methodology to identify studies reporting use of implantable electrical neuromodulation systems in children. The primary outcome parameters collected were analgesic relief and functional benefits. Additionally, previous interventions attempted, neuromodulation parameters, and limitations were collected as reported.

RESULTS

A total of 11 studies was identified, which described 19 patients who were refractory to multidisciplinary pain management strategies. The cohort was mostly adolescent (18/19), suffered from CRPS (14/19), and received SCS (17/19). Nearly all patients, both those with CRPS (13/14) and non-CRPS conditions (4/4), reported significant pain relief and functional recovery following neuromodulation. There were no severe complications reported; limitations included suboptimal benefit or loss of analgesia (3/19), lead or device revision (3/19), and subcutaneous infection (1/19), all of which were congruent with adult outcomes.

CONCLUSION

There exist children with chronic pain refractory to standard of care approaches who could be considered for neuromodulation interventions. The existing data, which was limited and from a low tier of evidence, suggest that these interventions are relatively safe and provide meaningful pain reduction and functional improvements. While not previously reported, we recommend careful consideration of the pubertal growth spurt prior to device lead placement-if reasonable and appropriate-given the possibility of inferior lead migration with physiologic growth in patients with SCS devices or foraminal extrusion in patients with dorsal root ganglion stimulation devices.

Loss-adjusting: Young People's Constructions of a Future Living With Complex Regional Pain Syndrome

OBJECTIVES

Complex Regional Pain Syndrome (CRPS) is a chronic pain condition that can present specific difficulties when occurring in adolescence. There is limited work exploring future narratives of healthy adolescents, and how these may differ for those who have chronic health conditions, but there is no research on the future narratives of adolescents who have CRPS.

MATERIALS AND METHODS

In this study, 50 adolescents (44 females, 5 males, 1 preferred not to say) aged 14 to 25 years (mean=19.8, SD=3.68), completed an online story completion task, with a further sample of 10 completing a follow-up telephone interview.

RESULTS

Story completion data were initially analyzed deductively based on the work of Morley and colleagues using hoped-for and feared-for future codes, revealing higher instances of hope (291 over 48 stories) than fear (99 over 27 stories). These codes were subsequently analyzed alongside the in-depth interview data using inductive thematic analysis, generating 2 themes that represent distinct, yet related, approaches of how adolescents incorporate CRPS into their future narratives: (1) the centrality of loss theme identifies the ways some adolescents described how CRPS brings loss, with narratives focused on how these adolescents imagine such losses continuing into the future, and (2) the adjusting to loss theme illustrates the ways other adolescents were able to imagine a future in which they were able to adjust to the losses which CRPS may bring.

DISCUSSION

CRPS may damage the future plans of adolescents. However, being or learning how to be flexible about these goals, may help them to build more positive future narratives.

Neuropsychological Changes in Complex Regional Pain Syndrome (CRPS)

Complex Regional Pain Syndrome (CRPS) is a poorly understood chronic pain condition of multifactorial origin. CRPS involves sensory, motor, and autonomic symptoms primarily affecting one extremity. Patients can also present with neuropsychological changes such as reduced attention to the CRPS-affected extremity, reminiscent of hemispatial neglect, yet in the absence of any brain lesions. However, this "neglect-like" framework is not sufficient to characterise the range of higher cognitive functions that can be altered in CRPS. This comprehensive literature review synthesises evidence of neuropsychological changes in CRPS in the context of potential central mechanisms of the disorder. The affected neuropsychological functions constitute three distinct but not independent groups: distorted body representation, deficits in lateralised spatial cognition, and impairment of non-spatially-lateralised higher cognitive functions. We suggest that many of these symptoms appear to be consistent with a broader disruption to parietal function beyond merely what could be considered "neglect-like." Moreover, the extent of neuropsychological symptoms might be related to the clinical signs of CRPS, and rehabilitation methods that target the neuropsychological changes can improve clinical outcomes in CRPS and other chronic pain conditions. Based on the limitations and gaps in the reviewed literature, we provide several suggestions to improve further research on neuropsychological changes in chronic pain.

Evaluation of pain in pediatric upper extremity conditions

STUDY DESIGN

Narrative Review.

INTRODUCTION

Hand surgeons and therapists play an important role in the early identification of children at risk of developing chronic or recurrent pain after an upper extremity injury. Early identification of children at risk of developing a pain syndrome is critical because their physical, psychological, and/or social functioning may decline quickly without proper management due to the multidimensional nature of pain.

PURPOSE OF THE STUDY

This article outlines one approach to evaluating upper extremity pain in children to help identify those with, or at risk of, chronic pain.

METHODS

An assessment framework that recognizes the biological, sensory, emotional, and psychosocial components of pain is described.

RESULTS

The key components of a screening evaluation include obtaining a detailed history and a thorough physical examination that involves: systematic upper extremity mapping of sensory thresholds, mapping of sensory disturbances, and screening of self-reported pain intensity, location, descriptors, and interference.

DISCUSSION AND CONCLUSION

The evaluation approach described will enable hand therapists to identify children with upper extremity pain that are at risk of developing a chronic pain and make an early referral to a multidisciplinary pain team that provides education, pharmacological pain management, physical rehabilitation, and psychological treatments.

Recovery from acute pediatric complex regional pain syndrome type I after ankle sprain by early pharmacological and physical therapies in primary care: a case report

Background

Complex regional pain syndrome type I (CRPS I) in children is a serious condition disrupting the family and school life of patients with the condition after it fully develops. It has been emphasized that early diagnosis is closely associated with earlier reduction of pain leading to preferable outcomes.

Objectives

To report a case of acute CRPS I in a boy who was found to develop this condition by a routine visual analog scale (VAS) pain monitoring and who recovered from CRPS I at an early phase by prompt pharmacological, physical, and educational therapies.

Study design

Case report.

Case report

A 12-year-old boy sprained his left ankle while playing soccer and was referred to our clinic 4 days after the injury. At the first visit, he could walk, reporting motion pain with a VAS scale of 80 mm. On day 5, pain intensity increased to 100 mm, and a diagnosis of acute CRPS I was made. On day 7, he could not move the injured ankle; therefore celecoxib and pregabalin were administered, and physical and educational therapies started. On day 35, pain intensity was 0 mm and he could walk and run normally.

Conclusion

Routine monitoring of VAS for every patient in pain is useful to discover an abnormal transition of VAS, enabling the early diagnosis of CRPS I. Inflammation and peripheral or central sensitization are postulated for early development of CRPS I. The present case suggested a combination of physical therapy and pharmacological intervention with celecoxib and pregabalin reduced peripheral and central sensitization.

Continuous Regional Anesthesia and Inpatient Rehabilitation for Pediatric Complex Regional Pain Syndrome

BACKGROUND

Evidence supports treatment of pediatric complex regional pain syndromes (CRPS) with physical and occupational therapy and cognitive-behavioral therapy. Some patients have persistent pain and/or limb dysfunction despite these treatments. We performed a retrospective study of pediatric patients with CRPS treated by continuous epidural or peripheral perineural local anesthetic infusions along with inpatient rehabilitation at Boston Children's Hospital.

METHODS

After approval from the institutional review board, electronic medical records were reviewed for patients treated between September 2003 and September 2014. Primary outcomes were pain and functional scores. Data were collected at the first encounter, at follow-up visits between 4 months before and after admission, and daily while inpatient. Changes over time were assessed using Wilcoxon tests with Dunn corrections. Clinical significance of benefit or harm was assessed by the method of Jacobson and Truax. Response predictors were analyzed using linear mixed models and exploratory logarithmic regression analyses.

RESULTS

Pain, function, and disability scores improved during hospitalization and in follow-up over a 4-month period. Seventy percent of patients achieved clinically significant benefit (56% for pain reduction and 40% increased functionality, respectively). Univariate and adjusted predictors of favorable outcome included preadmission resting Numeric Pain Rating Scale score of less than 6 (odds ratio, 5.0; P = 0.0164 and subsequent attendance at the Pediatric Pain Rehabilitation Center at Boston Children's Hospital (odds ratio, 5.0; P = 0.0206). Mean pain scores greater than 3 during the regional anesthesia infusion predicted less favorable outcome.

CONCLUSIONS

Continuous regional anesthesia may be an option to facilitate intensive rehabilitation for selected pediatric patients with CRPS. Further research should help clarify the role of regional anesthesia in a comprehensive management program.

Pediatric Pain Syndromes and Noninflammatory Musculoskeletal Pain

Chronic musculoskeletal pain (CMP) is one of the main reasons for referral to a pediatric rheumatologist and is the third most common cause of chronic pain in children and adolescents. Causes of CMP include amplified musculoskeletal pain, benign limb pain of childhood, hypermobility, overuse syndromes, and back pain. CMP can negatively affect physical, social, academic, and psychological function so it is essential that clinicians know how to diagnose and treat these conditions. This article provides an overview of the epidemiology and impact of CMP, the steps in a comprehensive pain assessment, and the management of the most common CMPs.

Complex regional pain syndrome in children: a systematic review of clinical features and movement disorders

Aim: To ascertain clinical features of complex regional pain syndrome (CRPS) in children with a focus on movement disorders. Methods: all publications with original data on children with CRPS were assessed. Data were tabulated and descriptive statistics were applied. Results: One population-based study and nine clinic-based studies provided data on demographic and clinical characteristics of childhood CRPS. Mean age of onset was 12.5 years and 85% of patients were females (risk ratio: 1.70; 95% CI: 1.54−1.88). History of trauma in 71% and the lower limbs were affected in 75% of patients. A secondary site involvement was present in 15%. Movement disorders and dystonia were reported in 30% of children. Conclusion: Majority of cases of CRPS in children are females with mean age of 12.5 years. Movement disorders (mainly dystonia) affect at least one in three children with CRPS.

[Pain syndrome of the musculoskeletal system in children and adolescents]

Chronic pain syndromes in children and adolescents are defined as continuous or recurrent pain without an underlying causative diagnosis and lasting for more than 3 months. It is estimated that every fourth child in Germany suffers from chronic pain with every twentieth suffering from extreme recurrent pain. The incidence of chronic pain in children and adolescents is increasing with headache, abdominal pain and musculoskeletal pain being the most frequent. The quality of life declines not only due to the pain but to relieving postural and psychological factors, such as fear and sadness. School attendance, social activities and hobbies are mostly affected. This review summarizes the background of chronic pain syndromes and introduces a multimodal therapeutic approach.

Spontaneous recurrent episodes of wrist pain in a 16-year-old girl: a case of complex regional pain syndrome

CRPS in children may imitate rheumatologic diseases, but should be considered if typical signs are present. Diagnosis can be supported by three-phase bone scintigraphy.

Introduction: Complex regional pain syndromes (CRPS) are disabling pain syndromes that can develop after minor tissue injury or trauma and are characterized by sensory, motor, and autonomic abnormalities distributed in a glove-like or stocking-like manner. Complex regional pain syndrome is well known in adults, but is relatively rare in children. Most of the reported cases of CRPS in children are clinical diagnoses that are not supported by examinations such as three-phase bone scintigraphy. Furthermore, different centres often use different diagnostic criteria for CRPS, which sometimes questions the diagnosis of CRPS.

Objective/Methods: Although, recurrences and in particular relapses of CRPS have been observed, a periodically, nearly self-limiting course of disease without any residues in pain-free episodes and without any new obvious injury in CRPS is rather unusual. We present the case of a 16-year-old girl who reported recurrent spontaneous pain which lasted for 2 to 3 weeks and occurred approximately 2 times a year after the patient had experienced a mild trauma 3 years ago.

Results: The pain was accompanied by swelling, temperature asymmetry, and decreased range of motion of the right hand without any complains in pain-free episodes. Recurrent symptoms occurred without any obvious trauma. Diagnosis of CRPS was made from clinical findings including quantitative sensory testing, increased periarticular radioisotope uptake in the delayed phase of three-phase bone scintigraphy and examination during anaesthesia. Multimodal inpatient pain treatment resolved her symptoms substantially.

Conclusion: Complex regional pain syndrome in children may imitate rheumatologic diseases, and the course is different from adults despite similar clinical findings.

Complex regional pain syndrome in children: incidence and clinical characteristics

OBJECTIVE

To study the clinical and epidemiological characteristics of complex regional pain syndrome (CRPS) in children.

PATIENTS AND METHODS

All children and adolescents under 16 years of age with a new diagnosis of CRPS who were reported to the Scottish Paediatric Surveillance Unit were included. Patients' recruitment ran between 1 November 2011 and 31 October 2015. Information was collected on patients' demography, clinical features, investigations, management and impact of disease on child and family. The diagnosis of CRPS was made on fulfilling the clinical criteria of the International Association for the Study of Pain.

RESULTS

26 cases of CRPS were reported over 4 years, giving a minimum estimated incidence of 1.16/100 000 (95% CI 0.87 to 1.44/100 000) children 5-15 years of age. Nineteen patients were female (73%) and mean age at diagnosis was 11.9 (range 5.5-15.4 years). The median interval between onset of symptoms and diagnosis was 2 months (range 1-12). The majority of children have single site involvement, with legs been more often affected than arms and the right side is more often affected than the left. There was a clear trauma at onset of the illness in 19 children and possible nerve injury in one. All investigations were normal and several treatment modalities were used with variable success. The disease had significant impacts on the patients' education and family lives.

CONCLUSIONS

The estimated incidence of CRPS is 1.2/100 000 children 5-15 years old. The diagnosis of CRPS is often delayed. CRPS has a significant impact on children and their families.

The Pharmacological Management of Complex Regional Pain Syndrome in Pediatric Patients

The awareness of complex regional pain syndrome (CRPS) in the pediatric population is increasing. The condition involves regional pain that is out of proportion to any initiating event (if there is one) and is associated with sensory, functional, autonomic, and inflammatory changes in the region of the pain. The signs and symptoms of CRPS can vary between patients and stage of the disease process. Like many chronic pain conditions, it is often associated with significant disability and a detrimental effect on quality of life. It has a complex pathophysiology that remains poorly understood but provides many potential targets for treatments. Management involves a biopsychosocial formulation that encompasses physical and psychological interventions alongside pharmacological strategies. We review the current evidence for the treatment of this condition in children, with particular reference to pharmacological management.

Pediatric complex regional pain syndrome: a review

Complex regional pain syndrome (CRPS) is a chronic, intensified localized pain condition that can affect children and adolescents as well as adults, but is more common among adolescent girls. Symptoms include limb pain; allodynia; hyperalgesia; swelling and/or changes in skin color of the affected limb; dry, mottled skin; hyperhidrosis and trophic changes of the nails and hair. The exact mechanism of CRPS is unknown, although several different mechanisms have been suggested. The diagnosis is clinical, with the aid of the adult criteria for CRPS. Standard care consists of a multidisciplinary approach with the implementation of intensive physical therapy in conjunction with psychological counseling. Pharmacological treatments may aid in reducing pain in order to allow the patient to participate fully in intensive physiotherapy. The prognosis in pediatric CRPS is favorable.

Complex Regional Pain Type 1

Complex regional pain syndrome is increasingly recognized in the pediatric population. Owing to the nature of presentation with pain, many of these children present to the emergency setting at different stages of the syndrome with or without numerous prior interactions with health professionals. Complex regional pain syndrome type 1 (CRPS1) is a clinical syndrome characterized by amplified musculoskeletal limb pain that is out of proportion to the history and physical findings, or pain due to non-noxious stimuli (allodynia/hyperalgesia), and accompanied by one or more signs of autonomic dysfunction. Differential diagnosis may include significant trauma (eg, fractures), inflammatory conditions, malignancies, and systemic illness. The diagnosis is clinical. The treatment goals for CRPS1 are restoration of function and relief of pain. Education, physical, and occupational therapy with psychotherapy and defined goals of achievement with reward are the mainstay of treatment for this population. Most children with CRPS1 will have a favorable outcome.

Complex regional pain syndrome type I in children. Clinical description and quality of life

INTRODUCTION

Complex regional pain syndrome type 1 (CRPS I) in children differs from its adult counterpart and relevant literature is scarce. Our aim was to investigate potential risk factors and to assess midterm outcome and quality of life.

MATERIAL AND METHODS

Medical records of patients diagnosed with CRPS I between 2004 and 2012 were analyzed. Patients and parents were called for a phone interview including the PEDS Quality of Life 4-0 questionnaire. Results were compared to a control group matched for age, gender and socio-economic status.

RESULTS

Seventy-three patients were included (64 girls, 9 boys). Mean age at diagnosis was 11.5 years and mean time to diagnosis was 14.2 months. The lower limb was affected in 89% of cases. Allodynia, coldness and cyanosis were noted in 95%, 81% and of 74% of cases, respectively. Forty-nine percent of patients reported a physical injury. Multivariate analysis showed a strong association with being anxious (OR = 44.9, 95% CI [7.4-273]), presence of an atopic background (OR = 25.0, 95% CI: [4.6-135]), being good to excellent school performers (OR = 8.4 95% CI [1.3-52.1]), and having trouble falling asleep (OR = 5.3, 95% CI [1.6-17.0]). At a mean 37 months' follow-up (12-102), PEDS QL 4-0 score was significantly lower in CRPS patients compared to controls. Fifty-seven percent of patients acknowledged healing and 55% had presented a relapse.

CONCLUSION

Childhood onset CRPS I affects predominantly preadolescent girls at the ankle. The present study highlights the relatively poor outcome, especially its physical and emotional aspects and the large role of psychology.

LEVEL OF EVIDENCE

IV.

An update on complex regional pain syndromes in children and adolescents

PURPOSE OF REVIEW

Complex regional pain syndrome (CRPS) is a chronic pain condition typically involving a limb, which is characterized by neuropathic pain, sensory abnormalities and neurovascular findings. The exact cause of CRPS is unknown; however, proposed theories include alterations in the sympathetic and central nervous system (CNS), small fibre changes in the peripheral nervous system and psychological factors. Although this condition was previously considered rare among children and adolescents, it has been increasingly recognized in paediatric patients and can result in significant disability.

RECENT FINDINGS

The diagnosis of paediatric CRPS is based upon clinical criteria obtained from a thorough history and physical examination. Other possible causes, such as orthopaedic, infectious, vascular and rheumatologic disorders, should be ruled out prior to making the diagnosis. Treatment focuses on a rehabilitative strategy consisting of physical therapy, occupational therapy and cognitive-behavioural therapy with an overall focus on return to functioning.

SUMMARY

CRPS in children and adolescents is characterized by a painful, mottled appearing, swollen limb with allodynia and hyperalgesia. For most patients, pain is severe, resulting in significant functional disability. More recent evidence suggests that a rehabilitative programme results in improvement in both pain and functional measures.

Psychological distress and stressful life events in pediatric complex regional pain syndrome

BACKGROUND

There is little knowledge regarding the association between psychological factors and complex regional pain syndrome (CRPS) in children. Specifically, it is not known which factors precipitate CRPS and which result from the ongoing painful disease.

OBJECTIVES

To examine symptoms of depression and anxiety as well as the experience of stressful life events in children with CRPS compared with children with chronic primary headaches and functional abdominal pain.

METHODS

A retrospective chart study examined children with CRPS (n=37) who received intensive inpatient pain treatment between 2004 and 2010. They were compared with two control groups (chronic primary headaches and functional abdominal pain; each n=37), who also received intensive inpatient pain treatment. Control groups were matched with the CRPS group with regard to admission date, age and sex. Groups were compared on symptoms of depression and anxiety as well as stressful life events.

RESULTS

Children with CRPS reported lower anxiety and depression scores compared with children with abdominal pain. A higher number of stressful life events before and after the onset of the pain condition was observed for children with CRPS.

CONCLUSIONS

Children with CRPS are not particularly prone to symptoms of anxiety or depression. Importantly, children with CRPS experienced more stressful life events than children with chronic headaches or abdominal pain. Prospective long-term studies are needed to further explore the potential role of stressful life events in the etiology of CRPS.

Invasive Treatments for Complex Regional Pain Syndrome in Children and Adolescents

This review aimed to synthesize the current evidence on the effectiveness of invasive treatments for complex regional pain syndrome in children and adolescents. Studies on children and adolescents with complex regional pain syndrome that evaluated the effects of invasive treatment were identified in PubMed (search March 2013). Thirty-six studies met the inclusion criteria. Articles reported on a total of 173 children and adolescents with complex regional pain syndrome. Generally, many studies lack methodological quality. The invasive treatments applied most often were singular sympathetic blocks, followed by epidural catheters and continuous sympathetic blocks. Rarely, spinal cord stimulation and pain-directed surgeries were reported. An individual patient frequently received more than one invasive procedure. Concerning outcome, for approximately all patients, an improvement in pain and functional disability was reported. However, these outcomes were seldom assessed with validated tools. In conclusion, the evidence level for invasive therapies in the treatment of complex regional pain syndrome in children and adolescents is weak.

Complex regional pain syndrome in a 15-year-old girl successfully treated with continuous epidural anesthesia

A 15-year-old girl developed severe pain in her right upper limb within a few days after she experienced an astatic epileptic seizure accompanied by falling on her right side. She was treated with fluid infusion through a cannula into her right hand. Swelling, mild flaring, and muscle weakness of the right arm subsequently appeared. Pharmacotherapy and stellate ganglion block were ineffective, and continuous epidural anesthesia was commenced 14 days after the falling event. The pain and accompanying symptoms completely disappeared within 5 days. Early treatment with continuous epidural anesthesia may be a promising option for the management of complex regional pain syndrome during childhood.

Management of Bilateral Complex Regional Pain Syndrome in a Pediatric Patient

PURPOSE

To describe the physical therapy management of a pediatric patient with bilateral lower extremity complex regional pain syndrome (CRPS).

CASE DESCRIPTION

The participant was a 13-year-old adolescent girl who was admitted to an inpatient rehabilitation unit with bilateral lower extremity CRPS-I. Examination included assessment of lower extremity active range of motion, transfers, mobility, and completion of the Functional Independence Measure for Children (WeeFIM). Intervention consisted of gradual desensitization techniques, progressive weight bearing and mobility, functional transfer training, progressive strengthening, and cardiovascular exercises-all conducted using a modified pain exposure therapy approach.

OUTCOME

WeeFIM scores increased to modified independence or independent in all areas.

DISCUSSION

The severity of the patient's CRPS necessitated a progressive and function-based approach to physical therapy management. Motivation, a pain exposure-based approach, and a multidisciplinary team approach appeared to affect the participant's recovery of function and reintegration into school and leisure activities.

The incidence of idiopathic musculoskeletal pain in children with upper extremity injuries

INTRODUCTION

Children with upper extremity injuries may report persistent pain beyond the period of acute injury. In the published literature, it is unclear whether these children develop idiopathic musculoskeletal pain (IMP) such as complex regional pain syndrome (CRPS). The purpose of this study was to determine the incidence rate of IMP after upper extremity injury in school-aged children over a 5-year period and to describe the characteristics of these children.

METHODS

A retrospective case series was conducted of all children aged 8-18 years with an upper extremity injury who attended the outpatient hand clinic in a tertiary care pediatric hospital.

RESULTS

A reported incidence rate of IMP was 1.9% over a 5-year period in the 879 children reviewed. Girls were more likely to have IMP. The categorical distribution of the type, etiology and anatomical location of injury was proportionately different for those with IMP compared to those without documentation of IMP. In comparison, a higher percentage of children with IMP reported disproportionate pain and hypersensitivity or neuropathic pain symptoms compared to the children who had pain from a known etiology.

CONCLUSION

The incidence rate of IMP after upper extremity injury in school-aged children is low. Some common characteristics of this population that may help clinicians identify these children and make timely referrals for treatment include female gender, disproportionate pain, previously seen by multiple specialists, generalized injury in the hand, unspecific etiology or type of injury and unremarkable x-rays.

Complex regional pain syndrome type 1 in a pediatric patient: Case report

Complex regional pain syndrome type 1 is one of the causes of morbidity of childhood which is also named reflex symphathetic dystrophia. The syndrome is characterized with regional pain and vasomotor, sudomotor and sensory changes in the distal parts of the extremities involved. Complex regional pain syndrome type 1 shows difference in children in terms of clinical picture and imaging methods compared to adults. The most important point is that the prognosis is generally better in children if early diagnosis and treatment is provided. On the other hand, causes including presence of psychological factors or less contribution of imaging methods in children lead to delayed diagnosis or erroneous diagnosis. In this article, a 10 year-old male patient who was diagnosed with complex regional pain syndrome type 1 was described. Thus, we aimed to remind clinicians that this syndrome should also be kept in mind in the differential diagnosis of pain in children.

Children and adolescents with complex regional pain syndrome: more psychologically distressed than other children in pain?

BACKGROUND

Historically, in both adult and pediatric populations, a lack of knowledge regarding complex regional pain syndrome (CRPS) and absence of clear diagnostic criteria have contributed to the view that this is a primarily psychiatric condition.

OBJECTIVE

To test the hypothesis that children with CRPS are more functionally disabled, have more pain and are more psychologically distressed than children with other pain conditions.

METHODS

A total of 101 children evaluated in a tertiary care pediatric pain clinic who met the International Association for the Study of Pain consensus diagnostic criteria for CRPS participated in the present retrospective study. Comparison groups included 103 children with abdominal pain, 291 with headache and 119 with back pain. Children and parents completed self-report questionnaires assessing disability, somatization, pain coping, depression, anxiety and school attendance.

RESULTS

Children with CRPS reported higher pain intensity and more recent onset of pain at the initial tertiary pain clinic evaluation compared with children with other chronic pain conditions. They reported greater functional disability and more somatic symptoms than children with headaches or back pain. Scores on measures of depression and anxiety were within normal limits and similar to those of children in other pain diagnostic groups.

CONCLUSIONS

As a group, clinic-referred children with CRPS may be more functionally impaired and experience more somatic symptoms compared with children with other pain conditions. However, overall psychological functioning as assessed by self-report appears to be similar to that of children with other chronic pain diagnoses. Comprehensive assessment using a biopsychosocial framework is essential to understanding and appropriately treating children with symptoms of CRPS.

Complex regional pain syndrome in children: asking the right questions

BACKGROUND

Complex regional pain syndrome (CRPS) is a painful disorder without a known unifying mechanism. There are little data on which to base evaluation and treatment decisions, and what data are available come from studies involving adults; however, even that literature is relatively sparse. Developing robust research for CRPS in children is essential for the progress toward optimal treatment.

OBJECTIVES

To determine potential avenues of research in pediatric CRPS based on a review of the literature. Areas of concern include diagnostic criteria, peripheral mechanisms, central nervous system mechanisms, the role of the autonomic nervous system, possible risk factors, options for prevention and potential avenues of treatment.

METHODS

A literature review was performed and the results applied to form the hypotheses posited in the form of research questions.

RESULTS AND CONCLUSIONS

CRPS is a complicated entity that is more than a painful sensory condition. There is evidence for peripheral inflammatory and neurological changes, and reorganization in both sensory and motor cortexes. In addition, a significant motor component is frequently observed and there appear to be tangible risk factors. Many of these pieces of evidence suggest options for prevention, treatment and monitoring progress and outcome. Most of the data are derived from adult studies and need to be replicated in children. Furthermore, there may be factors unique to pediatrics due to developmental changes in neuroplasticity as well as somatic, endocrinological and emotional growth. Some of these developmental factors may shed light on the adult condition.

[Please don't hurt me!: a plea against invasive procedures in children and adolescents with complex regional pain syndrome (CRPS)]

BACKGROUND

Complex regional pain syndrome (CRPS; formerly known as Morbus Sudeck/reflex dystrophy) is diagnosed in children and adolescents, but the clinical presentation is often atypical. Unfortunately, potentially harmful, invasive treatments are used in pediatric patients.

PATIENTS AND METHODS

A retrospective chart study of pediatric chronic pain patients with CRPS was performed.

RESULTS

Over the course of 6 years, 37 (35 girls) children and adolescents took part in a multidisciplinary chronic pain inpatient program. At admission, patients took on average 4.4 (range 1-10) different medications and 29 different pharmaceuticals were used overall. Prior to admission, invasive pain treatments were performed without success in 16 of the children (43%). At least 13 children received two or more invasive treatments. Although sympathetic blocks were most prevalent, operations and regional anesthesia were also used.

CONCLUSION

Despite a lack of evidence for invasive procedures, these continue to be used in children and adolescents with CRPS, who later respond positively to conventional treatment. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Complex regional pain syndrome of the pediatric lower extremity: a retrospective review

BACKGROUND

Complex regional pain syndrome (CRPS) type 1 is a disorder of the extremities characterized by pain, edema, limited range of motion, integument changes, and vasomotor instability often after an inciting event. In the pediatric population, CRPS may be misdiagnosed, or missed entirely, as CRPS literature for this patient population is lacking.

METHODS

Twenty-seven pediatric patient medical records with the diagnosis of CRPS type 1 from the institutional and private practices of the principal investigator (E.J.H.) were reviewed for demographics, inciting event, lower-extremity clinical examination, ancillary testing, previous treatments, time to diagnosis, treatment after diagnosis, and time to resolution of symptoms.

RESULTS

Females composed 85.2% of the patient population (n = 23) (mean age of females, 11.11 years). An inciting event preceded pain in 74.1% of patients (n = 20). On physical examination, more than 50% of patients were identified as having changes in skin color and temperature, edema to the affected lower extremity, painful or decreased range of motion in affected joints, and intact lower-extremity motor function. The average time to resolution of symptoms was 6.8 weeks for the entire population.

CONCLUSIONS

Diagnosis of CRPS type 1 should be considered in a preadolescent female complaining of pain out of proportion after an inciting event with a physical examination demonstrating change in skin color, decrease in skin temperature, edema, and painful or diminished range of motion in affected joints. Prompt diagnosis can decrease the time to resolution of symptoms.

The successful use of pamidronate in an 11-year-old girl with complex regional pain syndrome: response to treatment demonstrated by serial peripheral quantitative computerised tomographic scans

Complex regional pain syndrome (CRPS) is a disorder that can cause significant functional morbidity. While it usually presents in adulthood, it has also been reported in children. Multiple treatment modalities have been reported with mixed success. Bisphosphonate therapy has been shown to be effective in adult patients, but there are limited data in children. We report the successful use of intravenous pamidronate therapy in diminishing pain, improving function, and restoring bone mass in an 11-year-old girl with CRPS of her left lower limb following a tibial fracture. Previous treatment with intense physiotherapy and regional sympathetic blockade had not improved her symptoms. Pain improved within weeks of the first pamidronate infusion, with subsequent improvement in function. The benefit in pain reduction and function was sustained during the 2-year treatment regime. Improvement in bone mass and density was demonstrated by dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computerised tomography (pQCT). pQCT scans showed marked improvement in bone size and geometry and muscle bulk on the affected side. No adverse affects were reported. We conclude that intravenous pamidronate was associated with reduced pain, a return of function, and recovery of bone and muscle parameters in a child with CRPS. Before definitive conclusions can be drawn, a randomised controlled trial similar to those undertaken in adults previously is required to fully validate this approach.

Neuropathic pain in children: Special considerations

Neuropathic pain is relatively uncommon in children. Although some syndromes closely resemble those found in adults, the incidence and course of the condition can vary substantially in children, depending on developmental status and contextual factors. There are some neuropathic pain syndromes that are rare and relatively unique to the pediatric population. This article discusses the array of neuropathic pain conditions in children and available treatment strategies. Data are limited by small numbers and few randomized controlled trials. Research and clinical implications are discussed.

Spinal cord stimulation: "neural switch" in complex regional pain syndrome type I

INTRODUCTION

Complex regional pain syndrome type I (CRPS I) is a neuropathic pain disorder of unclear etiology. It commonly follows a trivial injury and is characterized by spontaneous pain manifesting regionally that is disproportionate to the inciting event. Associated signs and symptoms include allodynia, hyperalgesia, edema, sudomotor, vasomotor abnormalities, and trophic changes. Although multiple modalities exist to treat CRPS I, significant disability, diminution in quality of life, and reduction in overall health often accompany the syndrome.

CASE

A case of a 57-year-old man with CRPS I who was treated with spinal cord stimulation (SCS) after failing conservative therapy is presented. One month following treatment, he experienced complete symptom resolution such that stimulation was subsequently discontinued without recurrence over the 1-year follow-up period.

CONCLUSIONS

To date there is currently no reliably validated "cure" for CRPS. There has only been one recent report where SCS resulted in the complete eradication of the signs and symptoms associated with CRPS. This series involved adolescent girls aged 11-14 years of age, who tend to have a more benign and self-limited treatment course than that seen in adults. This raises the question as to whether a "neural switch" exists, and if so, where it is located. We postulate that the inter-neuronal connections between the central and peripheral nervous systems implicated by the current pathophysiological model is the most plausible site of this "neural switch," and that reorganization of this interface can account for the ability of SCS to effect a complete "cure" in CRPS.