Including Parents in the Treatment Of Pediatric Complex Regional Pain Syndrome

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

Disclosures

Pediatr Nurs. 2017;43(1):16-21. 

In This Article

Treatment of CRPS in Pediatrics

Treatment for CRPS is multidisciplinary, typically including physical therapy, occupational therapy, and psychology. Studies show that pediatric patients respond better to these therapies than adults and are more likely to gain remission from their pain (Brooke & Janselewitz, 2012). In published studies about treatment programs for pediatric patients, the rate of resolution of pain ranges from 34% to 100%, and the rate for restoration of physical function ranges from 89% to 100% (Brooke & Janselewitz, 2012; Lee et al., 2002; Sherry, 2000). Conventional pain medications are ineffective in treating CRPS. However, medication may be indicated for the treatment of comorbid conditions, such as anxiety, depression, or sleep disturbances. Further, some research has shown that using medication in the beginning of a treatment session can improve the patient's ability to fully participate in therapies (Low et al., 2007). One study conducted among 13 patients with CRPS refractory to previous therapies found that continuous peripheral nerve blocks were 100% effective in relieving pain and allowing the patient to begin intensive therapy (Dadure et al., 2005). Other interventions, such as intravenous ketamine, sympathetic nerve blocks, and epidural infusions, have been proposed; however, data among pediatric patients are limited. These procedures are not without risks, so a less invasive approach is preferred. Additionally, these interventions, unless used solely at the initiation of therapy, discount the psychological and social influences on pain.

Physical therapy focuses on restoration of motor function and includes activities to increase range of motion, endurance, and strength. Occupational therapy aims to improve functional ability related to activities of daily living and desensitize areas with hyperalgesia or allodynia. Aquatic therapy may also be employed to promote weight bearing on the affected limb(s) and has the secondary benefit of reducing edema, if present (Harden, Swan, King, Costa, & Barthel, 2006). Psychologists work with the patient to identify stressors and improve coping mechanisms. The ultimate goal of all therapies is for adolescents to regain the ability to function independently within their home and school environments, and develop the necessary coping skills to manage the pain if it recurs. This multidisciplinary approach can be implemented in outpatient, inpatient, or day hospital settings. Efficacy and satisfaction with programs in each setting is comparable (Brooke & Janselewitz, 2010; Lee et al., 2002; Logan et al., 2012; Maynard, Amari, Wieczorek, Christensen, & Slifer, 2010). For patients with the most severe CRPS, an inpatient setting is often necessary. Benefits of the inpatient program include that the patient is removed from the home environment, the pain-disability cycle is disrupted, the adolescent is supervised constantly to ensure adherence with therapies, and ineffective parenting strategies are removed (Katholi, Daghstani, Banez, & Brady, 2014). However, few inpatient programs are available, and insurance coverage for these programs is variable. Often, patients must fail outpatient therapy before they may be considered for an inpatient program.

Figure 2 overlays common therapeutic interventions in chronic pain programs onto the biopsychosocial framework to demonstrate how these interventions target the pain. Reducing stress, improving function, and adapting the parent-child dyad are analogous to weakening the sides of the triangle, such that the complex relationships that exacerbate the experience of pain are unable to persist.

Figure 2.

Treatment Modalities Targeting the Biopsychosocial Framework for Pediatric CRPS

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