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Published on: January 21, 2020
Continuous Regional Anesthesia and Inpatient Rehabilitation for Pediatric Complex Regional Pain Syndrome
Carolina Donado1, Kimberly Lobo, María Fe Velarde-Álvarez
1From the *Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital; and Department of Anaesthesia, Harvard Medical School, Boston, MA; and †Department of Physical and Occupational Therapy, Boston Children's Hospital, Boston, MA.
Insights
Continuous regional anesthesia infusions aided intensive rehabilitation for pediatric complex regional pain syndrome (CRPS) patients. This treatment improved pain and function in 70% of patients, offering a viable option for those with persistent symptoms.
Area of Science:
- Pediatric pain management
- Regional anesthesia
- Rehabilitation medicine
Background:
- Standard treatments for pediatric complex regional pain syndrome (CRPS) include physical, occupational, and cognitive-behavioral therapies.
- Some children experience persistent pain and limb dysfunction despite conventional therapies.
- Continuous epidural or peripheral perineural local anesthetic infusions combined with inpatient rehabilitation were utilized in this study.
Purpose of the Study:
- To evaluate the effectiveness of continuous regional anesthetic infusions combined with inpatient rehabilitation for pediatric CRPS patients.
- To identify predictors of successful treatment outcomes.
Main Methods:
- Retrospective study of pediatric CRPS patients treated between September 2003 and September 2014.
- Primary outcomes assessed were pain and functional scores, collected during hospitalization and at follow-up.
- Statistical analyses included Wilcoxon tests, Jacobson and Truax method for clinical significance, and mixed models for predictor analysis.
Main Results:
- Seventy percent of patients achieved clinically significant improvement in pain and/or function.
- 56% experienced pain reduction and 40% showed increased functionality.
- Lower preadmission pain scores and attendance at a specialized rehabilitation center predicted favorable outcomes, while higher intra-infusion pain scores predicted less favorable outcomes.
Conclusions:
- Continuous regional anesthesia can be a valuable adjunct to intensive rehabilitation for select pediatric CRPS patients.
- Further research is needed to define the optimal role of regional anesthesia within a comprehensive CRPS management program.
Background:
Evidence supports treatment of pediatric complex regional pain syndromes (CRPS) with physical and occupational therapy and cognitive-behavioral therapy. Some patients have persistent pain and/or limb dysfunction despite these treatments. We performed a retrospective study of pediatric patients with CRPS treated by continuous epidural or peripheral perineural local anesthetic infusions along with inpatient rehabilitation at Boston Children's Hospital.
Methods:
After approval from the institutional review board, electronic medical records were reviewed for patients treated between September 2003 and September 2014. Primary outcomes were pain and functional scores. Data were collected at the first encounter, at follow-up visits between 4 months before and after admission, and daily while inpatient. Changes over time were assessed using Wilcoxon tests with Dunn corrections. Clinical significance of benefit or harm was assessed by the method of Jacobson and Truax. Response predictors were analyzed using linear mixed models and exploratory logarithmic regression analyses.
Results:
Pain, function, and disability scores improved during hospitalization and in follow-up over a 4-month period. Seventy percent of patients achieved clinically significant benefit (56% for pain reduction and 40% increased functionality, respectively). Univariate and adjusted predictors of favorable outcome included preadmission resting Numeric Pain Rating Scale score of less than 6 (odds ratio, 5.0; P = 0.0164 and subsequent attendance at the Pediatric Pain Rehabilitation Center at Boston Children's Hospital (odds ratio, 5.0; P = 0.0206). Mean pain scores greater than 3 during the regional anesthesia infusion predicted less favorable outcome.
Conclusions:
Continuous regional anesthesia may be an option to facilitate intensive rehabilitation for selected pediatric patients with CRPS. Further research should help clarify the role of regional anesthesia in a comprehensive management program.
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