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Complex regional pain syndrome type-I after rubella vaccine
Abstract
Complex regional pain syndrome type I (CRPS-I) is a complex disorder characterised by pain, autonomic dysfunction, and decreased range of motion. The syndrome was believed as a well-recognized disorder in adults but, less commonly recognized in children. CRPS-I after vaccination has been rarely reported. We reported an 11-year-old young girl with CRPS-I due to rubella vaccine. © 2004 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved.
... In recent years, there has been a few reports of CRPS following immunization, especially in children and adolescents (2)(3)(4)(5). To the authors' knowledge, this is the first case of CRPS in an adult following tetanus-diphteria toxoid vaccine. ...
... As mentioned earlier CRPS following immunization have been reported in children and adolescents (2)(3)(4)(5). Possible risk factors causing CRPS are noxious events or trauma, particularly minor trauma. It has been proposed that intramuscular injection is a sufficient noxious stimuli to trigger the development of CRPS-1 (2,4,5). ...
... Possible risk factors causing CRPS are noxious events or trauma, particularly minor trauma. It has been proposed that intramuscular injection is a sufficient noxious stimuli to trigger the development of CRPS-1 (2,4,5). Our patient's clinical findings fulfilled all the diagnostic IASP criteria for CRPS-1, and we agree with the authors that the reaction most likely results from injection trauma as an initiating noxious event. ...
Background: Complex regional pain syndrome [CRPS] is a painful and disabling chronic neuropathic disorder, and unfortunately, due to its wide spectrum of clinical manifestations, the diagnosis may often be missed by primary-care physicians. To the authors’ knowledge, there are no reported cases of CRPS following immunization with tetanus–diphteria toxoid booster vaccine in an adult.Findings: We present a 26-year-old woman with severe pain, swelling, and limited range of motion of the left forearm following a booster dose of the tetanus–diphteria toxoid vaccine.Conclusion: Disease awareness among practitioners, early recognition, and appropriate treatment is essential to minimize the risk of adverse outcome.
... Woolf explained that peripheral and central sensitization can lead to continuous chronic pain [5]. Genc et al. reported a case of CRPS post rubella vaccination [6]. Kwun et al. reported a case of CRPS post vaccination of influenza A (H1N1) in a 17-year-old female and suggested that the injection had caused the trauma [7]. ...
... Therefore, mental stress exists in my situation; however, it cannot be directly attributed to my CRPS. The International Association for the Study of Pain (IASP) presented the best-known criteria for CRPS ( Table 1) [6]. ...
Complex regional pain syndrome (CRPS) is a pathological exaggeration caused by trauma from injections and vaccine administration characterized by severe pain (often burning), hyperesthesia, allodynia, edema, vasomotor changes, decreased range of motion, hyperhidrosis, and trophic changes. It occurs at all ages with female predominance, and the incidence increases until late middle age. Hand and foot involvement is well recognized, and this may spread proximally. Treatment usually requires a multimodal approach, including medications and physical and cognitive therapy. Reports of CRPS after vaccination are rare. The incidence of CRPS post coronavirus disease 2019 (COVID-19) vaccination is not yet reported. This case report describes my experience with deltoid hematoma, tennis elbow, and living with CRPS post COVID-19 vaccine shot, including the psychosocial adaptations I made in my day-to-day life.
... There have been documented cases of CRPS in children following immunizations with hepatitis B (HBVx) and rubella vaccines (11,12). No link was found between the 2 vaccines and the proposed conclusion was that these cases were a result of injection trauma or a reaction to the vaccine constituents. ...
... Previously, 4 cases of CRPS have been reported following HBVx and one case following a rubella vaccination. Similar to our patient, the symptoms in the other vaccine-related cases of CRPS occurred soon after the inciting event and no other causes could be found for the immense pain and dysfunction (11,12). Public concern regarding vaccine safety is aimed not only at perceived vaccine-associated diseases (autism, multiple sclerosis, autoimmune disorders, etc.) but also at the hazards of the components, i.e., preservatives, stabilizers, adjuvants, and biological growth media (8,9). ...
Background: Complex regional pain syndrome (CRPS) is a clinically diagnosed multifaceted condition comprising of physical complaints often with a psychological component. CRPS can result in devastating chronic pain and disability if not treated early and aggressively. Mostly seen in adults, CRPS is being described more frequently in children. There have been some rare reports of CRPS occurring after vaccine administration. This is a case report of a young boy who developed CRPS after receiving a routine vaccination. Case Presentation: Although CRPS has been reported after rubella and hepatitis B vaccine, this is a case of CRPS after a diphtheria, tetanus, and acellular pertussis vaccine. Delays in diagnosis may cause undue pain, extended lengths of treatment, requirements for more intense therapy, and less likelihood for complete functional restoration. Because there seems to be no common constituent to the vaccines described in this case, the resultant CRPS may be purely due to injection-site trauma. Conclusion: We encourage physicians to be wary of the syndrome and its link to multiple vaccines in order to initiate prompt treatment. Key words: Complex regional pain syndrome (CRPS), reflex sympathetic dystrophy (RSD), children, vaccination, diphtheria, tetanus, acellular pertussis (TDAP)
... There are indications that autoinflammatory and/or genetic predisposition (for example, polymorphisms of human leucocyte antigen (Kemler et al., 1999;Mailis & Wade, 1994; Van de Beek et al., 2003;Van Hilten et al., 2000;De Rooij et al., 2009a;Dirckx et al., 2015), TNF-alpha (Vaneker et al., 2002), or possibly angiotensin-converting enzyme gene (Hühne et al., 2004;Kimura et al., 2000) play a role in the pathophysiology (De Rooij et al., 2009b;Goebel & Blaes, 2013). Associations have been suggested between CRPS and exposure to some viruses and or bacteria, such as parvovirus B19, herpes simplex virus, Campylobacter jejuni, Borrelia burgdorferi, and spirochetes (Van de Vusse et al., 2001;Muneshige et al., 2003;Goebel et al., 2005;Sibanc & Lesnicar, 2002;Neumann et al., 1989), and to some vaccines (Jastaniah et al., 2003;Genc et al., 2005). ...
... There is no acknowledged risk period for CRPS after a precipitating event. While reports of possible CRPS after vaccination have occurred on the same day as the vaccination (Jastaniah et al., 2003;Genc et al., 2005), we considered a theoretical risk window of six days after vaccination. The observed-versusexpected analysis was conducted separately for Japan, the UK and worldwide. ...
Complex regional pain syndrome (CRPS) is a chronic pain disorder that typically follows trauma or surgery. Suspected CRPS reported after vaccination with human papillomavirus (HPV) vaccines led to temporary suspension of proactive recommendation of HPV vaccination in Japan. We investigated the potential CRPS signal in relation to HPV-16/18-adjuvanted vaccine (Cervarix®) by database review of CRPS cases with independent expert confirmation; a disproportionality analysis and analyses of temporality; an observed versus expected analysis using published background incidence rates; systematic reviews of aggregate safety data, and a literature review.
The analysis included 17 case reports of CRPS: 10 from Japan (0.14/100,000 doses distributed) and seven from the United Kingdom (0.08/100,000). Five cases were considered by independent experts to be confirmed CRPS. Quantitative analyses did not suggest an association between CRPS and HPV-16/18-adjuvanted vaccine. Observed CRPS incidence after HPV-16/18 vaccination was statistically significantly below expected rates. Systematic database reviews using search terms varying in specificity and sensitivity did not identify new cases. No CRPS was reported during clinical development and no unexpected results found in the literature.
There is not sufficient evidence to suggest an increased risk of developing CRPS following vaccination with HPV-16/18-adjuvanted vaccine. Post-licensure safety surveillance confirms the acceptable benefit-risk of HPV-16/18 vaccination.
... As with other chronic pain syndromes, diagnosis of CRPS is based on a thorough medical history and physical examination to rule out other conditions such as infection, stress fracture and neoplasm. There are no indicative laboratory findings for CRPS, although bone scan may show increased update in the involved limb if performed early in the process [34]. Although no studies in the past year directly addressed diagnosis or assessment of CRPS in children, a case study reported CRPS type I in a child developing after routine vaccination in the affected limb [34]. ...
... There are no indicative laboratory findings for CRPS, although bone scan may show increased update in the involved limb if performed early in the process [34]. Although no studies in the past year directly addressed diagnosis or assessment of CRPS in children, a case study reported CRPS type I in a child developing after routine vaccination in the affected limb [34]. Clearly much remains to be learned about the etiology of this mystifying disorder. ...
As many as 25% of new patients in pediatric rheumatology clinics present with idiopathic chronic pain and recent data suggest the prevalence of these conditions is increasing. Knowledge of the latest developments in assessment and treatment is critical for providing optimal clinical care. This review summarizes advances published in the past year forwarding our understanding of chronic musculoskeletal pain syndromes in children.
Research has recently focused on the impairment associated with chronic pain syndromes in children, issues impacting the diagnosis of these conditions, and the efficacy of pharmacological and psychosocial treatments. No diagnostic criteria have been developed for specific chronic pain syndromes in children; however, data from several studies substantiate the need for thorough assessment of the child and family in multiple domains. In addition, studies have expanded both pharmacologic and psychosocial treatment options for children with these syndromes.
Despite a growing body of research on chronic pain syndromes in children, there are no established standards of care. Data continues to support an interdisciplinary approach for effectively assessing and managing these conditions.
... Reports of CRPS after a vaccine are extremely rare and only few cases of CRPS after vaccination such as the hepatitis B [13], influenza [14] , rubella [15], and human papillomavirus [16] vaccines have been published. ...
... 151 Finally, rubella and hepatitis B vaccination have been noted in case reports to precede CRPS. 152,153 Recently, two studies have demonstrated the presence of autoantibodies against neuronal structures in CRPS patients, 148,154 but their actual contribution is not yet elucidated. ...
The mechanisms underlying complex regional pain syndrome (CRPS) have been increasingly studied over the past decade. Classically, this painful and disabling disorder was considered to emerge from pathology of the central nervous system. However, the involvement of additional peripheral disease mechanisms is likely, and recently these mechanisms have also attracted scientific attention. The present article provides an overview of the current understandings regarding pathology of the autonomic and somatic nervous system in CRPS, as well as the roles of neurogenic inflammation, hypoxia, and the contribution of psychological factors. Potential connections between the separate disease mechanisms will be discussed. Additionally, currently known risk factors for CRPS will be addressed. Insight into risk factors is of relevance as it facilitates early diagnosis and tailored treatment. Moreover, it may provide clues for further unraveling of the pathogenesis and etiology of CRPS.
Pediatric patients with complex regional pain syndrome (CRPS) differ from their adult counterparts in several ways. The lower limb is disproportionately affected and there is a higher percentage of cases that present after no known trauma. While many pediatric CRPS patients have psychological comorbidities, evidence does not suggest a psychological origin of pediatric CRPS. Adult criteria for diagnosis is often used, although many recognize the need for pediatric-specific criteria. Multidisciplinary therapy is the foundation of treatment. There is not good evidence to support the use of medications in pediatric CRPS. Invasive procedures are not recommended as first-line therapy, but may be helpful for cases that are refractory to conservative treatment. The prognosis is generally favorable, though recurrence is very common. Despite a tremendous growth in research on pediatric CRPS in the recent decades, there is a still a great need for more high-quality evidence in the treatment of pediatric CRPS.
Complex regional pain syndrome (CRPS) is a chronic pain condition that usually follows minor extremity trauma and is characterized by sensory, vasomotor, sudomotor, and motor/trophic changes. While epidemiological studies are limited, CRPS occurs with an estimated incidence between 5.5 and 29.0 cases per 100,000 person-years and is more common in female patients. The pathophysiology underlying CRPS remains an active area of study, likely varying between patients and even over time in a single patient. Proposed mechanisms include sympathetically maintained pain, peripheral and central sensitization, oxidative stress, autoimmunity, and psychological factors. Changes in presentation are common with increasing duration of symptoms and often include a shift from a warm, edematous, and erythematous limb to a cool, atrophic, and blue/purplish limb with non-dermatomal spreading. This more chronic phase coincides with increased refractoriness to treatment and suggests a transition from peripheral to central mechanisms over time.
Complex regional pain syndrome (CRPS) Type I, a chronic pain disorder, occurs in the sequel of certain predisposing conditions. Recurrence may be observed in 4%–10% of cases in the same or another limb. There are no specific parameters to prevent CRPS after surgery or trauma. However, some authors have reported several recommendations about surgical techniques and Vitamin C supplementation. We report a case who had CRPS Type I history before and developed recurrent CRPS Type I in the lower limb due to surgery for osteonecrosis of the hip. We observed significant improvement with physical therapy and medication.
The occurrence of hematoma and bruise formation, accounting for the majority of donation-related complications in the arm, rarely results in complex regional pain syndrome (CRPS). We report a 24-year-old man who presented with CRPS on his right upper limb two months later due to hematoma and bruising formation just after a blood donation following with immediate performance of strenuous exercise in the upper limbs. Triple phase bone scan, one of the bone scintigraphic studies, revealed positive findings and was compatible with the symptoms of CRPS, e.g. hyperalgesia, swelling and discoloration. The potentially disabling condition, however, ended up with a thankfully benign outcome because of our early finding and proper treatment that included three-day oral prednisolone and two-week physiotherapy and occupational rehabilitation. To our knowledge, CRPS produced by donation-related complications with subsequent hematoma and bruise due to vigorous exercise is rare. CRPS should be taken into consideration in a blood donor who demonstrated allodynia because of performing heavy exercise immediately after blood donation.
Objective:
To evaluate the association between quadrivalent human papillomavirus vaccination and syndromes with autonomic dysfunction, such as chronic fatigue syndrome, complex regional pain syndrome, and postural orthostatic tachycardia syndrome.
Design:
Population-based self-controlled case series.
Setting:
Information on human papillomavirus vaccinations and selected syndromes with autonomic dysfunction (chronic fatigue syndrome, complex regional pain syndrome, and postural orthostatic tachycardia syndrome) identified using ICD-10 (international classification of diseases, revision 10) diagnostic codes from Danish nationwide registers.
Participants:
869 patients with autonomic dysfunction syndromes from a cohort of 1 375 737 Danish born female participants aged 10 to 44 years during 2007-16.
Main outcome measures:
Self-controlled case series rate ratios (95% confidence intervals) of the composite outcome of chronic fatigue syndrome, complex regional pain syndrome, and postural orthostatic tachycardia syndrome, adjusted for age and season, comparing female participants vaccinated and unvaccinated with the quadrivalent human papillomavirus vaccine. Chronic fatigue syndrome, complex regional pain syndrome, and postural orthostatic tachycardia syndrome were also considered separately in secondary analyses.
Results:
During 10 581 902 person years of follow-up, 869 female participants with syndromes of autonomic dysfunction (136 with chronic fatigue syndrome, 535 with complex regional pain syndrome, and 198 with postural orthostatic tachycardia syndrome) were identified. Quadrivalent human papillomavirus vaccination did not statistically significantly increase the rate of a composite outcome of all syndromes with autonomic dysfunction in a 365 day risk period following vaccination (rate ratio 0.99, 95% confidence interval 0.74 to 1.32) or the rate of any individual syndrome in the risk period (chronic fatigue syndrome (0.38, 0.13 to 1.09), complex regional pain syndrome (1.31, 0.91 to 1.90), or postural orthostatic tachycardia syndrome (0.86, 0.48 to 1.54)).
Conclusions:
When vaccination is introduced, adverse events could occur in close temporal relation to the vaccine purely by chance. These results do not support a causal association between quadrivalent human papillomavirus vaccination and chronic fatigue syndrome, complex regional pain syndrome, or postural orthostatic tachycardia syndrome, either individually or as a composite outcome. An increased risk of up to 32% cannot be formally excluded, but the statistical power of the study suggests that a larger increase in the rate of any syndrome associated with vaccination is unlikely.
Objectives: Complex regional pain syndrome (CRPS) cases have followed human papillomavirus (HPV) vaccination, but no causal link has been established.
Methods: Using insurance claims, the authors observed unvaccinated 11-year-old girls for CRPS diagnoses. The authors used time-dependent Cox regression to identify health-related CRPS predictors using diagnosis codes. Next, the authors identified HPV vaccinations using procedural codes. HPV vaccination and CRPS predictors were considered time-dependent covariates to estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) for CRPS, 30, 90, and 180 days post-vaccination.
Results: 1,232,572 girls received 563 unique CRPS diagnoses. In a 10% sub-cohort of 123,981 girls accounting for potential confounders and predisposing risk factors (i.e. injury, infection, mental illness, primary care use), CRPS hazard was not significantly elevated 30 days (HR: 0.90, 95% CI: 0.46, 1.73), 90 days (HR: 1.17, 95% CI: 0.83, 1.65), or 180-days post-vaccination (HR: 1.11, 95% CI: 0.83, 1.47).
Conclusion: The results support the safety and continued administration of HPV vaccines to adolescents.
CRPS bij kinderen in Kindertraumachirurgie. Tweede, herziene druk.
Publicatiedatum: 19 mrt. 2019
Bohn, Stafleu en van Loghum
Omschrijving publicatie:
In zestig hoofdstukken wordt door meer dan honderd specialisten een gedetailleerd en actueel overzicht gegeven over de preventie, diagnostiek en behandeling van ongevalsletsels bij kinderen.
Ik mocht meewerken aan hoofdstuk 52 over #CRPS bij kinderen.
Akute Erkrankungen bei Kindern sind zumeist von Schmerzen begleitet, ohne dass diese in der Praxis immer suffizient therapiert werden. Besonders relevant ist eine gute Schmerztherapie bei Verbrennungstraumen, der Otitis media sowie anderen Infektionskrankheiten. Auch im Rahmen seltener Erkrankungen wie der Epidermolysis bullosa ist eine gute Schmerztherapie entscheidend für die Lebensqualität des Kindes. Abdominelle Schmerzen sind immer eine therapeutische Herausforderung, die umso größer scheint, je jünger das Kind ist. Im direkten Patientenkontakt ist die verdeckte Placebogabe ein unethischer und unsinniger Versuch einer Schmerztherapie.
Complex regional pain syndrome type I (CRPS-I) is a complex disorder characterised by pain, autonomic dysfunction and decreased range of motion. The syndrome was believed as a well-recognized disorder in adults, but less commonly recognized in children. In this article, literature was reviewed for assessing clinical features, diagnostic methods and treatment modalities of the syndrome in children. Some of the clinical features that we reviewed from some case reports on CRPS-I, ware different from the features given in the textbooks or some other literature. Changing concepts about diagnosis and treatment methods of this disorder was also observed. This syndrome was thought to be well-recognized in recent years in children. However, further studies are necessary for a better understanding and effective treatment of this disorder.
No definitive etiology or risk factors have been identified that predispose individuals to developing complex regional pain syndrome (CRPS). We experienced two cases of CRPS developed after arterial and venous puncture which were done in regular medical work. A 35-years old female patient was suffered from pain and allodynia with swelling at right hand and wrist after radial artery puncture for monitoring of blood pressure during general anesthesia. A 24-years old male patient had pain and swelling with allodynia at the right fingers and arm after median cubital vein puncture for blood sampling. They did not have proper pain management as CRPS patients in the past weeks and months after their pain occurred. They were diagnosed as CRPS and started undergoing various interventional procedures, which led to improve their pain condition. Our cases suggest that CRPS could develop without any proved tissue damage in routine medical practice. In conclusion, health care workers should be educated in knowledge about the uncommon medical condition and proper consultation to pain specialist when it happens.
Objective:
To investigate the causes of neurological manifestations in girls immunized with the human papillomavirus (HPV) vaccine.
Methods:
During the past nine months, 44 girls visited us complaining of several symptoms after HPV vaccination. Four patients with other proven disorders were excluded, and the remaining forty subjects were enrolled in this study.
Results:
The age at initial vaccination ranged from 11 to 17 years, and the average incubation period after the first dose of the vaccine was 5.47±5.00 months. Frequent manifestations included headaches, general fatigue, coldness of the legs, limb pain and weakness. The skin temperature examined in 28 girls with limb symptoms exhibited a slight decrease in the fingers (30.4±2.6 °C) and a moderate decrease in the toes (27.1±3.7 °C). Digital plethysmograms revealed a reduced height of the waves, especially in the toes. The limb symptoms of four girls were compatible with the Japanese clinical diagnostic criteria for complex regional pain syndrome (CRPS), while those in the other 14 girls were consistent with foreign diagnostic criteria for CRPS. The Schellong test identified eight patients with orthostatic hypotension and four patients with postural orthostatic tachycardia syndrome. The girls with orthostatic intolerance and CRPS commonly experienced transient violent tremors and persistent asthenia. Electron-microscopic examinations of the intradermal nerves showed an abnormal pathology in the unmyelinated fibers in two of the three girls examined.
Conclusion:
The symptoms observed in this study can be explained by abnormal peripheral sympathetic responses. The most common previous diagnosis in the studied girls was psychosomatic disease. The social problems of the study participants remained unresolved in that the severely disabled girls stopped going to school.
Complex regional pain syndrome (CRPS) is characterized by pain, allodynia, hyperalgesia, autonomic and vasomotor dysfunction which arise on the distal of extremity. There are many factors reported in the literature that causes CRPS. It commonly emerges after minor traumas. CRPS after vaccination is very rare and it was not completely clarified whether clinical findings arise from content of vaccine or trauma of injection. In this case report, a patient who had CRPS type 1 developed after receiving tetanus vaccination is discussed.
Complex regional pain syndrome (CRPS) type I (formerly
reflex sympathetic dystrophy) is an incompletely understood
response of the body to an external stimulus, resulting in
pain that usually is nonanatomic and disproportionate to the
inciting event or expected healing response.1 A careful history
and general examination are essential for accurate diagnosis.
We report a case of CRPS type I of the right upper extremity
following an injection with tetanus toxoid vaccine into
the same extremity. Only 1 similar case was reported before in
the French literature in 1977.
Complex regional pain syndrome type I (CRPS I) is a disorder of one or more extremities characterized by pain, abnormal sensitivity (allodynia), swelling, limited range of motion, vasomotor instability, fatigue and emotional distress. The symptoms may be aggravated by even minor activity or weather change. It is usually provoked by injury, surgery or injection but in a small proportion of patients CRPS I develops without a clear causative event. There are several literature reports on CRPS after rubella and hepatitis B vaccination. We present a case of CRPS I affecting the left arm after diphtheria and tetanus (Di-Te) vaccination in the left deltoid muscle in a young girl having experienced profound emotional stress before the vaccination procedure. History data on previous minor trauma at the site of vaccination or emotional stress may necessitate temporary vaccination delay due to their proneness to impaired local or systemic immune response and CRPS as a complication of vaccination. If a child or an adult has prominent swelling and severe pain after vaccination, the diagnosis of CRPS I should be considered and if confirmed, the multidisciplinary treatment should start as soon as possible.
Complex regional pain syndrome type 1 (CRPS-1) is a clinical syndrome that affects one or more extremities and is characterised by persistent pain disproportionate to any inciting event, and at least one sign of autonomic dysfunction in the affected limb(s). The pathogenesis of this syndrome is poorly understood, but its onset is often precipitated by a physical injury, such as minor trauma, fracture, infection or a surgical procedure. In the literature, there are reports of CRPS-1 following immunisation with rubella and hepatitis B vaccines. Here we present a case series of CRPS-1 following immunisation in adolescents, with either diphtheria-tetanus-acellular pertussis (1 case), or human papillomavirus vaccines (4 cases). Enhanced awareness of this syndrome and its potential to occur following immunisation in the paediatric population is vital to the prompt and effective management of this condition.
Complex regional pain syndrome (CRPS; formerly known as Morbus Sudeck/reflex dystrophy) is diagnosed in children and adolescents, but the clinical presentation is often atypical. Unfortunately, potentially harmful, invasive treatments are used in pediatric patients.
A retrospective chart study of pediatric chronic pain patients with CRPS was performed.
Over the course of 6 years, 37 (35 girls) children and adolescents took part in a multidisciplinary chronic pain inpatient program. At admission, patients took on average 4.4 (range 1-10) different medications and 29 different pharmaceuticals were used overall. Prior to admission, invasive pain treatments were performed without success in 16 of the children (43%). At least 13 children received two or more invasive treatments. Although sympathetic blocks were most prevalent, operations and regional anesthesia were also used.
Despite a lack of evidence for invasive procedures, these continue to be used in children and adolescents with CRPS, who later respond positively to conventional treatment. The English full-text version of this article is available at SpringerLink (under "Supplemental").
Neuropathic pain is relatively uncommon in children. Although some syndromes closely resemble those found in adults, the incidence and course of the condition can vary substantially in children, depending on developmental status and contextual factors. There are some neuropathic pain syndromes that are rare and relatively unique to the pediatric population. This article discusses the array of neuropathic pain conditions in children and available treatment strategies. Data are limited by small numbers and few randomized controlled trials. Research and clinical implications are discussed.
Reflex sympathetic dystrophy (RSD) is a serious and potentially disabling condition and is a very complex syndrome, which consists of pain maintained by the sympathetic nervous system. There have been no data present demonstrating that this condition can be treated with electroacupuncture and Chinese herbal medicine effectively.
The objective of this study was to present a case treated by electroacupuncture and Chinese herbal decoction successfully. Patient data: A young Australian woman, who presented with the symptoms of severe swollen left foot, foot pain, swollen ankle and ankle pain, and lower-extremity RSDs, was the subject of the treatment.
A needle-free electroacupuncture method was applied to the affected meridian region. An individually designed Chinese herbal decoction was used for a coordinated approach.
Noticeable progress occurred within 2 weeks of the treatment, and 1.5-2 months later, the patient could walk without crutches. A full recovery occurred after a further 2 weeks.
The outcome measurement was change in pain score and swollen status (severity of swollenness), as well as function restoration.
There are no published articles showing the efficiency and safety of this needle-free acupuncture and herbal medicine treatment regimen. Therefore, an accumulation of similar clinical cases or further research is needed to evaluate this particular treatment method.
We report on the experience with our first seventy patients who had reflex sympathetic dystrophy and were less than eighteen years old (average age, 12.5 years). In our series, the patients were predominantly girls (male to female ratio, 11:59) and the lower extremity was involved most often (sixty-one of the seventy patients). The average time from the initial injury to the diagnosis was one year, which indicates that the syndrome remains under-recognized in patients in this age-group. Conservative treatment with physical therapy, transcutaneous electrical nerve stimulation, psychological therapies including cognitive-behavioral management and relaxation training, and tricyclic anti-depressants was effective in improving the average scores for pain and function for forty patients. Sympathetic blocks were helpful for twenty-eight of thirty-seven patients. Thirty-eight of the seventy patients in the series continued to have some degree of residual pain and dysfunction. Reflex sympathetic dystrophy in children differs in presentation and clinical course from the syndrome in adults. It is best treated in a multidisciplinary fashion.
• Reflex sympathetic dystrophy syndrome is a well-recognized disorder in adults, but it is rarely diagnosed in the pediatric age group. This report summarizes our experience with this condition from 1975 to 1985. We diagnosed, treated, and followed up this condition in 18 children and adolescents. The condition usually followed trauma. The most prominent feature in all patients was a constant limb pain with episodes of paroxysmal exacerbation. The pain was associated with two or more of the following: edema, hyperhidrosis or anhidrosis, cyanosis or erythema, and, in severe cases, dystrophic skin changes and muscle atrophy. Roentgenograms were normal. Bone scans were helpful to exclude other possible causes of bone and joint pain. Reflex sympathetic dystrophy syndrome in children probably often goes unrecognized, sometimes being confused with psychiatric conditions such as conversion reaction and malingering. Reflex sympathetic dystrophy syndrome should always be considered in the differential diagnosis of unexplained persistent limb pain in children: early recognition and proper management may result in the prevention of potentially crippling sequelae.
(AJDC 1988;142:1325-1330)
Eleven children with reflex neurovascular dystrophy were investigated by technetium-labeled methylene diphosphonate bone scanning. Eight of 12 scans demonstrated abnormal findings, four showing diffusely decreased uptake and four diffusely increased uptake of the radionuclide in the affected site. Three scans showed normal findings initially, as did one previously abnormal scan when repeated in the asymptomatic patient 6 months later. Diffusely abnormal findings can be helpful in the diagnosis of childhood reflex neurovascular dystrophy, but a normal scan does not exclude the diagnosis.
Sixty-four patients were evaluated prospectively for a reflex sympathetic dystrophy syndrome (RSDS), using quantitative clinical measurements, high-resolution roentgenography and scintigraphy. Five separate groups were identified by their clinical features, allowing us to distinguish patients with definite or incomplete forms of the RSDS as well as 16 patients with other disorders. Scintigraphy was found to be a useful diagnostic study that may also provide a method of predicting therapeutic response. Systemic corticosteroid therapy proved to be a highly effective mode of treatment for up to 90 percent of the patients with the RSDS.
We present a revised taxonomic system for disorders previously called reflex sympathetic dystrophy (RSD) and causalgia. The system resulted from a special consensus conference that was convened on this topic and is based upon the patient's history, presenting symptoms, and findings at the time of diagnosis. The disorders are grouped under the umbrella term CRPS: complex regional pain syndrome. This overall term, CRPS, requires the presence of regional pain and sensory changes following a noxious event. Further, the pain is associated with findings such as abnormal skin color, temperature change, abnormal sudomotor activity, or edema. The combination of these findings exceeds their expected magnitude in response to known physical damage during and following the inciting event. Two types of CRPS have been recognized: type I, corresponds to RSD and occurs without a definable nerve lesion, and type II, formerly called causalgia refers to cases where a definable nerve lesion is present. The term sympathetically maintained pain (SMP) was also evaluated and considered to be a variable phenomenon associated with a variety of disorders, including CRPS types I and II. These revised categories have been included in the 2nd edition of the IASP Classification of Chronic Pain Syndromes.
Reflex sympathetic dystrophy is a syndrome characterized by pain in one or more extremities, usually associated with vasomotor changes. Its occurrence in childhood has long been thought to be rare. We describe six cases of pediatric reflex sympathetic dystrophy and suggest that this syndrome could be underdiagnosed in children and adolescents. Psychologic problems frequently play a role in this disorder, which often can be treated conservatively. We also point out that the diagnosis is mainly clinical. An early diagnosis can avoid unnecessary tests and potentially can improve response to treatment, and prognosis.
Aim of this study was to analyse the incidence CRPS-I after a fracture of the distal radius and to analyse risk factors. Patients who visited the Emergency Unit of the University Hospital, with a fracture of distal radius were asked to participate. As risk factors for CRPS-I, number of repositions (with or without local anaesthesia), additional cast changes and pain during the cast period, were assessed. In a structured interview social life events (SLEs) and psychological and/or psychiatric history were assessed. The patients filled out the Symptom Checklist-90 (SCL-90). In total 88 patients participated in the study. One female (1%, 95% CI: 0.2 to 6%), age 69 years with the following characteristics developed CRPS-I: one set of local anaesthetics, one repositioning attempt, no additional cast changes, average pain scores, no life events and her total score on the SCL-90 of 117, was slightly above average. Based on the results of this study it is concluded that the incidence of CRPS-I may be low (1%, 95% CI: 0.2 to 6%) after fractures of the distal radius. Further the risk factors described in literature play a minor role in the development of CRPS-I.
Complex regional pain syndrome, characterized by pain, autonomic dysfunction, and decreased range of motion, developed after hepatitis B vaccination in four grade-6 children since the introduction of the vaccination program in British Columbia in 1992. The reaction may result from injection trauma or may be secondary to a vaccine constituent.
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