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Murray CS, Cohen A, Perkins J et al. Archives of Diseases of Childhood V2000;82:231-233

This report is made from the case notes of children who were seen at the pediatric rheumatology clinic in the Royal Liverpool Children's Hospital between 1990 and 1996 and it reviews the presentation and course of 46 children in whom the diagnosis of chronic regional pain syndrome type I (CPRS I) was made. There were 35 females in the group and the age range was 8-15 years. Twenty-five children gave an history of antecedent trauma.

Management for all children began with intensive physiotherapy (sometimes done on an inpatient basis), NSAID's and often included child and adolescent psychiatry consultation. Of the 46 children in the report, 3 were lost to follow-up, 3 were continuing to have problems during the time of the study (12-24 months from diagnosis) the balance of the patients having experienced improvement or recovery. For those who did so, the median time to recovery was 7 weeks but there was a very wide range ( 1-140 weeks). During the two years of follow-up, 11 of the children who made full recoveries suffered a relapse.

The authors report that the children saw from 1-5 specialists with an average of 2.3 specialists seen for each child. The specialists seen by the children included: Emergency, General Practice, Orthopaedics, Paediatrics, and Adult Rheumatology.

Five of the 46 children on this study had prior hospital admissions for abdominal pain and 3 had appendectomies as a result. The appendix in all 3 cases was normal in histology. Approximately one-fourth of the children were thought to have psychosocial issues that might have contributed to the CRPS.

Comment: This report is of interest because it illustrates how RSD (CRPS I) is seen and treated outside of the pain clinics where pediatric anesthesiologists might see and manage it. I dare say that the overall "cure" rate of 29 children of the 46, 63% compares favorably with the results that many pain clinics throughout the world achieve. The authors mention that the average interval between onset of symptoms and diagnosis of CRPS I was 23 weeks, with a range of 1-130 weeks. Given the reasonably long follow-up period of 24 months, many, if not most relapses were probably seen by the authors. These results were achieved without any invasive interventions such as epidural infusions or bolus administration of medications, IV regional techniques or even IV analgesic administration. In the discussion the authors mention that since this study was completed, it is now their practice to include referral to child and adolescent psychiatry referral for all patients with CRPS I. The children in this study from the United Kingdom shows the importance of both physiotherapy and psychiatric intervention for children with CRPS I. The relapse rate (approximately 25%) and the extended length of therapy needed for some children are unfortunately not surprising. Although the foundation of therapy is physiotherapy and counseling, I was surprised that none of the children were seen by pain specialists of any kind since the services these children need are often provided and well-coordinated by pain clinics.

Reviewed by: Thomas J. Mancuso, MD, FAAP
Children's Hospital, Boston, MA