Reflex sympathetic dystrophy in a 12-year-old twin with comorbid conversion disorder in both twins

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.

A day-hospital approach to treatment of pediatric complex regional pain syndrome: initial functional outcomes

OBJECTIVES

To examine clinical outcomes of an interdisciplinary day-hospital treatment program (comprised of physical, occupational, and cognitive-behavioral therapies with medical and nursing services) for pediatric complex regional pain syndrome (CRPS).

METHODS

The study is a longitudinal case series of consecutive patients treated in a day-hospital pediatric pain rehabilitation program. Participants were 56 children and adolescents with ages 8 to 18 years (median=14 y) with CRPS spectrum conditions who failed to progress sufficiently with a previous outpatient and/or inpatient treatments. Patients participated in daily physical therapy, occupational therapy, and psychological treatment and received nursing and medical care as necessary. The model places equal emphasis on physical and cognitive-behavioral approaches to pain management. Median duration of stay was 3 weeks. Outcome measures included assessments of physical, occupational, and psychological functioning at program admission, discharge, and at posttreatment follow-up at a median of 10 months after discharge. Scores at discharge and follow-up were compared with measures on admission by Wilcoxon tests, paired t tests, or analysis of variance as appropriate, with corrections for multiple comparisons.

RESULTS

Outcomes demonstrate clinically and statistically significant improvements from admission to discharge in pain intensity (P<0.001), functional disability (P<0.001), subjective report of limb function (P<0.001), timed running (P<0.001), occupational performance (P<0.001), medication use (P<0.01), use of assistive devices (P<0.001), and emotional functioning (anxiety, P<0.001; depression, P<0.01). Functional gains were maintained or further improved at follow-up.

DISCUSSION

A day-hospital interdisciplinary rehabilitation approach seems effective in reducing disability and improving physical and emotional functioning and occupational performance among children and adolescents with CRPSs that have failed to improve with outpatient treatment.

Streamlined classification of psychopathological hand disorders: A literature review

In the surgical hand clinic, psychopathological hand disorders can be sorted into one of the following four categories: (1) factitious wound creation and manipulation; (2) factitious edema; (3) psychopathological dystonias, and (4) psychopathological sensory abnormalities and psychopathological Complex Regional Pain Syndrome. This article introduces these four categories. Pertinent literature that includes descriptions of each category's syndromes and diseases, demographic and psychological profiles, differential diagnoses, and appropriate treatment recommendations is reviewed.

Management of Pediatric Patients With Complex Regional Pain Syndrome

This review summarizes current information about diagnosis and treatment of complex regional pain syndrome (CRPS) in children. Although it has been widely held that CRPS in children is intrinsically different from adults, there appear to be relatively few differences. However, there is a marked preponderance of lower extremity cases in children. Historically, psychological factors have been invoked to explain the genesis and persistence of CRPS in children, but the evidence is not compelling. Treatment outcome studies are limited but indicate that children generally respond to a primary focus on physical therapy. Multidisciplinary treatment reports are particularly encouraging. The general perception that children have a milder course may relate to the potentially greater willingness of children to actively participate in appropriately targeted treatment rather than to innate differences in the disease process itself. Recurrence rates appear higher than in adults, but response to reinitiation of treatment seems to proceed efficiently. Clinical judgment dictates the extent of medication or interventional therapy added to the treatment to facilitate rehabilitation. In many ways, the approach to the treatment of children mirrors that of adults, with perhaps greater restraint in the use of medications and invasive procedures. The rehabilitation of children with CRPS, like that of adults with CRPS, needs further rigorous investigation.

Controversies surrounding reflex sympathetic dystrophy: a review article

The topic of reflex sympathetic dystrophy (RSD) has generated an increasingly significant volume of medical literature and controversy over the last decade. A search of PubMed, the online site of the National Library of Medicine, for papers on RSD reveals nearly 2200 articles on the topic (using algodystrophy as the search word, wherein RSD references are also included, and more older and European articles are also listed). From 1991 through 1998 inclusive there is an average of nearly 100 articles per year on the topic, which represents more than a third of all the articles referenced since 1965. In the decade of the 1980s, there is an average of 64 articles per year, 74 per year in the last half of the decade and 54 per year in the first half. Prior to the decade of the 1980s, one finds an average of 40 articles per year back to the mid-1960s. The controversy surrounding the disorder centers around the nature of the problem and whether it is a primary organic disorder or a primary psychogenic disorder associated with the accomplishment of some secondary gain. If it is the former, then clearly research should continue to determine the nature and etiology of the malfunctioning organ(s). If, on the other hand, RSD is a psychogenic disorder, then the medical community does well to focus mainly on the peripheral manifestations of the problem. In that instance, therapy should be primarily psychological and cognitive with regard to the secondary gain, and persistent organic treatments are unlikely to improve the condition in general and worsen individual cases.