Chronic musculoskeletal pain in children: assessment and

managementReview

Amir Hooshang Vahedi MD - Physiatrist

five related objectives.

epidemiology of musculoskeletal pain in childhood.

etiology of pain. clinical features of common pain

presentations and their relevance to diagnosis and treatment planning.

rehabilitation interventions aimed at the management of chronic pain.

recommendations for further action.

The most common chronic pain conditions reviewed in pediatric rheumatology settings include :

Diffuse idiopathic musculoskeletal pain (juvenile fibromyalgia)

Hyper mobility syndromeComplex regional pain syndromes

(CRPS)Chronic back painJuvenile idiopathic arthritis (JIA)

epidemiologyThe incidence of chronic

musculoskeletal pain peaks at the age of 14 years.

Musculoskeletal pains accounted for 64% of all the pains that were reported.

we have a population of 1–2% of children with severe disabling chronic pain beginning to find their way to clinic.

Clinical features of chronic childhood musculoskeletal pain

It is not unusual for pain to start in a localized area of the body The pain may radiate to other areas.

avoidance of movement. muscular spasms. abnormal posture and gait.

pain has a direct affect on other systems:

Hyper vigilance and hypersensitivityPerceived thermo dis regulationAutonomic dysfunctionMusculoskeletal disequilibrium

Specific childhood musculoskeletal pain conditions

1.Diffuse idiopathic pain syndromes (juvenile fibromyalgia).

The onset of pain in diffuse idiopathic pain (DIP) syndrome is often gradual.

The pain is generalized. There may be areas of allodynia and hyperalgesia but there is often an absence of the autonomic changes that we see in more localized pain conditions .

Fibromyalgia is an idiopathic chronic pain syndrome defined by widespread nonarticular musculoskeletal pain and generalized tender points. The syndrome is associated with a constellation of symptoms, including fatigue, irritable bowel, poor sleep, anxiety, stress, headaches, and paresthesias

2.CRPS( Complex regional pain syndrome) refers to a syndrome of persistent

neuropathic pain associated with nondermatomal autonomic dysfunction. It often is seen after minor injury, and patients have findings that include temperature and color changes (thermodynamic instability) ,reduced cutaneous perfusion, allodynia, edema, cyanosis, eventual trophic changes of the skin, osteoporotic changes, reduction in range of movement

In children, the lower limb is much more commonly involved than the upper limb.

The current IASP(The International Association for the Study of Pain ) diagnostic criteria

(1)at least two neuropathic pain descriptors (burning, dysesthesias, paresthesias, mechanical allodynia, and hyperalgesia to cold)

(2)at least two physical signs of autonomic dysfunction (cyanosis, mottling, hyperhidrosis, >3°C lower temperature in affected limb, edema).

for children and adolescents, the dystrophic changes and long-term disability are less common when compared with adults.

FIG. 1. Shiny, mottled appearance of left leg indicative of changes seen early in CRPS.

FIG. 2. Extreme hyperextension of the right leg in a child with a 3-yr history of CRPS.

FIG. 3. Thermography shows poor cutaneous circulation in affected left foot(barely visible).

FIG. 4. Severe CRPS with trophic changes and ulceration

FIG. 5. Fixed flexion following minor injury.

3.Juvenile hypermobility( Hypermobility syndrome)

A condition in which the joints are able to be moved beyond the usual limits

Synonyms:

Joint hyperlaxity Familial ligamentous laxity Joint hypermobility Articular hypermobility

Symptoms&Signs chronic pain in joints, muscles and ligaments ,

widespread pain, anxiety, and fatigue are common autonomic nervous system Heartburn and irregular bowel habit have been

found in up to 60% of patients nerve entrapment syndromes like

carpal tunnel syndrome or thoracic outlet syndrome

sprains, subluxation, or dislocation of joints Increased range of movement Hyperextension of elbows and knees Ability to bend the thumb at the first

metacarpophalyngeal joint back to the wrist There may be signs of scoliosis, kyphosis, or

hyperlordosis Loose ligaments predispose to flat feet The skin should be examined for excessive

elasticity

DD;Hypermobility syndrome Ehlers-Danlos syndrome (EDS) osteogenesis imperfectaMarfan syndrome Down syndrome

4.Juvenile idiopathic arthritis (JIA)group of immuno inflammatory diseases

of the connective tissues characterized by synovitis of the peripheral joints

JIA is the most common childhood rheumatic illness

It is characterized by persistent joint swelling, pain, and functional limitation

The relationship between juvenile arthritis and chronic pain is well recognized .

5.Back pain. Low back pain specifically is

commonly reported in the adolescent population.

Often this is thought to be related to lifestyle influences on a developing spine such as postural habit (slouching), load bearing on the back (e.g. school bags) or engagement in sedentary activity (e.g. computer use).

6.Childhood disease and chronic pain. Diffuse and localized chronic pains can

also complicate almost any other chronic childhood illness including

juvenile arthritis IBD cerebral palsy cancer sickle cell disease muscular dystrophies cystic fibrosis

The aetiology of chronic pain in childhood (biopsychosocial model of pain)

Psychological influences. There is no evidence for purely psychologically generated pain conditions in children.

Genetic influences. There is emerging evidence that patients with CRPS may have a genetic predisposition

Environmental influences. Although there is no strong evidence for the intergenerational transmission of pain and pain-related behaviour

Developmental influences. There is current interest in the neuropathic mechanisms of paediatric pain.

The impact of chronic pain on the child and family

Young people with chronic pain report sleep disturbance, disordered mood, appetite disruption, low feelings (depression is often masked in this population), social isolation and unwelcome dependency on parents.

Assessment of the young person (and family) with chronic pain

History. Physical examinationPsychometric instruments Varni/Thompson Paediatric (focusing on pain )the Functional disability Index( focusing on

disability.)visual analogue scale (VAS) Physiological measures of pain-related indexes

Functional MRI has recently been shown to be a useful tool in evaluating the role of the CNS in childhood CRPS

RehabilitationEducation

Pharmacotherapy.Oral treatments tricyclic anti-depressants, NSAIDs, opioids,

anti-convulsants and glucocorticoids. Sympathetic blockade and botulinum

toxin injections have been used in localized muscular pain.

Gabapentin and pregabalin may have a role in addressing neuropathic pain in CRPS .

tricyclic anti-depressants do have a role in modifying aspects of neuropathic pain in some patients

Psychological therapies.

A Cochrane systematic review of psychological therapy reported on the effectiveness of psychological treatments for pain control in common chronic pain problems .

Brief psychological therapies such as relaxation, habit reversal and attention-based interventions are highly effective for use with persistent and recurrent pain .

Physical therapy. Exercise is key to the rehabilitation

of young people with persistent pain. In CRPS, early intensive

physiotherapy is the treatment of choice.

We also do not know the optimal methods for the rehabilitation of their child in pain.

Hypermobility syndromeTreatment is symptomatic. The basis

of therapy is to try to stabilize the joint as much as possible.

This is best achieved by physical therapy building up the muscles around the joints and avoiding activities that may cause injury.

COMPLEX REGIONAL PAIN SYNDROME

physical therapy and mobilization are the best methods of treatment of this disorder

when most children complain of pain, immobilization is the first step in treatment

Physical therapy and mobilization alone or with transcutaneous nerve stimulation have been used in over 70% of patients.

Pediatric Fibromyalgia Pharmacologic Treatment:effectiveness of the (gabapentin and pregabalin) and

SNRI(duloxetine and milnacipran) in FM in adults.In children who have FM, Analgesics and nonsteroidal

antiinflammatory drugs are not very effective. There are only limited data for the efficacy of

cyclobenzaprine and amitriptyline.No data are available on the effect of SSRIs and

SNRIs in pediatric FMNonpharmacologic Treatment:Education Aerobic Exercise Training Complementary and Alternative MedicineCognitive Behavioral Therapy

key messagesUntreated complex paediatric pain is

personally, socially and financially burdensome for individuals, families and societies.

Evidence shows that early dedicated therapy can significantly improve the outcome of childhood chronic pain.

Key areas for further research include physiology of childhood pain, role of parents and evaluating efficacy of pharmacological intervention in children.