Amplified Musculoskeletal Pain

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When Children Hurt Too Much: Diagnosis and Treatment of Amplified

Musculoskeletal Pain

Amplified musculoskeletal pain has a typical presentation, mostly

among adolescent girls, consisting of allodynia, marked pain and

dysfunction disproportionate to the known stimulus, and an

incongruent affect. Conversion symptoms are not uncommon. The

treatment is intense exercise therapy focused on function,

desensitization, and attention to current conditions. The outcomes

are very good, with virtually all patients regaining full function

and between 80-90% resolving all pain. These are multiple forms

of " amplified musculoskeletal pain " in children, and range from

complex regional pain syndrome (CRPS) in one limb to total body pain.

A case presentation is given of a bright, athletic 14-year-old girl

who stepped on a rock at the bottom of a swimming pool and hurt her

right foot. Although the skin was not broken, over the next 2 days

her foot became progressively more painful, swollen, blue, and cool

to the touch. A radiograph was normal and a splint applied. Crutches

were required and there was marked tenderness to touch. The pain

spread to include her entire right leg and her left foot, and to both

hands, presumably from using crutches. At present the pain prevents

washing or shaving her right leg, and she no longer attends school.

She is unable to concentrate, she suffers from loss of sleep, and the

pain registers > 10 of 10 on a VAS in the hands and left foot.

The symptoms are not unusual for a child with amplified

musculoskeletal pain. There are multiple forms, usually defined by

the location or presence of autonomic dysfunction. These children

fall into 2 broad categories: those with localized pain and those

with diffuse pain. The most easily recognized type of localized pain

is CRPS. Many, if not most, of these children have localized pain

amplification without autonomic signs. In studies of children with

diffuse pain, fibromyalgia receives the most attention.

Children with amplified musculoskeletal pain are more disabled than

those with arthritis or with mechanical joint problems, and they and

their families suffer intensely. In addition, these children often

experience isolation from peers and are commonly told by medical

professionals that they are " faking it. "

Children with amplified musculoskeletal pain comprise approximately

10% of children in pediatric rheumatic disease clinics, and are

deemed by many clinicians as increasing in number. The average age of

onset is preteen to early teen, mainly in females, predominantly of

Caucasian extraction. The etiology of amplified musculoskeletal pain

is unknown, but can usually be related to trauma, illness, or

psychological distress.

The typical patient is a mature and accomplished adolescent girl who

suffers a minor injury or illness and then has increasing pain and

dysfunction over several days to months. The pain may be localized or

diffuse. It may began locally and spread. Allodynia is common. There

is a high level of pain, frequently with an incongruently cheerful

affect. They present themselves as mature and accomplished teens who

are perfectionists and who meet the emotional needs of their peers

and others rather than their own. All laboratory tests are normal.

These children should have a careful evaluation for other causes,

most commonly spondyloarthropathies. Malignancies are the most

serious condition one can miss.

It is paramount to establish a trusting relationship with the child

and family. All medications for pain need to be discontinued.

Medications for depression or anxiety disorders, however, may need to

continue. Several medications used may need to be tapered. Treatments

are legion and include pain medications, antidepressants, gabapentin,

transcutaneous nerve stimulation, nerve blocks and sympathectomy,

epidural catheters, pain pumps, lidocaine and opioid patches,

acupuncture, massage, cognitive-behavioral therapy, psychotherapy,

and exercise therapy.

The author has found exercise therapy to be the most helpful with the

longest-lasting results. He recommends 5 hours of exercise therapy

daily for an average of 3 weeks. In addition, the psychodynamics of

the child and family should be evaluated.

(Aundrea 12 fibromyalgia)