Similarly, another study showed increases in pro-inflammatory cytokines interleukin-1b IL-1b , interleukin-6 IL-6 , but not in tumor necrosis factor alpha TNF-a in the cerebrospinal fluid CSF of 24 CRPS patients ages 17—60 years, compared 16 controls, [ 32 ]. However, no direct connection was found between CRPS and a previous infection, with Parvovirus B19 or any of the other microorganisms screened in the study [ 33 ]. There have been several case reports of pediatric CRPS that occurred following vaccinations [ 34 — 36 ].
Lending Library Subjects
Currently there is no information regarding pediatric CRPS and a positive history of allergies. There have been reports of familial occurrence of CRPS, though no specific inheritance pattern or gene has been discovered [ 38 — 40 ]. All the children met the established criteria for mitochondrial disease, with six of the seven families meeting the criteria for maternal inheritance. Pediatric CRPS patients display a variety of sensory and motor findings, which can be linked to altered response and lower threshold of the central, autonomic and peripheral nervous systems.
Common clinical features include pain and higher sensitivity to painful and non-painful stimuli of the affected limb, autonomic findings, motor disturbances, and trophic changes changes resulting from interruption of nerve supply [ 3 , 5 , 14 , 47 , 48 ]. All patients describe constant pain in the affected limb, even at rest.
The pain increases with movement of the limb [ 5 , 14 , 47 ]. If the patient recalls a precipitating event, the pain is usually disproportionate to it [ 3 ]. Most patients suffer from allodynia when an ordinarily nonpainful stimulus elicits pain , other common manifestations are hyperalgesia when a mildly painful stimulus elicits intense pain [ 4 , 6 , 14 , 47 ].
Most patients describe their pain as burning, shooting, stabbing or electrical [ 14 ]. Patients can present with muscle weakness and muscle atrophy varying from mild to moderate to severe, mostly due to lack of use from chronic pain [ 14 , 47 ]. Patients may present with crutches or in a wheelchair due to chronic limb disuse. However, it is important to first rule out other causes for muscle weakness and atrophy, such as neuromuscular disorders, when a patient demonstrates with muscle weakness and atrophy.
Complex Regional Pain Syndrome Fact Sheet
In such cases, one must consider a more extensive evaluation, including muscle MRI, nerve conduction tests and muscle biopsy. Autonomic findings of the affected limb include swelling and edema, temperature changes usually the affected limb is cooler , hyperhidrosis, changes in skin color, cyanosis and sensitivity to cold, and mottled, dry skin [ 3 , 5 , 47 ]. With time, trophic skin changes ensue in the affected limb, such as a decrease or increase in hair and nail growth [ 14 , 47 ]. Different motor disturbances have been described among pediatric CRPS patients, such as weakness, dystonia, tremors, spasms and fasciculations [ 14 , 48 ].
They found that the most common motor disturbance was dystonia, predominantly characterized by tonic flexion posture, followed by tremor and myoclonus [ 48 ]. The clinical diagnosis of CRPS is based on a thorough history and physical examination, with a meticulous neurologic assessment.
The physical examination is usually non-revealing, with a normal neurologic examination, allodynia and signs of autonomic dysfunction might be present [ 20 ]. When there is doubt in the diagnosis, the initial inquiry usually includes laboratory examination, imaging including plain radiographs, MRI, computed tomography [CT] and bone scans and may include an electromyography EMG of the affected limb.
Baseline laboratory tests include a complete blood count, blood chemistry, C-reactive protein CRP , erythrocytes sedimentation rate ESR , creatinine kinase and antinuclear antibody ANA. Usually CRPS patients have normal laboratory values. Imaging findings are normal, however, if the duration of the disease is prolonged or the degree of disability is very high, imaging modalities can demonstrate osteoporosis due to disuse [ 20 ].
A bone scan might report decreased isotope uptake of the affected limb. MRI can reveal marrow edema [ 49 ]. There is no gold standard diagnostic test for CRPS in the pediatric or adult population. Therefore, several diagnostic criteria have been developed. These criteria have not been formally validated in the pediatric population. Budapest clinical diagnostic criteria for CRPS [ 53 ].
As previously mentioned, the diagnosis of CRPS is a clinical one, based on a meticulous history and physical examination which includes a thorough neurologic assessment. When the history or physical examination arouses suspicion of an active thyroid disease, thyroid function test should be performed as well. It is also recommended to perform a plain radiograph if not previously performed of the affected limb to rule out any localized pathology to the bones, joints and surrounding tissue. Usually, no further diagnostic evaluations are needed if there are no abnormal findings in the initial diagnostic workup.
However, if the initial diagnostic workup suggests a different diagnosis, such as infection, a rheumatic disease, or a malignancy, further laboratory and imaging test are needed.
Pediatric complex regional pain syndrome: a review
The scope of therapy includes an intensive physical therapy program combined with cognitive behavioral therapy CBT intervention. A Cochrane review published in on interventions for treating pain and disability in adults with CRPS concluded that there was a lack of high quality evidence for most CRPS therapies [ 55 ]. In , The American Pain Society published a position statement on assessing and managing children with chronic pain.
It recommended the use of interdisciplinary treatment programs for children with chronic pain, which incorporate CBT with physical and occupational rehabilitation [ 56 ]. However, there is no consensus regarding the duration, intensity or content of treatment. Gradually increasing aerobic activity is the gold standard therapy for CRPS.
You are here
Several good outcomes with PT and other mobilization treatments for pediatric CRPS, alone and in addition to other therapeutic modalities have been reported [ 3 , 5 , 6 , 58 — 62 ]. In a recent study, Dietz et al. They assigned 28 patients to receive either low frequency PT once a week or high frequency PT three times a week.
Additionally, both groups had weekly CBT. Pain and function measures improved significantly in both groups, no significant difference was found between the two groups at follow-up [ 59 ]. Very intense exercise programs have been found helpful for pediatric CRPS.
For instance, Sherry et al. Brooke and Janselewitz reported complete resolution of pain in 25 of 32 children with CRPS after intensive inpatient rehabilitation, which consisted of physical, occupational, and psychological therapy, with no other medical intervention, followed by a home program [ 60 ]. A study of a day hospital pediatric pain rehabilitation program performed by Logan et al. They found statistically significant improvements from admission to discharge in pain intensity, functional disability, subjective reports of limb function and occupational performance, these functional gains were maintained or further improved at follow-up [ 61 ].
Psychological therapies are a mainstay in the treatment of pediatric CRPS, and are recommended as an integral part of the interdisciplinary treatment approach [ 56 ]. Patients and their families should undergo psychological assessment in order to understand and properly address possible issues, whether they are individual, familial, social or academic [ 20 ]. There are no current large, prospective, blinded, placebo-controlled studies of the efficacy of cognitive and behavioral strategies for treating CRPS, in adults or children.
However, the usefulness of psychological treatments has been demonstrated in many studies of pediatric patients with chronic pain [ 63 — 67 ]. A recent Cochrane review published in [ 68 ] discussing psychological therapies for the management of chronic and recurrent pediatric pain concluded that psychological therapies were effective in reducing pain intensity for children with headache and non-headache pain conditions; yet, long-term pain control effects were maintained only for children with headache conditions.
In addition, they found limited evidence available to estimate the effects of psychological therapies on depression and anxiety in children with chronic pain. The use of the internet as a mode of delivery of psychological interventions for children and adolescents with chronic pain and their families is an important new development. A Cochrane review published in examined the yield of remotely delivered psychological therapies in managing chronic and recurrent pediatric pain [ 69 ]. Conclusions were that remotely delivered psychological therapies, primarily via the internet, confer benefit in reducing the intensity or severity of pain in pediatric chronic pain conditions.
However, the long-term effects of this treatment modality could not be ascertained due to lack of follow-up data. In addition, because only eight studies including children contributed to the results there is considerable uncertainty around these estimates of effect.
- Account Options.
- les nabis (French Edition)?
- Сведения о продавце!
- Complex Regional Pain Syndrome (CRPS) Explained;
The final conclusion was that large scale trials are needed to fully ascertain the efficacy of remotely delivered psychological therapies. Subsequently, Palermo et al. A total of adolescents ages 11—17 with mixed chronic pain conditions participated in the study along with their parents. They were assessed prior to and immediately following treatment and at 6-month follow-up. This research opens the door to a possible widespread, easily accessible treatment modality for pediatric chronic pain patients.
To date, there are no specific pharmacological treatments recommended for pediatric CRPS and no large scale, clinical trials of any medications are being conducted. Nonsteroidal anti-inflammatory drugs NSAIDs and paracetamol are common over-the-counter medications; thus, they are readily available to patients when chronic pain symptoms first appear. In a clinical study by Wilder et al. Amitriptyline and phenytoin have been used in cases of pediatric CRPS, usually in addition to physical therapy and sometimes in combination with an antiepileptic drug, mostly gabapentin. Some patients reported improvement [ 3 , 5 , 12 , 70 ].
There are few case reports describing the use of gabapentin for the treatment of pediatric CRPS patients [ 3 , 5 , 71 — 73 ]. These drugs were usually given early on, in order to facilitate physiotherapy, and were reduced and finally discontinued when symptoms subsided [ 3 ]. Small case series on the use of oral steroids in pediatric CRPS did not show any perceived clinical effect [ 5 , 74 ].
Ketamine is an anesthetic with an analgesic effect; it is an NMDA receptor antagonist. It can cause psychomimetic side effects, which can produce delirium and hallucinations. There are studies among adult patients of the efficacy of ketamine infusions for CRPS [ 75 — 78 ]. In a study of 60 adult CRPS patients, pain scores over the week treatment period were significantly lower among the group who received ketamine than the group receiving a placebo; however, at week 12, the significance in pain relief between groups was lost.
In addition, the treatment did not lead to any functional improvement [ 78 ]. Moreover, additional studies show that when there is a response to ketamine treatment, the duration of its effect can be limited, from a few weeks to two months [ 76 , 77 ]. One case report described an adolescent CRPS patient treated successfully with a combination of a continuous sciatic peripheral nerve block and parenteral ketamine infusion [ 79 ]. In a study of oral ketamine treatment for children with chronic pain, 5 of 12 participants reported an improvement in pain scores.
A few non-controlled reports support the use of bisphosphonates, mainly in early stages [ 81 ]. In a recent review [ 82 ] of invasive treatments for CRPS in children and adolescents, the more commonly used invasive treatments were single sympathetic blocks, followed by epidural catheters and continuous sympathetic blocks. Far less common were reports of spinal cord stimulation and pain-directed surgeries. Most invasive treatments were performed several times in an individual patient, in particular sympathetic blocks, with an average of two treatments per patient range 1— Regarding the outcome of these invasive treatments, reports were of improvement in pain and functional disability scores in almost all patients.
However, outcomes were seldom assessed with validated tools. To date there are no specific, large, prospective, blinded, placebo-controlled studies of invasive treatments in pediatric CRPS. There are, however, many case reports and small case studies on use of these treatment modalities. Invasive treatments for CRPS carry a risk of complications and the potential risks against the potential benefits should be considered carefully. To illustrate, a retrospective record review of 37 German pediatric CRPS patients, documented considerable polypharmacy, with each patient taking an average of 4.
Transcutaneous electrical nerve stimulation TENS is a noninvasive therapy method that uses low-voltage electrical current for pain relief. The use of this treatment modality has been described in the literature with regards to pediatric CRPS treatment [ 5 , 9 , 84 — 86 ]. However, the current literature has yet to provide sufficient proof of the efficacy of TENS treatment, and there are currently no prospective, blinded studies of the use of TENS.
In general, pediatric CRPS patients have more favorable outcomes compared to adults. Many will have spontaneous resolution after a few months. The multidisciplinary team approach combing PT and CBT will lead to remission in most children; however, relapses are common. In a study by Sherry et al. Relapses were reported in 7 children at follow-up, but 6 achieved full resolution of symptoms. Younger patients were also more likely to return to sports [ 5 ]. Other reports concluded that the prognosis of pediatric CRPS is not as favorable as reported [ 87 , 88 ].
At follow-up the median age of the patients was Overall, men had better outcomes than women [ 87 ]. Pediatric CRPS is a chronic pain syndrome that differs from the adult version. It is more common among adolescent girls and the distal lower extremity is most commonly affected. The exact mechanism is unknown, although many different mechanisms have been suggested. The diagnosis is clinical, with the aid of the current adult criteria for CRPS.
A complete patient history and examination are needed with judicious laboratory and radiographic tests to rule out other possible causes. Once pediatric CRPS is diagnosed, the standard care consists of a multidisciplinary approach with the implementation of intensive physical therapy in conjunction with psychological treatment. Treatment should take into consideration the child and the surrounding environment, family, and academic and social issues. Invasive treatments should be reserved for refractory CRPS cases, after considering the benefits versus the risks in each case.
With the current knowledge and an intensive approach, the prognosis in pediatric CRPS has improved considerably. Further studies are needed in order to develop better diagnostic tools, improve understanding of this syndrome, and improve treatment outcomes and lower recurrence rates. The authors declare that they have no competing interests.
The study was not funded. RW participated in the literature review and in writing the manuscript. YU participated in the literature review and in writing the manuscript. Both authors read and approved the final manuscript. National Center for Biotechnology Information , U. Pediatr Rheumatol Online J. Published online Apr Rotem Weissmann and Yosef Uziel. Author information Article notes Copyright and License information Disclaimer. Received Feb 24; Accepted Apr This article has been cited by other articles in PMC.
Abstract 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. Background Musculoskeletal pain is the most common reason for referral to pediatric rheumatologists. Trauma In many cases, CRPS follows a relatively minor trauma, usually a sprain, twist, dislocation or soft tissue injury.
Abnormal neurologic findings The literature suggests several neurological mechanisms for CRPS, such as central sensitization and alterations in the central nervous system CNS and small fiber changes [ 21 ]. Inflammatory and immune abnormalities Alexander et al. Genetics There have been reports of familial occurrence of CRPS, though no specific inheritance pattern or gene has been discovered [ 38 — 40 ].
Clinical findings Pediatric CRPS patients display a variety of sensory and motor findings, which can be linked to altered response and lower threshold of the central, autonomic and peripheral nervous systems. Pain — amplification of the pain All patients describe constant pain in the affected limb, even at rest.
- Pediatric complex regional pain syndrome: a review.
- Erst ich ein Stück, dann du - Twinkel, die Weihnachtsmaus (Erst ich ein Stück... Das Original 26) (German Edition).
- Search our LIbrary!
- Leaving A Legacy/ Notes To My Children.
- Ecology and Management of Coppice Woodlands;
- Background.
- More on this topic for:?
Autonomic findings Autonomic findings of the affected limb include swelling and edema, temperature changes usually the affected limb is cooler , hyperhidrosis, changes in skin color, cyanosis and sensitivity to cold, and mottled, dry skin [ 3 , 5 , 47 ]. Trophic changes With time, trophic skin changes ensue in the affected limb, such as a decrease or increase in hair and nail growth [ 14 , 47 ].
Motor disturbances Different motor disturbances have been described among pediatric CRPS patients, such as weakness, dystonia, tremors, spasms and fasciculations [ 14 , 48 ]. Diagnosis The clinical diagnosis of CRPS is based on a thorough history and physical examination, with a meticulous neurologic assessment. Table 1 Differential diagnosis of pediatric chronic muscular pain. Diagnosis Distinguishing charateristics Fibromyalgia Diffuse chronic musculoskeletal pain with multiple predictable tender points Hypermobilty Common, younger age preschool to elmentary school age , pain more sever towards the end of the day, usually associated with specific activities, evidence of hypermobility in physcal examination Myofascial pain Pain arises from sustained contraction of a muscle, especially in the head, jaw, and upper back.
Presence of a trigger point tender point and reproduction of the pain by maneuvers which place stress upon proximal structures or nerve roots. Arthritis Inflamation of one or more joints, pain is constant, localized to the affected joint. Spondyloarthropathy Lumbar spinal pain associated with arthritis, imaging or other evidence of arthritis affecting the sacroiliac joints and the lumbar vertebral column, response to nonsteroidal anti-inflammatory medications. Leukemia Child appears sick, presence of anorexia and lethargia, fever is common, nucturnal pain and bone pain.
Abnormal blood count, relative thrombocytopenia, and elevated erythrocytes sedimentation rate. Spinal cord tumors Slow progression of pain, pain quality — low and steady intesity, abnormal neurologic examination, pathologic MRI. Chronic recurrent multifocal osteomyelitis Chronic, noninfectious inflammation in the metaphyses close to the physes of multiple bones. Bony tenderness over the affected sites.
Presence of lytic lesions on plain radiographs. Lesions appear on bone scan. Pain usually responds to nonsteroidal anti-inflammatory drugs or corticosteroids. Episodes are short lived, pain, numbness, or tingling can be experienced with the episode. Pain can be reproduced with a cold challenge.
Digital tip ulcers might occur. Episodic excruciating burning pain in the hands and feet. Symptomes usuall begin in adolescence. Presence of bluish maculopapular hyperkeratotic lesions around the perineum, elevated erythrocytes sedimentation rate. Erythromelalgia Rare disorder characterized by burning pain, warmth, and redness of the extremities. Can be familial or secondary to myeloproliferative disorders. Pain alleviated by cold exposure.
Chronic compartment syndrome Usually occurs in athletes, repetitive loading or exertional activities cause exercise-induced pain that is relieved by rest. Onset of symptoms typically occurs at a specific exercise distance or time interval or intensity level, symptoms tend to subside with rest and are minimal during normal daily activities. Peripheral mononeuropathy More common among adults. Occurs following an injury or infection. Can cause severe burning pain in the distribution of the involved peripheral nerve. Findings in a physical examination are limited to the area supplied by the injured nerve.
Progressive diaphyseal dysplasia Begins in adolescence. Causes severe leg pain, fatigue, headaches, weight loss, weakness, abnormal waddling gait. To examine psychological and physical functioning variables between groups, these variables were analyzed using one-way ANOVAs followed by post hoc least significant difference tests between the CRPS group and each of the other pain groups. Demographic and pain-related variables that differed significantly between the CRPS group and other pain groups were included as covariates in the model if they also correlated significantly with the dependent variable.
All data were examined to ensure that they met assumptions of normality and were suitable for parametric statistical analyses. All variables met these criteria with the exception of number of school absences, which was not normally distributed and was subsequently analyzed with nonparametric statistical tests. Among children with CRPS, the vast majority Upper extremity CRPS pain was far less common 7. Comparing demographic and pain characteristics of the CRPS group with the other pain groups yielded a number of statistically significant distinctions means and frequencies according to pain group are presented in Table 2.
Several differences emerged between the CRPS group and the back pain group that did not differ when children with CRPS were compared with children with headache or abdominal pain. The pain groups did not differ with regard to family history of chronic pain. There were no group differences in reported rates of using acupuncture for pain treatment. Of the demographic variables that differed among pain groups, those that correlated with the outcome variable for each individual analysis as listed above were included.
Pain duration did not correlate with any outcomes of interest and was, therefore, not included in the analyses. No significant difference in school attendance rates emerged between children with CRPS and children with back pain. No significant differences were observed between the CRPS group and any comparison pain diagnostic group. In the normative sample of to year-old females, a T score of 60 represents the 83rd percentile and a T score of 65 represents the 93rd percentile These percentages are similar to those from the normative comparison sample.
Post hoc comparisons revealed that children with CRPS reported more somatic symptoms on the CSI eg, difficulty walking, pains in the arms or legs, weakness, numbness or tingling, pains in the joints than children with headache and back pain; there were no significant differences on the CSI between CRPS and abdominal pain groups. There were no significant differences between children with CRPS and any of the comparison groups on the anxiety measure.
Post hoc comparisons revealed that children with CRPS reported significantly less passive coping on the PRI than children with headaches; there were no significant differences in passive pain coping between children with CRPS and children with abdominal or back pain. The present study sought to describe a sample of children diagnosed with CRPS using well-validated and accepted diagnostic criteria and to compare this sample with children with other pain conditions in terms of demographic, pain, physical functioning and psychological characteristics using standardized, validated measures.
Results reveal that the vast majority of children with CRPS are female, with an even greater sex disparity in this diagnostic group compared with other pediatric chronic pain conditions. The previously documented lower extremity preponderance in pediatric CRPS 6 , 7 was confirmed in the present study. Relative to other chronic pain conditions seen at our tertiary care pediatric pain clinic, children with CRPS have shorter mean pain duration at the time of referral to a tertiary care pain clinic and report higher current pain severity. Children with CRPS are more likely to have tried physical therapy and anesthetic block procedures before their initial multidisciplinary evaluation than children with other pain conditions, but are less likely to have pursued psychological treatment compared with children with abdominal pain.
It is possible that the longer time since pain onset for the abdominal pain group compared with the CRPS group accounts for their increased previous exposure to psychological treatment. The difference in current reported pain severity between the CRPS group and other diagnostic groups is particularly striking, given that ratings were taken at rest and CRPS pain is exacerbated by touch and movement. Partially confirming the study hypotheses, differences between CRPS and other pain conditions were noted in levels of pain-related disability, with the CRPS group reporting more global functional disability than the other diagnostic groups.
Similarly, these children reported more widespread pain and other symptom complaints on the CSI. Because pediatric CRPS typically involves a lower extremity, thus inhibiting ambulation, it is not surprising that daily functional abilities are more impaired in this group. The greater number of somatic symptoms may be accounted for by the fact that CRPS is considered to entail central pain sensitization and thus may lead to pain and hyperesthesia in other areas of the body over time.
However, the alternative explanation, that children with CRPS have heightened levels of hypervigilance to physiological or somatic experiences, cannot be ruled out and merits further investigation In terms of school attendance, the opposite pattern emerged. Children with CRPS reported fewer missed school days than children with headache or abdominal pain, suggesting that even in the face of greater physical disability, children with CRPS as a group report comparatively less school impairment.
This is somewhat surprising because CRPS is typically characterized by constant pain whereas headache and abdominal pain may be intermittent. Perhaps some children with constant pain find ways to function in spite of their ongoing pain, whereas children with episodic pain are more debilitated by their pain episodes. More research is required in this area to understand these patterns.
Contrary to the hypothesis, at the group level, children with CRPS reported no greater anxiety or depressive symptoms than children with other pain conditions, with self-reported symptoms within normal limits compared with standardized scores based on normative samples.
- Square Persimmon and Other Stories.
- Geoffrey Chaucer’s The Tale of Sir Thopas: Elements of Parody and Satire?
- Implementing RtI with Gifted Students: Service Models, Trends, and Issues;
- Покупки по категориям?
- Get a Life! - The Guide Book.
In some respects, the CRPS group appears to be less psychologically impaired than children with other types of chronic pain. Relative to other diagnostic groups in the sample, the CRPS group was less likely to use passive coping strategies eg, pain catastrophizing , which have been demonstrated to be less effective ways of coping with pain 42 , The finding that these children, on average, do not manifest clinically significant psychological distress is consistent with previous research of children with CRPS using standardized assessment tools 36 , and in opposition to studies relying solely on interview and case study methodologies that report elevated levels of psychological impairment 25 , It is clear that group means do not capture the individual variation that undoubtedly exists within the pediatric CRPS population.
Clinical experience suggests that some children with CRPS do, in fact, present with elevated symptoms of depression and anxiety, similar to children with other chronic pain conditions, whereas other children may demonstrate psychological resilience in the face of the challenges of chronic pain. In the setting of a chronic pain clinic where children present with a mean pain duration of one to two years, it is not possible to determine whether this distress, when present, is a cause or consequence of the pain experience, or simply a coexisting condition.
However, these group-level findings provide an important balance against previous case studies and clinical observations that imply a primarily psychological etiology in patients with CRPS. It should be noted that the absence of significant psychological differences between pediatric CRPS patients and patients with other chronic pain conditions in the present study can be interpreted with more confidence than in previous studies due to the relatively large sample size available and the application of rigorous CRPS diagnostic criteria.
Recent work involving adult CRPS patients suggests that the role of psychological factors in the condition may be linked to physiological processes Although results of the current study indicate that children with CRPS may not experience a unique degree of psychological distress compared with children with other chronic pain conditions, this does not necessarily rule out a possible impact of emotional distress on CRPS development, potentially via links between distress and adrenergic mechanisms contributing to CRPS For example, Harden et al 2 found that in adults, greater increases in anxiety and depression in the four weeks following total knee arthroplasty predicted greater levels of CRPS symptoms up to 12 months following surgery.
In a daily diary study of adults with CRPS, Feldman et al 56 suggest that a transactional relationship exists among pain, emotional distress and social support, such that pain and emotional distress depression, anger, anxiety exacerbate one another, with social support exerting a protective buffering influence. In a study of brain anatomy using magnetic resonance imaging techniques, Geha et al 57 detected abnormal gray-white matter interactions that could account for both pain and emotional reactions in adults with CRPS. Collectively, these studies suggest that psychological factors are frequently involved in the experience of CRPS among adult patients; however, their role is likely to be complex and is not yet fully understood.
Clearly, more research is needed to understand these associations in the pediatric population. Overall, the findings of the present study support the view that pediatric CRPS is a complex condition that can be best understood and treated through a biopsychosocial framework. These results do not support assertions in some previous reports that the psychological aspects of CRPS are more pronounced than those of other chronic pediatric pain disorders.
Certainly, the identification and treatment of psychological concomitants, such as symptoms of depression or anxiety, and of interpersonal factors that can influence the course of the disorder, such as family dynamics and parental responses to pain behaviours, are important goals in managing pediatric CRPS. However, it is crucial to recognize that although the symptom pictures may overlap, true ie, properly diagnosed CRPS should not be presumed to be a conversion reaction or other psychosomatic disorder but should be viewed as a complex biopsychosocial phenomenon.
Consequently, treatment should entail coordinated interdisciplinary efforts that address the biological, physical and psychosocial aspects and sequelae of this complex condition. The findings of the present study must be evaluated in light of several limitations. First, the study was retrospective and cross-sectional in design. The tertiary clinic-based sample may not be fully representative of the larger population of all children who experience chronic pain.
The study is further limited by reliance on self-report assessments of psychological functioning at a single time point, which may be open to social desirability influences, particularly in the setting of a first-time clinical evaluation Although children with CRPS were classified using specific diagnostic criteria, inclusion in the comparison groups did not require adherence to strict diagnostic criteria; therefore, the comparison groups may represent heterogenous conditions with a shared pain location. Finally, it is important to highlight that the diagnostic criteria for CRPS were developed for adult patient populations and were applied to a pediatric sample in the present study because no pediatric criteria have been developed.
These criteria may be overly stringent for use with children. Further work is needed to advance our understanding of pediatric CRPS. Prospective longitudinal studies, particularly those that capture a wide sample of children before some develop CRPS, could provide valuable additional insight into the interplay and causal relations of psychological and biological influences on the condition over time.
Clinically, much remains unknown regarding this complex chronic pain condition. However, it is hoped that studies such as this will lead to the thorough and accurate assessment and treatment of CRPS by clarifying to medical and mental health practitioners alike that CRPS is a complex chronic pain experience, the maintenance and expression of which are influenced by many individual and environmental factors.
Careful diagnosis and evaluation of children with symptoms of CRPS and the provision of treatments to address the multiple biopsychosocial facets of this complex condition are crucial tasks facing pediatric psychologists and other health care providers who encounter this challenging pain condition. National Center for Biotechnology Information , U. Journal List Pain Res Manag v. Author information Copyright and License information Disclaimer. Telephone , fax , e-mail ude. This article has been cited by other articles in PMC.
Chronic pain, Complex regional pain syndrome, Functional disability, Pediatric, Psychological functioning. Procedure The present study entailed a retrospective chart review. To make the clinical diagnosis of CRPS, the following criteria must be met: Continuing pain that is disproportionate to any inciting event. Patient must report one symptom by history in three of the four symptom categories: Must display at least one sign at the time of evaluation in two or more sign categories: There is no other diagnosis that better explains the signs and symptoms For research purposes, the diagnostic decision rule is at least one symptom in all four symptom categories by history and at least one sign in two or more sign categories observed on evaluation.
Open in a separate window. Basic demographic and pain information: Data analysis Data analyses consisted of comparisons between the CRPS group and the headache, abdominal pain and back pain groups combined, as well as individually. RESULTS Preliminary analyses All data were examined to ensure that they met assumptions of normality and were suitable for parametric statistical analyses. Differences in demographic and pain characteristics between groups Comparing demographic and pain characteristics of the CRPS group with the other pain groups yielded a number of statistically significant distinctions means and frequencies according to pain group are presented in Table 2.
CRPS Complex regional pain syndrome. Merskey H, Bogduk N, editors. Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. Proposed new diagnostic criteria for complex regional pain syndrome. Bruehl S, Chung OY.
How common is complex regional pain syndrome-Type I? Complex regional pain syndrome type I in children. Pediatric complex regional pain syndrome. Reflex sympathetic dystrophy in children. Clinical characteristics and follow-up of seventy patients. J Bone Joint Surg. A treatment approach worth validating. Bruehl S, Carlson CR. Predisposing psychological factors in the development of reflex sympathetic dystrophy. A review of the empirical evidence. Psychologic factors in the development of complex regional pain syndrome: History, myth, and evidence. Chronic pain behavior pattern: A simple theoretical framework for health-care providers.
Review of the literature and initial clinical results. Psychother Psychosom Med Psychol. Somatization of dissociated traumatic memories in a case of reflex sympathetic dystrophy. Am J Clin Hypn. Psychological aspects of reflex sympathetic dystrophy: A review of the adult and paediatric literature.
A series of posttraumatic cases of reflex sympathetic dystrophy. Prevalence and psychodynamic interpretation of premorbid hyperactivity in patients with chronic pain. Psychological differences between reflex sympathetic dystrophy and non-RSD chronic pain patients. Psychological dysfunction in patients with reflex sympathetic dystrophy. Henson P, Bruehl S. Complex regional pain syndrome: State of the art update. Curr Treat Options Cardiovasc Med. Emotional and neuropsychological profiles of children with complex regional pain syndrome type-I in an inpatient rehabilitation setting.
The biopsychosocial approach to chronic pain: Scientific advances and future directions. Management of pediatric patients with complex regional pain syndrome. Pseudodystrophy at the lower limb in children. Reflex sympathetic dystrophy in a year-old twin with comorbid conversion disorder in both twins. J Paediatr Child Health. Psychiatric approach in the treatment of reflex sympathetic dystrophy in an adolescent girl: Pearson RD, Bailey J.