|Year : 2014 | Volume
| Issue : 3 | Page : 184-188
Post traumatic pain: ?CRPS
Joint Secretary, ISSP-Mumbai; Managing Committee Member-AMC (Association of Medical Consultants); Convener, Anti Noise Pollution Cell of AMC; Dr Doshi's Pain Relief Centre, Thane; Consultant in Pain-Bethany, Jupiter Hospitals, Thane, Maharashtra, India
|Date of Web Publication||11-Aug-2014|
104, Rohini, Tarangan II, Thane - 400 606, Maharashtra
Source of Support: None, Conflict of Interest: None
Although there is an increased awareness of and treatment of acute pain in infants and children, the lack of awareness on various chronic and persistent pains in children often leads to physicians/pediatricians pursuing an endless search for the underlying etiology of the discomfort. Continued lab investigations are undertaken for the sake of "completeness" to search for a biological explanation for the pain. The author would like to present this case report where there was no obvious cause for the pain found on investigations. The child was treated for neuropathic pain with complete recovery. Though complex regional pain syndrome (CRPS) was suspected, the difficulty in establishing a diagnosis, convincing caregivers and compliance to pharmacotherapy are the major challenges in the pediatric pain patients.
Keywords: Caregivers, investigations, neuropathic pain, pediatric pain, post-trauma pain
|How to cite this article:|
Doshi K. Post traumatic pain: ?CRPS
. Indian J Pain 2014;28:184-8
| Introduction|| |
Pain is defined by the International Association for the Study of Pain (IASP) as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.
Pain elicited by injury and activation of nociceptors is called 'acute pain' and is one of the most common reasons for seeking medical help.
Chronic pain maybe elicited by injury or disease but is likely to get perpetuated by factors that are pathogenetically and physically remote from the originating cause.
The World Health Organization (WHO) estimates that 4.8 billion people (79% of the world's population) have inadequate access to treatment for moderate to severe pain.  The pain treatment for children is assumed to be even worse than for adults. Reports in literature emphasize the prevalence of pain in children:
- Chronic pain affects 25% of children, 8% of these have intense and frequent pain. 
- Another report shows-out of the 57% of children with recurrent pain, 6% will have chronic pain ,
- Statistics in Canada from 12-17 yrs old children report 2% of boys and 6% girls report chronic pain 
- Huguet & Miro have reported the Pain related disability to be 5% 
Assessing pain in children is challenging. Some of the various factors compounding the problem are:
- Adult pain measures cannot be applied to preverbal and young children
- They are dependent on adult caregivers to interpret their behavior and other signs that they have pain
- Fear and anxiety complicate the assessment of pain as they may have the fear of "injections" and underreport their pain.
Pediatricians as the primary physicians need to ask, assess and measure pain because untreated pain can have long-term deleterious effects. Pain can cause limitations in activity, psychological problems as well as contribute to disability-hence, recurrent and chronic pains have an impact not only on the child but also on their families!
Children who seek treatment for their pain represent the group of patients experiencing the worst impairment.  Persistent pain also affects the emotional status of children -they are less cheerful and more depressed compared to children without pain 
As Pain practioners, we need to prevent progression of pain to chronicity not only on humanitarian grounds but also as evidence suggests to prevent long-term neurophysiological changes  as well as immunological changes. 
Chronic pain also has negative effects on family life:
- increased financial burden- direct cost of hospitalization, doctors' fees
- Indirect costs due to time taken off work, transportation etc.
This case represents the usual challenge to the Clinician where no obvious pathophysiologic source of pain can be identified.
Konijenberg  highlighted this problem where the child continues to suffer; parents are frustrated by lack of diagnosis and investigations do not offer any solution.
| Case Report|| |
A 10 years, male child weighing 26 kg, a 5 th std student was referred by to the Pain Clinic by the Rheumatologist for severe left lower limb pain refractory to analgesics.
The child had a fall while training for "long jump" when he fell on his back. He presented 2 days after fall to the pediatrician with h/o pain in left hip joint with difficulty in walking.
Patient was hospitalized in view of severe pain for further investigations and treatment.
- Past history included h/o allergic cough, surgery for congenital hydrocoele at 8 years of age.
- Routine investigations showed:
- Hb= 13.9 g/dl, CBC= 8,530/cumm, ESR= 07mm/hr, Urine R= wnl , CPK = 101U/L (26-192),
- SGOT = 43U/l , Sr Ca++ = 10 mg/dl, Sr Phos= 5.8 mg/dl, Alk po4= 153 U/L
- LDH=506u/l, Uric acid= 1.6 mg/dl
- HLAB27 : Negative, G-6 PD : 30 min (normal)
- Magnetic resonance imaging (MRI) of Lumbar Spine [Figure 1] and [Figure 2] with screening whole spine and pelvis with both hip joints showed: No abnormality in spine; Pelvis- abnormal marrow changes in left sacral ala without cortical disruption or soft tissue abnormality-?post traumatic ?Post inflammatory/ early infective pathology
|Figure 2: Axial cut showing abnormal marrow changes in left sacral ala without cortical disruption or soft tissue abnormality|
Click here to view
Day 2 of hospital admission:
- Pediatric Orthopedic opinion was sought who clinically diagnosed patient to have Sacroilitis.
- Patient was started on analgesics (brufen 400 mg, naprosyn 250 mg) and physiotherapy.
- Rheumatologist consulted and since anti-nuclear antibody (ANA) was negative advised maximum dose of analgesics, heat, physiotherapy.
After 2 weeks, pain continued at NRS 9-10/10, ADL ( activities of daily living) affected.
Now, patient was further investigated to rule out any infective pathology :
- Sr Creat= 0.4; ASO: Negative; CRP=3 mg/l, Procalcitonin <0.5 ng/ml (negative)
- Sr B12= 298 pg/ml, Sr Vit D3= 19.54 ng/ml , SGOT= 65U/L;
After intensive investigations, as there was no relief in pain or improvement in activity, patient was then referred to pain clinic on outpatient basis.
In pain clinic
Patient was seen 2 weeks after fall. Child presented with limping gait, inability to bear weight on left leg. Pain was NRS 10. He had been absent from school since the fall (for 15 days).
Child was in severe pain according to mother- though child appeared comfortable while sitting; mother said he was constantly groaning in his sleep.
Child was a bright, intelligent child who said his pain was 10/10 at rest. He was constantly describing pain over left thigh, knee, calf and ankle [Figure 3].
O/E: There was minimal allodynia, he was unable to lift left leg against gravity-?weakness /?severe pain causing inability to flex left hip.
CRPS-I Type of Neuropathic pain was suspected and patient was started on combination of (Paracetamol 175 mg + Tramadol 9 mg) tds and Pregabalin 25 mg at bed time.
After 48 hrs of neuropathic drugs, mother said there was some relief in pain as he was not groaning in his sleep, but pain continued to be at numerical rating scale (NRS) 10, child was still unable to bear weight on left leg.
After 5 days of neuropathic drugs, NRS= 9.6 according to child, 6-7 according to mother.
- o/e: Trophedema, skin changes were visible, there was delayed capillary refill, increase in local temperature
- Now, Amitryptyline 5 mg was added to previous drugs.
By Day 10: (25 days after fall).
By now, the parents and grandparents of the child were worried as the child was on multiple drugs for almost 10 days and yet child was unable to resume normal school activity.
As there was subtle reduction in pain, no confirmatory test suggesting cause of pain as CRPS, pain continued at NRS 6-7, the child's parents and grandparents were skeptical and stopped medications. They wanted to try alternative treatment like acupressure.
After 1 week of stopping medications, mother said pain had increased from NRS 6-7/10 to NRS 8-9/10, child was more distressed, not sleeping well and in constant pain.
He was still unable to attend school due to severe pain.
- o/e: allodynia, skin color changes, decreased capillary refill, early wasting of muscles.
- Relatives were advised an electromyography-Nerve Conduction Velocity (EMG-NCV) test, Bone Scan, and a diagnostic Lumbar Sympathetic Block for confirmation of diagnosis. Since the child would not cooperate these were not done. However, as child had missed school for more than 2 weeks, parents agreed to start and continue medications as advised.
10 days (42 days after fall) after restarting Neuropathic drugs i.e. Pregabalin 25 mg + Amitryptyline 5 mg + PCM 525mg + Tramadol 27 mg:
- Pain reduced to NRS-5-7, child was able to walk with limping gait;
- He had started attending school without any increase in pain, but was unable to climb stairs or participate in any sports activity.
- o/e: severe pain on Left hip flexion, Apparent shortening of left LL, early signs of disuse atophy
- Now, gentle physiotherapy was started.
3 weeks later: Child had gained weight, Wt= 27.9 kg, Baseline pain had reduced to NRS =1-2; he complained of intermittent escalation of pain to NRS 5-6 unrelated related to activity. These attacks of spontaneous paroxysmal pain confirmed the presence of neuropathic pain.
- He was able to run, jump but complained of pain in the calf, knee later; ADL were back to preinjury level.
After 2 months:
- Baseline pain had reduced to NRS = 0-1, activity was normal, spontaneous pain NRS- 3/4 occurring infrequently ;
- o/e- left-sided hip flexors stiffness present for which he was advised physiotherapy for stretching hip flexors.
3.5 months after starting neuropathic medications: child was tapered off pregabalin, pain reduced to NRS: 0-1, ADL: normal.
He was able to pursue cycling, cricket, running etc without pain.
4 months after starting amitryptyline, it was tapered and stopped.
Night dose of PCM + Tramadol (175 mg + 9 mg) were continued for 3 more weeks and stopped.
5 months later, child was back to complete activity including athletics training with no residual deficit, weakness.
| Discussion|| |
When the child presented, he had pain in the left L4 dermatomal distribution-this did not correlate with MRI findings of abnormal marrow changes in left sacral ala without cortical disruption or soft tissue abnormality.
Clinically, there was apparent limb length discrepancy.
When the child had the fall, there was probably a blunt injury to the left hip flexors mainly psoas major with lumbar plexus irritation. The MRI had evidence of abnormal marrow changes in sacral ala- the psoas tendon and lumbar plexus are in anatomic proximity.
The nerve irritation or edema could cause pain that the child was experiencing and this would explain his response to neuropathic drugs and complete recovery from symptoms.
Long-term consequences of recurrent and chronic pain can have an impact not only on the child but also on their families. Pain can cause limitations in activity, psychological problems as well as contribute to disability.
The musculoskeletal system is one of the most common sites for pain in children and adolescents. There are few studies reporting on prevalence of CRPS in children. Available data indicate a female to male ratio of 6:1 and more common occurrence in lower than upper extremity. 
The differential diagnosis of musculoskeletal pain is vast. If pain is localized and the child is well, the DD includes 'growing pains', CRPS, mechanical pain, pauciarticular juvenile idiopathic arthritis (JRA) and spondyloarthropathy. If the child is unwell, infectious arthritis should be considered. If the pain is diffused and the child is unwell - malignancies or autoimmune diseases should be considered. Emerging literature supports association of chronic musculoskeletal pain with hypermobility. This may be due to central sensitization induced by constant subluxation and slippage.
Konijnenberg and colleagues presented a series of papers in which 17 different pediatricians reviewed the medical records of 134 children with unexplained chronic pain. There was disagreement on diagnostic approach in over a third of the patients and on the primary cause of pain in over half. 
When dealing with persistent and chronic pain, the impact of pain on the child's functioning - school attendance, work quality, mood etc should be given due attention as well as disability - which also needs to be measured.
The WHO treatment Guidelines on Persisting Pain in Children with Medical Illnesses (Geneva 2011) are available on: http://www.who.int/medicines/areas/quality_safety/guide_perspainchild/en/index.html.
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[Figure 1], [Figure 2], [Figure 3]