Exploring pediatric chronic regional pain syndrome (CRPS) diagnostic criteria and determining the efficacy of multidisciplinary treatment in managing pediatric CRPS
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Currently, there is a dearth of knowledge regarding pediatric Complex Regional pain syndrome (CRPS), whether it is in regards to its pathophysiological mechanisms, pediatric-specific diagnostic criteria, validated diagnostic tests, conclusive treatment regimens, or validation of invasive and noninvasive treatment protocols in the pediatric CRPS population. It is imperative to first explore and establish a pediatric CRPS diagnostic criteria in order to optimize diagnostic accuracy for clinical and research purposes. This study first examined the efficacy of the Budapest criteria, a validated diagnostic instrument for adult CRPS, in the pediatric population. The test was administered to 221 pediatric patients at the Pediatric Pain Rehabilitation Center (PPRC), an intensive day treatment program at Boston Children’s Hospital for youth with chronic pain, and included both CRPS and non-CRPS chronic pain patients. Utilizing the Budapest criteria, secondary analyses were performed to determine whether the pediatric CRPS patients had an alleviation of their diagnosis from admission to discharge from the program. The Budapest clinical decision rule (to satisfy at least 2 signs categories and 3 symptoms categories) was utilized in examining the data. The sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of the Budapest criteria in the pediatric sample were 0.56, 0.95, 10.39, and 0.47, respectively. The low sensitivity and high specificity was in contrast to the adult findings, and suggests that the Budapest criteria would be appropriate when the primary purpose is to identify stringent research samples as opposed to maximizing clinical diagnoses of CRPS. The likelihood ratios indicated that while satisfying the Budapest clinical decision rule may conclusively increase the probability of the pediatric patient actually having CRPS, a negative test does not significantly decrease the probability of the patient having CRPS. Therefore, modifications that appropriately increase the sensitivity while maintaining the high specificity of the Budapest Criteria are recommended. Repeated measures ANOVA resulted in a significant decrease of the Budapest signs and symptoms score in the 94 pediatric CRPS patients in the sample, both in the Clinician + Budapest (satisfied the Budapest clinical decision rule) and Clinician Diagnosed (did not satisfy the Budapest clinical decision rule) CRPS cohorts (p < 0.001). This further authenticated the use of a multidisciplinary treatment approach in managing pediatric CRPS, as the program was successful in alleviating the patients’ signs and symptoms. Further research must be conducted to explore the improvements that can be made to the Budapest Criteria for its use in pediatric CRPS so as to maximize its diagnostic accuracy. Overall, this study corroborated the use of interdisciplinary treatment regimens for pediatric CRPS, but further rigorous investigation is necessary to elucidate the mechanisms behind pediatric CRPS and the rehabilitation programs’ success in managing CRPS.