Complex Regional Pain Syndrome (CRPS)

CRPS/complex or chronic pain can present in varied ways; including reduced function and hypersensitivity with a pain response disproportionate to the movement or action. Minor injuries precipitate 80% of cases of CRPS e.g. an ankle sprain.

Paediatric red flags

This list is not exhaustive nor a diagnostic tool, but areas to consider.    

Children presenting with red flags, indicating the possibility of more serious underlying pathology, warrant urgent assessment, with some cases requiring referral directly to the Emergency Department or Acute Paediatrics.

• Unremitting pain
• Night pain (pain that awakens the child from sleep)
• Back pain < 6 years old
• Systemic symptoms; fever, malaise, unexplained weight loss, sickness
• Changes in bladder and bowel habit
• Hot, swollen and inflamed joint(s)
• Early morning stiffness (may indicate JIA) with persistent swelling
• Painful guarded movement/muscle spasm/significant loss of range of motion, in absence of trauma
• Regression of development/loss or deterioration of function
• Antalgic gait/inability to weight bear/gait disturbance/ lower limb asymmetry
• Sensation changes (pins and needles/numbness), absent or exaggerated reflexes, unexplained muscle weakness    

Action: Key assessment points

• Check for hypersensitivity to touch
• Pain response that is disproportionate to the injury
• Check joint range of movement
• Check gait /weight-bearing
• Check for autonomic changes including:  allodynia, swelling, colour changes, skin changes, shiny skin, hair growth, temperature changes

Action: Initial GP management

• Education to parents/guardian and child, to explain pain

For example: “Unlike the useful warning signal of acute pain, persistent or chronic pain messages no longer serve a useful purpose. These messages are not protecting our bodies from further damage. The nerves continue to respond with pain signals, because they have been so over active - like they are stuck on repeat, or amplified.”

Explain importance of regaining normal movement and sensation. Advice that weight bearing, gentle exercise and normal ADL’s should be maintained and encouraged

Give ‘Understanding and overcoming long term pain’ leaflet.

My pain toolkit: www.paintoolkit.org

Understanding pain:  www.Retrainpain.org

Action: Refer to Paediatric Physiotherapy

• Non, or reduced, weight-bearing
• Reduced function / gait changes
• Reduced / painful range of movement
• Autonomic changes / hypersensitivity
• Muscle weakness / tightness

Action: Refer to Paediatricians

• Limited progress with physiotherapy
• Indication for referral to a Specialist Pain Centre/Rehabilitation facility/clinical psychology
• Exclude serious  organic pathology / red flags

Action: Refer for Investigations

• X-ray/MRI to exclude pathology/used as a reassurance tool