Severe complex regional pain syndrome (CRPS) type I: a multidisciplinary treatment plan and intensive physiotherapy in pediatrics

Dr Béatrice LEUTHOLDa, Dr Chantal MAMIEa, Mrs Anne COHENa, Mrs Fanny ZUBILLERb, Dr Dante TROJANa, Prof Pierre LASCOMBESa

a Hôpitaux Universitaires de Genève :Département de l'enfant et de l'adolescent, b Hôpital de La Tour

Background: Nowadays, paediatric CRPS is a recognized disease with its own specificities compared to the adult CRPS. However, its treatment is difficult and there is sparse consensus among the management of those patients, partly due to a usually delayed diagnosis and a complex multifactoral pathogenicity including osteoarticular, neurological and psychological issues. Everyone agrees that the management of these patients should be multidisciplinary including physiotherapy, occupational therapy, psychotherapy and medication.

Case report: We are sharing our experience with two severe cases of paediatric CRPS type I involving the foot, a boy and a girl aged 12 and 11 respectively at the time of diagnosis. Symptoms were hyperalgesia, oedema, bone demineralisation on the radiological exams and a disturbed psychological profile. After the failure of different outpatient treatments, we decided to hospitalise them in the Department of Paediatrics Orthopaedics. The protocol of treatment followed a very strict and intensive daily schedule including multiple therapies in physiotherapy and occupational therapies (balneotherapy, music therapy, progressive desensitization, TENS, walking rehabilitation), the use of pain killers, a follow-up by a paediatric psychiatrist, a referent nurse, and a limitation to the family visiting hours. After 1 to 2 weeks, a significant improvement was seen and after 6 months, pain had disappeared and weight-bearing was possible for both children.

Discussion: To this day we don’t know the intensity and duration necessary to treat efficiently a paediatric CRPS. The hospitalisation is considered as the last resort for the management of CRPS, but it allows a close observation of the patient, the opportunity to take her/him out of his family and an intensive multidisciplinary treatment that is impossible as an outpatient. The precise factors allowing the treatment’s success are still not clear, but they could be a combination of intensive therapy and/or the withdrawal of the patient from his family. Nonetheless it seems that a strict and intensive protocoled schedule, as an inpatient benefits the management of severe cases of CRPS.

Ref : Logan DE, Carpino EA, Chiang G, et coll. A day-hospital approach to treatment of pediatric complex regional pain syndrome: initial functional outcomes. Clin J Pain. 2012;28:766-74.

Keywords : CRPS; paediatrics; inpatient treatment