Chronic Musculoskeletal Pain in a Pediatric Patient: Case Report From the United Kingdom, With Commentaries From Spain and Israel

ABSTRACT

A case of a 12-year-old female with complex regional pain syndrome (CRPS) is presented. Difficulties making the diagnosis are described. The importance of using an interdisciplinary approach that includes appropriate pharmacotherapy are discussed.

KEYWORDS :

• complex regional pain syndrome
• CRPS
• multidisciplinary
• opioids

COMMENTARY FROM SPAIN

Francisco Reinoso Barbero^a

Cases of “functional” chronic pain, typically without a clear underlying cause, are frequent among Spanish school-aged children and adolescents (with a prevalence of about 37%), but the pain was found to be due to a moderate or severe chronic pain syndrome in only 5% of cases.¹

This patient was initially diagnosed with “nonspecific” arthritis, but a diagnosis of type¹ CRPS was then made. However, this diagnosis was based on clinical judgments without considering investigations such as thermographic or gammagraphic results.

However, the treatment and multidisciplinary approach was certainly appropriate and successful. Cognitive-behavioral therapy is of paramount importance because CRPS affects cerebral cortical processing, as studied by functional MRI.² Efficacy is improved by a concomitant program of physical rehabilitation.

This patient could have also received an ipsilateral stellate ganglion block to check the involvement of the sympathetic nervous system. If the block had produced a positive result, it would have strongly suggested that treatment with an antidepressant or anticonvulsant drug may have been appropriate. Interventional techniques may be indicated in certain refractory cases.³

COMMENTARY FROM ISRAEL

Elon Eisenberg^b

The case of AP raises several important aspects of CRPS. Firstly, the diagnosis of CRPS, especially when made early in the course of the condition, is sometimes difficult. AP had no preceding trauma, which is rather unusual. Secondly, her reported signs and symptoms barely meet any CRPS diagnostic criteria. Several sets of CRPS diagnostic criteria have been published, with no consensus as to which should be used clinically.

This is emphasized in a recent article that shows that the diagnosis of type¹ CRPS in 596 patients with a single distal limb fracture ranged from 7% to 48.5%, according to the International Association for the Study of Pain criteria.¹

My third point relates to the lack of clarity regarding appropriate treatment for CRPS. After the diagnosis was made, AP received mostly physical therapy, with input from a clinical psychologist. Gabapentin was only started at a later stage. However, the value of physiotherapy alone in children with CRPS could not be determined in a recent systematic review of the literature.²

Nonetheless, AP seems to be doing well and one cannot argue with a successful outcome. So until proven otherwise, early diagnosis and prompt treatment initiation, preferably by a multidisciplinary team, with an emphasis on rehabilitation, should be available for children with CRPS.

Declaration of interest: The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.

Notes

a Dr. Francisco Reinoso Barbero is Clinical chief, Servicio de Anestesia Pediátrica, Hospital Universitario La Paz de Madrid, Madrid, Spain.

b Elon Eisenberg, MD is Associate Professor, Faculty of Medicine The Technion; and Director, Pain Research Unit, Rambam Medical Center, Haifa Israel.