Including Parents in the Treatment Of Pediatric Complex Regional Pain Syndrome

Shayleigh K. Dickson, MSN, APN, CPNPAC, CPN


Pediatr Nurs. 2017;43(1):16-21. 

In This Article

The Biopsychosocial Model of Pain

A biomedical explanation of pain purports that pain has a physical cause and can be eliminated by treating the physical pathology or block-experiing the pain pathway with medication (Gatchel & Okifuji, 2006). Acute pain (e.g., from a broken bone) can adequately be explained and treated within this framework. The fracture is the physical cause of the pain. More specifically, the pain results from the broken bone itself, damage to surrounding soft tissue, and inflammation. Treating the pathology with immobilization, casting, or surgery resolves the physical cause, while medications like acetaminophen, NSAIDs, and opioids can be used to block the pain pathway while healing takes place. Traditionally, as the fracture heals, pain decreases until complete resolution.

CRPS frequently, although not exclusively, is diagnosed after a child sustains an injury. However, although the injury heals, the pain persists and is resistant to therapies, such as medication, immobilization, heat, or ice. The biomedical explanation does not sufficiently explain CRPS because the pathophysiologic mechanism for this type of pain is unclear, and the pain pathway cannot consistently be blocked using pharmacologic interventions. The biopsychosocial approach is a more appropriate model to use to describe chronic pain, and particularly CPRS. Figure 1 depicts a biopsychosocial framework for CRPS created for this article. The model depicts the bidirectional interaction of the three domains that contribute to the complex pain experience of CRPS.

Figure 1.

The Biopsychosocial Framework for Pediatric CRPS

The three main domains in the model are biological, psychological, and social. Within each domain are several factors that carry varying weights for each patient with respect to their influence on the pain experience. Between each domain are complex bidirectional relationships. Stress, functional status, and the parent- child dyad form the sides of this triangle because these are three targets of therapeutic interventions. When stress is high, physical function is impaired, and parenting strategies are ineffective, the pain experience is most intense. In contrast, when therapeutic interventions reduce stress, improve functional status, and aid the parent-child dyad in developing positive coping skills through adaptive parenting, the pain experience is less intense.

Biological influences on the pain include the yet-to-be elucidated pathology behind CRPS, neurovascular changes (such as swelling, changes in skin temperature, and hypersensitivity), age, and sex. Age and sex are important considerations in the biological influences because the incidence of CRPS is much higher in girls as compared to boys, and in adolescents as compared to younger children (Low et al., 2007; Tan et al., 2008). Psychological and social factors also likely contribute to the higher prevalence of CRPS in these populations. Psychological influences include emotions and classifying the pain. The psychological distress may be pre-existing or result from the chronic pain. Most commonly, this distress is manifested as anxiety or depression. Finally, social influences on CRPS include the child's home and school environment, as well as relationships within these environments (i.e., parents, siblings, peers). Parental influences on the child's experience with pain have been the most studied. Current evidence suggests that parenting style, the parent-child relationship, and the parent's response to the pain impact the child's pain experience (Kozlowska et al., 2008; Palermo, Valrie, & Karlson, 2014).

The connection between the mind and body secondary to stress has also been well documented. Even in the absence of pain, many people can relate to muscle tension, particularly in the back and shoulders, which occurs during times of increased stress. Increased stress among adolescents may be identified at the time of diagnosis of CRPS, and continued stress can exacerbate symptoms and impede recovery. Impaired function secondary to pain and neurovascular changes are significant for adolescents with CRPS and can be influenced by the social environment. For example, parenting strategies that are overly solicitous and promote regressive behaviors or activity avoidance can worsen functional disability (Claar, Simons, & Logan, 2008). Finally, the parent-child dyad is at the core of the relationship between psychological and social influences.

In this model, two parallel lines are used to represent this dyad because literature has documented that the parent-child dyads between each parent and the child contribute differently to the pain experience (Gaughan, Logan, Sethna, & Mott, 2014). Further, cohesiveness or schisms in parenting, represented by the line between dyads, is influential in CRPS (Gaughan et al., 2014). Interestingly, most studies of children with CRPS contain children from intact two-parent families; however, these dyads could become more complex for a child with a non-traditional family (i.e., single parents, step-parents, same-sex parents). The individual psychological profiles of the adolescent and the parent, as well as their relationship, are critical considerations when analyzing the parentchild dyad and focusing therapeutic interventions.