Amplified musculoskeletal pain: treatment approach and outcomes

Juvenile Fibromyalgia

Juvenile fibromyalgia is a common referral in pediatric rheumatology settings. Providing a clear diagnosis and explanation of altered pain processing offers reassurance that pain has a biologic basis and the symptoms are part of a recognized pain syndrome. Physicians should acknowledge the impact of chronic pain and associated symptoms on patient's lives and take time to understand contributing factors including stress, mood, inactivity, and lifestyle factors. The optimal treatment for juvenile fibromyalgia is multidisciplinary, focusing on education about juvenile fibromyalgia, along with physical therapy, cognitive behavioral therapy, sleep hygiene, healthy lifestyle habits, and medications for symptom management as appropriate.

Disordered eating among adolescents with chronic pain: the experience of a pediatric rheumatology subspecialty pain clinic

BACKGROUND

Disordered eating and chronic pain often co-occur in adolescents, but the relationship between these conditions is not well understood. We aimed to determine the prevalence of and to identify the clinical characteristics associated with the presence of disordered eating among adolescents with chronic musculoskeletal pain (CMP) presenting to a pediatric rheumatology subspecialty pain clinic.

METHODS

This was a retrospective cohort study of pediatric patients presenting to a pediatric rheumatology subspecialty pain clinic for an initial consultation from March 2018 to March 2019. We complemented data from an existing patient registry with secondary chart review for patients identified with disordered eating. We compared patient characteristics based on the presence or absence of disordered eating among adolescents with CMP. Logistic regression modeling was used to determine factors associated with disordered eating.

RESULTS

Of the 228 patients who were seen for an initial consultation in the pain clinic in 1 year, 51 (22.4%) had disordered eating. Only eight (15.7%) of the 51 patients identified with disordered eating had a previously documented formal eating disorder diagnosis. Through multivariate logistic regression modeling, we found that disordered eating was associated with older age, higher functional disability, presence of abdominal pain, presence of gastrointestinal comorbidities, and presence of anxiety (all p < 0.05).

CONCLUSIONS

Adolescents with chronic pain, especially those who experience gastrointestinal issues, anxiety, and greater functional disability, should be evaluated for disordered eating by the treating clinician in order to ensure timely and appropriate treatment.

The spectrum of pediatric amplified musculoskeletal pain syndrome

BACKGROUND

Children presenting with musculoskeletal pain to pediatric rheumatology clinics are very heterogeneous and on a continuum from those with localized pain to total body pain. Many report intermittent, rather than constant, pain. We examined clinical and psychological characteristics of these children at presentation and specifically those who fulfilled the criteria for fibromyalgia.

METHODS

We performed a retrospective, cross-sectional cohort study of children under ≤18 years old presenting to the pediatric rheumatology pain clinic between January 2015 and July 2019 and enrolled in a patient registry. We included children diagnosed with amplified pain, excluding those fulfilling criteria for complex regional pain syndrome. Abstracted data included clinical characteristics, pain symptoms, functional disability inventory (FDI), widespread pain index, and symptom severity scale.

RESULTS

We analyzed 636 subjects, predominantly non-Hispanic Caucasian females. Using median split method, 54% had diffuse pain (≥ 5 body regions involved), but, of these, only 58% met criteria for fibromyalgia. Subjects with diffuse pain, compared to those with localized pain had a longer duration of pain (24 vs 12 months, p < 0.01), reported greater pain intensity (6/10 vs 5/10, p < 0.001), greater mental health burden, and poorer function (FDI 25 vs 19, p < 0.0001). Subjects with limited pain more often reported a history of trigger event (34% vs 24%, p < 0.01) but not autonomic changes (14% vs 14%, p = 0.94). The presence of adverse childhood experiences did not differ among those with limited versus diffuse pain except for parental divorce (16% vs 23%, p = 0.03). Intermittent pain was reported in 117 children (18%) and, compared to subjects with constant pain, they reported less pain (0/10 vs 6/10) and were more functional (FDI 13 vs 25) (both p < 0.0001).

CONCLUSIONS

There exists a wide spectrum of pain manifestations among children with amplified pain including limited or diffuse and constant or intermittent pain. Most children who presented to our clinic did not fulfill criteria for fibromyalgia but nonetheless had significant symptoms and disability. Studies focusing on fibromyalgia may miss the full extent of childhood amplified pain. Additionally, research limited to those meeting the fibromyalgia criteria likely underestimate the significant impact of amplified pain among the pediatric population.

Trends in Medicalization of Children with Amplified Musculoskeletal Pain Syndrome

Objective

The objective of this survey was to describe trends over time in medicalization of children with Amplified Musculoskeletal Pain Syndrome (AMPS).

Design

A retrospective evaluation was conducted using self-reported data from patients presenting to the pain clinic between January 1, 2008 and December 31, 2014, who were diagnosed with AMPS.

Setting and Subjects

This was a medical record review of 899 subjects ages 3-20 presenting with Amplified Musculoskeletal Pain Syndrome. Subjects were included if they presented to a single tertiary specialized clinic and obtained a diagnosis of AMPS between January 1, 2008 and December 31, 2014.

Methods

Information collected from subjects' medical records included: past medications, current outpatient medications, procedures, aids, therapies, studies, professionals seen, hospitalizations, and surgeries. Trends in medicalization were analyzed by year of initial visit.

Results

Medication use, procedures, studies, therapies, professionals seen, hospitalizations, and surgeries in children with AMPS all increased significantly by year ( P  < 0.001). The degree of physical dysfunction, pain, and the use of aids did not significantly increase.

Conclusions

Children with amplified musculoskeletal pain syndrome are becoming increasingly medicalized. Increased medicalization introduces risk of iatrogenic injury and burdens families with unnecessary medical costs. The significant increase in medicalization of children with AMPS is not related to an increase in patient reported pain, which is evidenced by the lack of significant increase in patients' pain score, pain duration, or functional disability at the time of their initial evaluation.

Medication use among pediatric patients with chronic musculoskeletal pain syndromes at initial pain clinic evaluation

AIM

To characterize medication use by adolescents with chronic musculoskeletal pain syndromes before an initial multidisciplinary clinic visit.

PATIENTS & METHODS

A cross-sectional sample of 120 adolescents and parents reported on standardized assessment measures, with medication use data extracted from the medical chart and categorized.

RESULTS

On average, 3.2 medications were reported; 70% used more than one pain-specific medication including opioids (17%), nonopioids (31%), psychotropics/neuropathics (45%) and other medications (13%). Adolescents with complex regional pain syndrome consistently reported greatest use of opioid, psychotropic/neuropathic and other pain medications. A regression model explained 17% of the variance in pain medication use. Nonpain medication use and disability contributed unique variance - pain duration and intensity did not.

CONCLUSION

Greater attention to factors contributing to prescriptive practices, medication use and long-term outcomes is warranted.

Fibromyalgia: Treating Pain in the Juvenile Patient

Presently, evidence for the efficacy of medications for the treatment of juvenile fibromyalgia syndrome (JFMS) is limited. While there are medications approved by the US Food and Drug Administration (duloxetine, milnacipran and pregabalin) for adults with fibromyalgia syndrome, there are none for the treatment of JFMS. A variety of medications have been prescribed for the treatment of JFMS, including (but not limited to) non-opioid analgesics, opioids, anticonvulsants, antidepressants, and muscle relaxants. Psychological therapies, most prominently cognitive behavioral therapy, are the most evidenced-based treatment modalities for JFMS. A multidisciplinary approach, combining pharmacological, behavioral and exercise-based modalities is currently the standard of care for JFMS. In the future, more stringent randomized, controlled trials with longer follow-up periods are needed in order to determine the long-term efficacy and safety of medications in the treatment of JFMS. Additionally, improved recognition of JFMS will allow for better patient recruitment to permit for adequately powered study designs.

Pain Amplification Syndrome: A Biopsychosocial Approach

Pediatric neurologists frequently encounter patients who present with significant musculoskeletal pain that cannot be attributed to a specific injury or illness, which can often be defined as pain amplification syndrome (PAS). PAS in children and adolescents is the result of a heightened pain sensitivity pathway, which is intensified by significant biological, psychological, and social contributors. Appropriate assessment and multimodal intervention of PAS are crucial to treatment success, including neurology and behavioral health collaborative treatment plans to restore patient function and reduce pain perception. Pediatric neurologists are imperative in the identification of patients with PAS, providing the family assurance in diagnosis and validation of pain, and directing patients to the appropriate multidisciplinary treatment pathway.

Pediatric Rheumatology for the Primary Care Clinicians-Recognizing Patterns of Disease

This review presents a diagnostic approach to musculoskeletal and rheumatic diseases in children for primary care clinicians. The focus is on juvenile idiopathic arthritis (JIA) as the major arthritis disease in children. It is necessary to know the personalities of these JIA categories. It is also crucial to be able to recognize the common infectious, orthopedic and mechanical, malignant, genetic, other rheumatic diseases, and other miscellaneous syndromes that can mimic JIA. To do so requires recognition of clinical patterns using a thorough musculoskeletal and rheumatic history and repeated complete physical exams with emphasis on the musculoskeletal exam. It also requires targeted and limited laboratory testing with careful follow-up over time.

A day-hospital approach to treatment of pediatric complex regional pain syndrome: initial functional outcomes

OBJECTIVES

To examine clinical outcomes of an interdisciplinary day-hospital treatment program (comprised of physical, occupational, and cognitive-behavioral therapies with medical and nursing services) for pediatric complex regional pain syndrome (CRPS).

METHODS

The study is a longitudinal case series of consecutive patients treated in a day-hospital pediatric pain rehabilitation program. Participants were 56 children and adolescents with ages 8 to 18 years (median=14 y) with CRPS spectrum conditions who failed to progress sufficiently with a previous outpatient and/or inpatient treatments. Patients participated in daily physical therapy, occupational therapy, and psychological treatment and received nursing and medical care as necessary. The model places equal emphasis on physical and cognitive-behavioral approaches to pain management. Median duration of stay was 3 weeks. Outcome measures included assessments of physical, occupational, and psychological functioning at program admission, discharge, and at posttreatment follow-up at a median of 10 months after discharge. Scores at discharge and follow-up were compared with measures on admission by Wilcoxon tests, paired t tests, or analysis of variance as appropriate, with corrections for multiple comparisons.

RESULTS

Outcomes demonstrate clinically and statistically significant improvements from admission to discharge in pain intensity (P<0.001), functional disability (P<0.001), subjective report of limb function (P<0.001), timed running (P<0.001), occupational performance (P<0.001), medication use (P<0.01), use of assistive devices (P<0.001), and emotional functioning (anxiety, P<0.001; depression, P<0.01). Functional gains were maintained or further improved at follow-up.

DISCUSSION

A day-hospital interdisciplinary rehabilitation approach seems effective in reducing disability and improving physical and emotional functioning and occupational performance among children and adolescents with CRPSs that have failed to improve with outpatient treatment.

Approach to the patient with noninflammatory musculoskeletal pain

Musculoskeletal pain is one of the most common presenting symptoms at the pediatrician's office. Etiology ranges from benign conditions to serious ones requiring prompt attention. This article addresses entities that present as musculoskeletal pain but are not associated with arthritis. The most common nonarthritic conditions are benign limb pain of childhood (growing pains), hypermobility, overuse syndromes with or without skeletal abnormalities, malignancies, and pain amplification syndromes. The| initial decision process, diagnosis, and treatment options for each of these conditions are discussed.