Beliefs, attitudes, knowledge, and behaviours of physical therapists towards pediatric complex regional pain syndrome

Abstract

BACKGROUND

Pediatric complex regional pain syndrome (CRPS) is a debilitating chronic condition that affects the quality of life and psychosocial development of children and adolescents. Despite increasing recognition, significant diagnostic and therapeutic challenges persist, partly due to the lack of clinical criteria tailored to the pediatric population.

AIM

To evaluate current diagnostic and therapeutic practices in pediatric CRPS, identifying barriers to timely intervention and gaps in provider knowledge.

METHODS

Physiotherapists who had treated at least one pediatric CRPS case in the past two years were surveyed. The online questionnaire included 40 questions divided into three sections: Professional knowledge, therapeutic approaches, and personal perceptions. Data were analyzed using descriptive statistics and χ² tests.

RESULTS

Most participants worked in private clinics (71%) and collaborated with other healthcare professionals. About 53% had specific training in pediatric pain, while 40% had training in CRPS. Only 13% had received training in cognitive-behavioral therapy (CBT). The use of the Budapest criteria was limited, primarily applied during the diagnostic suspicion phase. The most common therapeutic strategies included mirror therapy (40%) and relaxation techniques (80%). The main reported challenges were the lack of specific clinical guidelines (60%) and insufficient professional training (47%).

CONCLUSION

Physical therapists are key contributors to multidisciplinary diagnosis and play a central role in managing pediatric CRPS in most cases, adopting a collaborative and largely non-pharmacological approach. However, the absence of standardized clinical guidelines limits treatment consistency. The development of pediatric-specific protocols and enhanced training in psychological therapies such as CBT is recommended.

Key Words: Pediatric; Children; Pain; Physical therapy; Complex regional pain syndrome

Core Tip: Pediatric complex regional pain syndrome is a complex condition that significantly impacts children’s well-being, yet diagnostic and treatment challenges remain due to the lack of pediatric-specific criteria. This study surveyed physiotherapists to assess current practices and knowledge gaps. Limited use of diagnostic tools and the absence of standardized guidelines were major barriers identified. The findings highlight the need for tailored protocols and improved training in psychological therapies.

INTRODUCTION

Pediatric complex regional pain syndrome (CRPS) is a chronic and disabling pain condition that primarily affects children and adolescents. It has a profound impact on quality of life, physical function, and psychosocial development[1]. The syndrome is characterized by persistent pain that is often disproportionate to the initial injury, along with sensory disturbances such as allodynia and hyperalgesia, autonomic changes including temperature asymmetry and altered sweating, and motor impairments such as weakness and dystonia[2]. Although previously considered rare in pediatric population, growing awareness suggests that CRPS in children may be underdiagnosed due to its variable presentation and overlap with other chronic pain disorders[3].

The pathophysiology of pediatric CRPS remains incompletely understood but is believed to involve peripheral and central sensitization, inflammation, and cortical reorganization[4]. In pediatric population, the condition frequently follows minor trauma or occurs without a clear trigger, most commonly affecting the lower limbs[5].

Early diagnosis is critical, as delayed intervention can lead to chronic disability, school absenteeism, and significant emotional distress, including anxiety and depression[6]. However, diagnostic challenges persist due to the lack of definitive biomarkers and reliance on clinical criteria, which may not fully capture pediatric presentations[7].

Management today relies on a comprehensive, multidisciplinary approach involving physical therapy, psychological support, and medication to enhance function and manage symptoms[8]. Emerging evidence supports the use of graded motor imagery, mirror therapy, and desensitization techniques to reestablish normal sensory-motor integration[9]. According to a scoping review[10], integrating cognitive-behavioral therapy (CBT) with physiotherapy education can support a holistic biopsychosocial approach and lead to better patient outcomes. Nevertheless, treatment responses vary, and relapse rates remain concerning, highlighting the need for personalized, evidence-based strategies[11].

New approaches like sensory testing and thermography may facilitate earlier detection and more effective monitoring[12]. Additionally, innovative therapies like transcranial magnetic stimulation and virtual reality-based rehabilitation are being explored to target maladaptive neural pathways[13]. Despite these developments, disparities in access to specialized care and inconsistent adherence to clinical guidelines continue to hinder optimal outcomes[14].

Previous reviews[10,15,16] have highlighted the importance of a multidisciplinary approach while also noting the absence of pediatric-specific diagnostic tools, which contributes to delays and variability in treatment. Accordingly, this study aims to assess current diagnostic and therapeutic practices in pediatric CRPS, identifying barriers to timely intervention and gaps in provider knowledge. By examining clinical decision-making, the application of protocols, and the integration of emerging technologies, this research aims to improve multidisciplinary care and long-term outcomes, promote more consistent practice, and address existing deficiencies in clinical management. Ultimately, enhancing early recognition and evidence-based management may mitigate the profound physical and emotional burdens imposed by pediatric CRPS.

MATERIALS AND METHODS

Design

A cross-sectional study was carried out to examine the beliefs, attitudes, knowledge, and behaviors of physical therapists towards differential diagnostic and therapeutic practices in pediatric CRPS. The study was performed according to the ethical principles of the Declaration of Helsinki. It was carried out between October 2024 and January 2025 in France.

Participants

Participants were licensed physiotherapists (≥ 18 years) who have treated at least one child or adolescent diagnosed with CRPS within the past two years in hospitals, private practices, clinics, or rehabilitation centers. Participants should have an adequate understanding of the language in which the questionnaire is written to ensure that their responses are accurate and meaningful. Access to an internet connection is required for participation.

Physiotherapists not practicing in France, undergraduate physical therapy students, trainees, and individuals without professional experience in this field were excluded from participation. Furthermore, physiotherapists who do not complete the entire questionnaire will not be included in the study.

Questionnaire

A convenience sample of physiotherapists was recruited to participate voluntarily in the study. Participants provided informed consent before beginning the questionnaire, after reviewing the consent statement. The survey was conducted in accordance with France’s personal data protection regulations, which adapts the GDPR legal framework and ensure the anonymity and confidentiality of the participants.

The questionnaire was distributed through several channels, including the national health insurance physiotherapists’ directory, various professional and training networks for physiotherapists (such as 'réseau kinepediatrie', 'Kiné pédia PACA', 'kine-pédiatrie', 'MedOrtho', 'Superkiné pédiatrie', 'kiné pédia 2020-2021', 'kinésithérapie', 'superkiné parisien', 'le réseau des kinés', and 'le monde des kinés'), as well as social media platforms (Linkedln^®, Facebook^®, and Instagram^®; Menlo Park, CA, United States), to maximize participation among physiotherapists in private practice in France.

The platform “Eval and Go” was used to design the questionnaire. Previously, physiotherapists were contacted through various social media networks, and those who responded positively to the invitation subsequently received the URL link to access the questionnaire.

The questionnaire includes 40 questions divided into three sections: (1) “Knowledge and characteristics of the professionals in the sample population”, consists of four questions that explore the setting of care (such as “In what type of facility have you treated patients with CRPS?”), multidisciplinary collaboration, specific knowledge acquired by professionals, and diagnostic modalities of paediatric CRPS; (2) “Therapeutic approach of paediatric CRPS”, includes nine questions focused on the use of Budapest criteria (standard diagnostic criteria), initial assessment (such as “What treatments do you primarily use to manage pain in pediatric patients with CRPS?”), consideration of CRPS phase in pain management, recommendations during the acute phase, recommendations during the chronic phase, therapeutic education and cognitive-behavioural therapy (CBT) [such as “Do you incorporate cognitive-behavioral therapy (CBT) as part of your treatment?”], pain treatments in CRPS and associated treatments received by patients; and (3) “Professionals' own perceptions”, includes difficulties in the management of pediatric patients with CRPS (such as “What difficulties have you encountered in the management of pediatric CRPS patients?”).

The questionnaire comprised multiple-choice questions developed from existing literature to ensure structured and focused responses; with no open-ended questions included.

Statistical analysis

All questionnaire responses were collected directly through the application and subsequently exported to Microsoft Excel for processing. Statistical analyses were conducted using SPSS Version 23.0 statistical software (SPSS Inc., Chicago, IL, United States). Summary descriptive statistics, including mean values with 95% confidence intervals, were calculated for the socio-demographic data of the participants. Descriptive analyses of study variables were performed using absolute and relative frequencies (%). For categorical variables, frequencies and proportions were calculated to describe the distribution of the main characteristics of the population included. Results are presented in tables. The χ² test of independence was used to assess associations between categorical variables.

RESULTS

A total of 15 physiotherapists with experience in treating CRPS in the paediatric population were surveyed. The professionals’ characteristics and knowledge are presented in Table 1.

Table 1 Knowledge and characteristics of the professionals in the sample population.

Overall (n = 15)
Variable			%
Setting of care	Private clinics		71
	Hospitals and specialised centres		24
	Home care services		6
Multidisciplinary collaboration	With other healthcare professionals	Doctors/pain team	27
		Psychologists	20
Specific knowledge	Paediatric pain		53
	Chronic pain and CRPS		40
	CBT		13
	Without specific knowledge		7
Diagnostic modalities of paediatric CRPS	Doctor		38
	Physiotherapist		48
	Informal diagnosis		14

CRPS: Complex regional pain syndrome; CBT: Cognitive-behavioral therapy.

As for the setting of care, the majority of physiotherapist worked in private clinics (71%), followed by those based in hospitals or specialised centres (24%) and home care services (6%).

A high level of collaboration with other healthcare professionals was observed (60%), with the pain team (27%) and psychologists (20%) being the most contacted.

In terms of specific knowledge, 53% had received training in paediatric pain, 40% in chronic pain or CRPS, and 13% in CBT. A total of 7% of the professionals reported having received no specific knowledge in any of these areas.

Regarding the diagnostic modalities to paediatric CRPS, a relatively balanced distribution was observed between medical professionals (38%) and physiotherapists (48%) as those responsible for the diagnosis, while 14% reported that the diagnosis is not clearly established within the medical field.

Therapeutic approaches of paediatric CRPS are included in Table 2.

Table 2 Therapeutic approach of paediatric complex regional pain syndrome.

Overall (n = 15)
Variable		%
Use of Budapest criteria	Do not use Budapest criteria	33
	Used when CRPS is suspected (pre-diagnostic phase)	40
	Used during confirmed diagnosis (evaluation or treatment phase)	13
	Unfamiliar with Budapest criteria	7
Initial assessment	Pain and function	93
	Functional impact	53
	Quality of life	46
	Psychological aspect	40
Recommendations during the acute phase of CRPS	Rest and splint use	31
	Analgesic use	34
	Regular physical activity	21
	Warm baths	14
	Combination of strategies	40
Recommendations during the chronic phase of CRPS	Removal of supportive splint	47
	Regular physical activity	67
	Increasing of intensity and frequency of physical activity	53
	Analgesics no recommended	100
Therapeutic education	Relaxation techniques/stress management	80
	Behavioral education/emotional support	53
	parent-focused intervention	47
CBT	Find CBT useful	73
	Unable to apply CBT	20

CRPS: Complex regional pain syndrome; CBT: Cognitive-behavioral therapy.

The use of the Budapest diagnostic criteria was limited: 33% of participants reported not using them, 40% used them only when CRPS was clinically suspected, and 13% applied them during assessment or treatment. Notably, 7% indicated they were unfamiliar with the criteria.

Initial assessment focused primarily on pain and function (93%), followed by functional impact (53%), quality of life (46%), and psychological factors (40%).

Figure 1 shows that pain management is mainly based on mirror therapy (40%) and physiotherapy (27%). Physical approaches such as self-mobilisation, balneotherapy, and active movement strategies were employed in 20% of cases. Transcutaneous electrical nerve stimulation was used in 13% of cases. In contrast, massage, yoga, and hypnosis were integrated in 7% of the cases.

Figure 1 Pain treatments in complex regional pain syndrome (%).

During this acute (“hot”) phase, the most common therapeutic recommendations included the use of analgesics (34%), rest and splinting (31%), and regular physical activity (21%), while 40% reported employing a combination of strategies. In contrast, during the chronic (“cold”) phase, there was greater consensus: 100% of professionals discouraged the use of analgesics, and most promoted regular physical activity (67%).

Therapeutic education was widely implemented, with over 80% of professionals incorporating psychoeducation and stress management techniques. However, only 53% included behavioural education or emotional support, and 47% actively involved parents in the therapeutic process.

As for CBT, 73% of respondents considered it a useful tool, although only 33% reported actively integrating it into their clinical practice. Twenty per cent stated they lacked the necessary knowledge for its implementation.

Professionals' own perceptions. Figure 2 shows the professionals' own perceptions regarding the difficulties in managing pediatric patients with CRPS.

Figure 2 Difficulties in the management of pediatric patients with complex regional pain syndrome (%).

The main difficulties identified included the lack of specific guidelines (60%), diagnostic issues (40%), lack of training (47%), lack of collaboration (20%), communication issues with other professionals (40%), and the perceived absence of effective techniques (13%).

DISCUSSION

This study aimed to evaluate current diagnostic and therapeutic approaches to pediatric CRPS. We found that physiotherapists made most of the diagnoses, care was primarily delivered in private clinics, and professionals often had specialized training in pediatric pain and preferred to work collaboratively with others healthcare professionals. Additionally, the Budapest criteria were primarily applied when a diagnosis of pediatric CRPS was suspected. Initial evaluations focused on pain and functional assessment. Mirror therapy and relaxation techniques or stress management strategies (particularly CBT) were commonly used and found to be helpful. The acute phase involved a combination of treatments, whereas in the chronic phase, analgesics were not recommended, and physical activity was promoted. Finally, a major issue identified in the management of pediatric CRPS was the lack of standardized clinical guidelines.

Prior research evaluated the physiotherapy professional’s perception and the diagnosis and treatment of children[17] and adults[18] chronic illness.

Our findings highlight that physiotherapists play a central role in diagnosing pediatric CRPS, with care predominantly delivered in private clinics by professionals trained in pediatric pain management. Emerging evidence suggests that diagnostic criteria developed for adults may lack sufficient sensitivity when applied to pediatric populations. A systematic review[19] identified four main diagnostic tools: The Veldman criteria, the International Association for the Study of Pain criteria, Budapest Criteria, and the Budapest Research Criteria. However, none of these tools have been validated for use in pediatric CRPS. Recent literature emphasizing the importance of multidisciplinary collaboration in CRPS care, particularly for children, where early intervention improves outcomes[10]. The predominant use of the Budapest criteria for diagnosis reflects current guidelines[20], though their adaptation for pediatric populations remains debated. While these criteria improve diagnostic specificity in adults, children often present with atypical symptoms[21], suggesting a need for pediatric-specific modifications. Our finding that pain and functional assessments dominate initial evaluations is consistent with the biopsychosocial approach recommended for pediatric pain[22,23]. Future studies are needed to develop a diagnostic tool tailored to pediatric populations.

According to our findings, mirror therapy and CBT are the recommended options in the management of pediatric CPRS[10]. Although 73% of participants considered CBT to be useful intervention for pediatric CRPS, only 33% reported incorporating it into their clinical practice. This gap may be attributed to physiotherapists’ limited formal training or lack of confidence in applying psychological strategies[24].

Besides, there are preferences for non-pharmacological therapies aligned with recent studies to minimize opioid use in pediatric pain[25]. For example, a review[26] reported high recovery rates when physical and behavioral strategies were combined. Similarly, a descriptive study[27] found that physiotherapy and psychological support were included in approximately threequarters of treatment protocols, whereas pharmacological interventions were used less frequently. These findings indicate that nonpharmacological approaches (particularly those addressing both physical and psychosocial aspects) play a central role in therapeutic decision-making and may provide age-appropriate benefits compared to pharmacotherapy, which has limited evidence and carries potential side effects in children.

Future research should focus on developing consensus guidelines that integrate physical, psychological, and non-pharmacological approaches for managing pediatric CRPS. Although expert consensus and commonly accepted treatment protocols are strongly recommended to optimize outcomes in pediatric chronic pain management[10,28], specific guidelines for pediatric CRPS remain lacking, as highlighted by our study.

Several limitations should be acknowledged. First, the small sample size represents a major limitation and restricts the generalizability of the findings. It also does not provide sufficient empirical breadth to support the development of a robust graded intervention algorithm. Additionally, the lack of formal validation of the online questionnaire constitutes a significant limitation, and the results should be interpreted with caution. The study also relied on self-reported data from participants which may introduce response bias and social desirability bias[29], which may affect the reliability and generalizability of the results. Moreover, the absence of multivariate analyses further limits the findings. Future research should aim to validate the questionnaire, conduct larger multicenter studies before proposing a definitive clinical flowchart, and exploring alternative methods to obtain more reliable data.

CONCLUSION

Physiotherapists play a central role in the multidisciplinary diagnosis and management of pediatric CRPS, primarily adopting a collaborative, non-pharmacological approach in private practice settings. Although strategies such as the Budapest criteria and physical activity are commonly implemented, the lack of standardized clinical guidelines remain a significant limitation. Future research should aim to develop standardized diagnostic and treatment protocol for pediatric CRPS to improve clinical outcomes in this population. Moreover, the development of a clinical guideline that consider the heterogeneity of this population is recommended, together with practical dissemination strategies to ensure accessibility in rural or resource-limited areas.