Rarely in my profession do I encounter a patient whose story profoundly affects me. It happens more often when I see children. As a parent, I cannot possibly imagine any of my children in chronic pain.
This is why I was so disturbed when I met a young lady and heard her experience over the last six months or so. Her pediatrician sent her to me because she was in so much pain. She could not ambulate properly and would not put her heel down flat on the ground. Her pediatrician wanted me to evaluate her and see if this was a mechanical or sensory issue.
This 11-year-old girl had developed unremitting pain after spraining her ankle during a soccer game eight months ago. She also had an older sister who had sustained an injury to her hip and had developed complex regional pain syndrome (CRPS) in that location. The patient had all the strikes against her. She was female, between the ages of 8 to 14 (11 to 14 in some literature), had a family history of CRPS and a recent injury.
This is where it begins to get unusual. Apparently, all the experts she had seen agreed that she simply needed serial occupational or physical therapy to relieve her symptoms. For six months, she had sensory therapy to try to desensitize her ankle and allow for normal day-to-day functioning. The girl said things had improved but she ultimately still had enough pain that she could not function normally. Her mother explained that they had visited two specialty hospitals in the area but came away with recommendations for continued occupational/physical therapy and no other recourse.
I discussed this case with some of my colleagues. We concluded that a piece of the puzzle was missing.
A couple of years ago, the Podiatry Insurance Company of America (PICA) released a home study course concerning the number one reason people sue podiatrists. It involved the lack of proper and early diagnosis of CRPS and the lack of appropriate referrals for adequate early management. Once again, after discussion with my close colleagues and a couple of pain management physicians I know, it really seems that someone dropped the ball somewhere.
While there is quite a bit of literature on pediatric CRPS, most, if not all, of it is rather inconclusive.1-6 The one thing that is universally lacking in any of the literature is the efficacy of sympathetic blocks in the pediatric population. Apparently, occupational and physical therapies are the gold standard. However, some of these papers cite a high recurrence rate associated with the occupational/physical therapy regimen.2,4 Bear in mind that this gold standard was also evaluated almost 20 years ago. Have we not come any closer to helping these poor children than we were in the mid-1990s?
I asked the girl’s mother if anyone had discussed using sympathetic blocks for her daughter. She had never heard of anything like that. I explained that when I send patients for evaluation of CRPS, that is the first thing I request. Sometimes, the initial injection works well enough that patients then get serial injections every few months and are able to live virtually pain-free. I also noted the patients I have seen who eventually go on to have spinal implants to eliminate the pain. I asked the patient’s mother if I could talk to the girl’s doctors and therapists to see if the option of sympathetic blocks would be available.
Don’t get me wrong. It is frightening for a parent to think of giving a child injections and spinal stims considering the potential complications associated with this modality. However, I would hope any parent would at least consider trying something like this before dooming a child to a life in a wheelchair due to an ankle sprain.
Perhaps I am being dramatic. I am no CRPS expert but I cannot find any physiological reason not to try an injection like this in the pediatric population. To know that you may help stop a crippling process from progressing seems worth it to me.
1. Stanton-Hicks M, Baron R, Boas R, et al. Complex regional pain syndromes: guidelines for therapy. Clin J Pain. 1998;14(2):155-66.
2. Sherry DD, Wallace CA, Kelley C, et al. Short- and long-term outcomes of children with complex regional pain syndrome type I treated with exercise therapy. Clin J Pain. 1999;15(3):218-23.
3. Maneksha FR, Mirza H, Poppers PJ. Complex regional pain syndrome (CRPS) with resistance to local anesthetic block: a case report. J Clin Anesth. 2000;12(1):67-71.
4. Lee BH, Scharff L, Sethna NF, et al. Physical therapy and cognitive-behavioral treatment for complex regional pain syndromes. J Pediatr. 2002;141(1):135-40.
5. Wilder RT. Management of pediatric patients with complex regional pain syndrome. Clin J Pain. 2006; 22(5):443-8.
6. Meier PM, Alexander ME, Sethna NF, et al. Complex regional pain syndromes in children and adolescents: regional and systemic signs and symptoms and hemodynamic response to tilt table testing. Clin J Pain. 2006;22(4):399-406.