Psychosocial factors in children with idiopathic musculoskeletal pain: a prospective, longitudinal study

Sensory Function and Psychological Factors in Children With Complex Regional Pain Syndrome Type 1

OBJECTIVE

To assess thermal-sensory thresholds and psychosocial factors in children with Complex Regional Pain Syndrome Type 1 (CRPS-I) compared to healthy children.

METHODS

We conducted quantitative sensory testing on 34 children with CRPS-I and 56 pain-free children. Warm, cool, heat, and cold stimuli were applied to the forearm. Children with CRPS-I had the protocol administered to the pain site and the contralateral-pain site. Participants completed the self-report Behavior Assessment System for Children.

RESULTS

Longer pain durations (>5.1 months) were associated with decreased sensitivity to cold pain on the pain site (P = .04). Higher pain-intensity ratings were associated with elevated anxiety scores (P = .03). Anxiety and social stress were associated with warmth sensitivity (both P < .05) on the contralateral-pain site.

CONCLUSIONS

Pain duration is an important factor in assessing pediatric CRPS-I. Hyposensitivity in the affected limb may emerge due to degeneration of nociceptive nerves. Anxiety may contribute to thermal-sensory perception in childhood CRPS-I.

Nonspecific wrist pain in pediatric patients: A systematic review

Determining the cause of wrist pain is a challenge for clinicians due to the complex biomechanical characteristics of the multiple articulations which comprise the wrist, and the intricacies of the soft tissue supporting them. Patients presenting with wrist pain can be diagnosed by obtaining a detailed history, physical examination and radiographic images. For some patients, a diagnosis remains elusive even after a complete appropriate work up, and the pain may persist following conservative management. The aim of this systematic review was to analyze the effect that psychosocial factors have on the development chronic idiopathic wrist pain in children and adolescents.

The (Parental) Whole Is Greater Than the Sum of Its Parts: A Multifactorial Model of Parent Factors in Pediatric Chronic Pain

Parents play a critical role in children's experience of, and recovery from, chronic pain. Although several parental factors have been linked to child pain and functioning, these factors are typically examined in isolation or as moderators or mediators. Structural equation modeling affords the opportunity to examine the extent to which parental factors are interrelated, and if there are differential associations among parental factors and child outcomes. Based on extant literature, a unified model of parental factors, including chronic pain status, physical functioning, responses to child pain, and psychological factors, and their effect on child pain and functioning, was conceptualized. This model was evaluated using structural equation modeling based on data from 146 dyads recruited from a multidisciplinary pain clinic. Modifications to model iterations were made based on theoretical and statistical justification. The final model revealed associations among all parental factors, with significant loadings on child pain and functioning. Findings indicated the conceptual model was supported, with the exception of parent responses to child pain. Findings support the inclusion of parent chronic pain status and physical and psychological functioning as part of a comprehensive assessment of youth with chronic pain and may inform new parental intervention targets to improve child outcomes. PERSPECTIVE: A unified structural equation model indicated parents' own chronic pain characteristics and physical and psychological functioning represent important factors associated with child pain and functioning. Current family-based interventions that often primarily focus on parent responses to child pain may need to be adapted to more comprehensively address parental factors.

Adolescents' Observations of Parent Pain Behaviors: Preliminary Measure Validation and Test of Social Learning Theory in Pediatric Chronic Pain

Objective

Evaluate psychometric properties of a measure of adolescents’ observations of parental pain behaviors and use this measure to test hypotheses regarding pain-specific social learning.

Methods

We created a proxy-report of the Patient Reported Outcomes Measurement Information System (PROMIS) Pain Behavior–Short Form (PPB) for adolescents to report on parental pain behaviors, which we labeled the PPB-Proxy. Adolescents (n = 138, mean age = 14.20) with functional abdominal pain completed the PPB-Proxy and a parent completed the PPB. Adolescents and their parents completed measures of pain and disability during the adolescent’s clinic visit for abdominal pain. Adolescents subsequently completed a 7-day pain diary period.

Results

The PPB-Proxy moderately correlated with the PPB, evidencing that adolescents observe and can report on parental pain behaviors. Both the PPB-Proxy and PPB significantly correlated with adolescents’ pain-related disability.

Conclusions

Parental modeling of pain behaviors could represent an important target for assessment and treatment in pediatric chronic pain patients.

Transmission of risk from parents with chronic pain to offspring: an integrative conceptual model

Offspring of parents with chronic pain are at increased risk for pain and adverse mental and physical health outcomes (Higgins et al, 2015). Although the association between chronic pain in parents and offspring has been established, few studies have addressed why or how this relation occurs. Identifying mechanisms for the transmission of risk that leads to the development of chronic pain in offspring is important for developing preventive interventions targeted to decrease risk for chronic pain and related outcomes (eg, disability and internalizing symptoms). This review presents a conceptual model for the intergenerational transmission of chronic pain from parents to offspring with the goal of setting an agenda for future research and the development of preventive interventions. Our proposed model highlights 5 potential mechanisms for the relation between parental chronic pain and pediatric chronic pain and related adverse outcomes: (1) genetics, (2) alterations in early neurobiological development, (3) pain-specific social learning, (4), general parenting and family health, and (5) exposure to stressful environment. In addition, the model presents 3 potential moderators for the relation between parent and child chronic pain: (1) the presence of chronic pain in a second parent, (2) timing, course, and location of parental chronic pain, and (3) offspring's characteristics (ie, sex, developmental stage, race or ethnicity, and temperament). Such a framework highlights chronic pain as inherently familial and intergenerational, opening up avenues for new models of intervention and prevention that can be family centered and include at-risk children.

Idiopathic musculoskeletal pain in Indian children-Prevalence and impact on daily routine

OBJECTIVES

To study the prevalence of idiopathic musculoskeletal pain (IMSP) in school going children and its impact on daily life.

METHODS

One thousand eighteen apparently healthy school children aged 5-16 years were assessed and analysed for IMSP and its associated problems. Standard tests for significance were applied.

RESULTS

One hundred and sixty-five (16.2%) children mostly males (55.2%) reported IMSP. Lower limbs (52.1%) were the most common location of pain. More than 1 year of pain history was present in 15%. Thirty-seven percent children complained of discomfort during walking, 30.9%, had pain during physical exercise, 29.2% had difficulty attending lessons and 4.2% had interference in pursuing hobbies. The children were also further sub grouped into preadolescents and adolescents. There was significant difference in pain duration and duration of each pain episode in the two groups (p=0.01). A significant number of children (21.2%) with IMSP reported school absenteeism (p<0.001). A significant number of adolescents had history positive for contact sports (p=0.001). Sleep disturbances were also reported to be higher in children with IMSP (29% vs. 5.7%, p=0.001). Other associated problems in children with IMSP found were day time tiredness (51.1%), headache (47.3%) and abdominal pain (24.8%).

CONCLUSIONS

Prevalence of IMSP in school children aged 5-16 yrs was found to be 16.2% and a significant percentage of these children experience interference with daily activities including school absenteeism.

Pain in School: Patterns of Pain-Related School Impairment among Adolescents with Primary Pain Conditions, Juvenile Idiopathic Arthritis Pain, and Pain-Free Peers

Children with chronic pain frequently experience impairment in the school setting, but we do not yet understand how unique these struggles are to children with primary pain conditions compared to peers with disease-related pain or those without chronic pain symptoms. The objective of this study is to examine school functioning, defined as school attendance rates, overall quality of life in the school setting, and school nurse visits among adolescents with primary pain conditions, those with juvenile idiopathic arthritis (JIA)-related pain, and healthy peers. Two hundred and sixty adolescents participated in the study, including 129 with primary pain conditions, 61 with JIA, and 70 healthy comparison adolescents. They completed self- and parent-reported measures of school function. Findings show that as a group, youth with primary pain conditions reported more school absences, lower quality of life in the school setting, and more frequent school nurse visits compared to both adolescents with JIA-related pain and healthy peers. We conclude that compared to those who experience pain specific to a disease process, adolescents with primary pain conditions may face unique challenges in the school setting and may require more support to help them succeed in school in spite of pain.

Pediatric complex regional pain syndrome: a review

Complex regional pain syndrome (CRPS) is a chronic, intensified localized pain condition that can affect children and adolescents as well as adults, but is more common among adolescent girls. Symptoms include limb pain; allodynia; hyperalgesia; swelling and/or changes in skin color of the affected limb; dry, mottled skin; hyperhidrosis and trophic changes of the nails and hair. The exact mechanism of CRPS is unknown, although several different mechanisms have been suggested. The diagnosis is clinical, with the aid of the adult criteria for CRPS. Standard care consists of a multidisciplinary approach with the implementation of intensive physical therapy in conjunction with psychological counseling. Pharmacological treatments may aid in reducing pain in order to allow the patient to participate fully in intensive physiotherapy. The prognosis in pediatric CRPS is favorable.

[Idiopathic musculoskeletal pain in Indian Children-prevalence and impact on daily routine]

OBJECTIVES

To study the prevalence of idiopathic musculoskeletal pain (IMSP) in school going children and its impact on daily life.

METHODS

One thousand eighteen apparently healthy school children aged 5-16 years were assessed and analysed for IMSP and its associated problems. Standard tests for significance were applied.

RESULTS

One hundred and sixty five (16.2%) children mostly males (55.2%) reported IMSP. Lower limbs (52.1%) were the most common location of pain. More than 1 year of pain history was present in 15%. Thirty seven percent children complained of discomfort during walking, 30.9%, had pain during physical exercise, 29.2% had difficulty attending lessons and 4.2% had interference in pursuing hobbies. The children were also further sub grouped into preadolescents and adolescents. There was significant difference in pain duration and duration of each pain episode in the two groups (p=0.01). A significant number of children (21.2%) with IMSP reported school absenteeism (p<0.001). A significant number of adolescents had history positive for contact sports (p=0.001). Sleep disturbances were also reported to be higher in children with IMSP (29% vs. 5.7%, p=0.001). Other associated problems in children with IMSP found were day time tiredness (51.1%), headache (47.3%) and abdominal pain (24.8%).

CONCLUSIONS

Prevalence of IMSP in school children aged 5-16 yrs was found to be 16.2% and a significant percentage of these children experience interference with daily activities including school absenteeism.

Neonatal handling (resilience) attenuates water-avoidance stress induced enhancement of chronic mechanical hyperalgesia in the rat

Chronic stress is well known to exacerbate pain. We tested the hypothesis that neonatal handling, which induces resilience to the negative impact of stress by increasing the quality and quantity of maternal care, attenuates the mechanical hyperalgesia produced by water-avoidance stress in the adult rat. Neonatal male rats underwent the handling protocol on postnatal days 2-9, weaned at 21 days and tested for muscle mechanical nociceptive threshold at postnatal days 50-75. Decrease in mechanical nociceptive threshold in skeletal muscle in adult rats, produced by exposure to water-avoidance stress, was significantly attenuated by neonatal handling. Neonatal handling also attenuated the mechanical hyperalgesia produced by intramuscular administration of the pronociceptive inflammatory mediator, prostaglandin E2 in rats exposed as adults to water-avoidance stress. Neonatal handling, which induces a smaller corticosterone response in adult rats exposed to a stressor as well as changes in central nervous system neurotransmitter systems, attenuates mechanical hyperalgesia produced by water-avoidance stress and enhanced prostaglandin hyperalgesia in adult animals.

The incidence of idiopathic musculoskeletal pain in children with upper extremity injuries

INTRODUCTION

Children with upper extremity injuries may report persistent pain beyond the period of acute injury. In the published literature, it is unclear whether these children develop idiopathic musculoskeletal pain (IMP) such as complex regional pain syndrome (CRPS). The purpose of this study was to determine the incidence rate of IMP after upper extremity injury in school-aged children over a 5-year period and to describe the characteristics of these children.

METHODS

A retrospective case series was conducted of all children aged 8-18 years with an upper extremity injury who attended the outpatient hand clinic in a tertiary care pediatric hospital.

RESULTS

A reported incidence rate of IMP was 1.9% over a 5-year period in the 879 children reviewed. Girls were more likely to have IMP. The categorical distribution of the type, etiology and anatomical location of injury was proportionately different for those with IMP compared to those without documentation of IMP. In comparison, a higher percentage of children with IMP reported disproportionate pain and hypersensitivity or neuropathic pain symptoms compared to the children who had pain from a known etiology.

CONCLUSION

The incidence rate of IMP after upper extremity injury in school-aged children is low. Some common characteristics of this population that may help clinicians identify these children and make timely referrals for treatment include female gender, disproportionate pain, previously seen by multiple specialists, generalized injury in the hand, unspecific etiology or type of injury and unremarkable x-rays.

"I can't be what I want to be": children's narratives of chronic pain experiences and treatment outcomes

BACKGROUND

Chronic or recurrent nonmalignant pain is a significant problem for many children and adolescents and often limits the child's participation in normal physical, academic, and social activities.

OBJECTIVE

To better understand the impact of chronic or recurrent pain on children within the context of their own lives and experiences, using qualitative analysis, and to suggest the applications of the narrative method to clinical practice.

DESIGN

Grounded theory and narrative analysis of in-depth semi-structured interviews conducted at baseline and 6-12 months following clinic intake.

SETTING

Subject homes.

PATIENTS

Fifty-three children ages 10-17 presenting with recurrent pain to a university-based pain clinic. This sample did not differ significantly from the overall clinic population during the study period.

RESULTS

Five common themes were identified; these suggested that isolation, changed self-perception, activity limitations, concerns about barriers to future goals, and lack of medical validation were important to the children's perceived impact of pain on their lives. Five narratives were identified, each of which provided a coherent, integrated description of the factors and perspectives presented by a specific subset of children at baseline. These narratives were then compared against the children's reports of improvement in pain and functioning at 6-12 months; from this comparison, a sixth narrative of therapeutic change emerged for some of the children.

CONCLUSIONS

The authors suggest that physicians and parents who take the initiative to elicit the child's narrative can help the child to rewrite the story to promote therapeutic change, a better outcome, and higher satisfaction.

Preliminary evaluation of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain

PURPOSE

To describe the outcome of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain.

METHODS

STUDY DESIGN

exploratory retrospective cohort study. The study sample consisted of a cohort of 70 children and adolescents (age: 8-21 years) with chronic musculoskeletal pain who completed a 3-month inpatient multidisciplinary pain management program. The program consisted of graded physical exercises, graded activities and counseling of the children and their parents. Assessed were motor and social activities, pain intensity, global assessment of physical functioning and psychosocial well-being (by patient and physician), understanding of the pain process and reduction of medical consumption. Assessments were performed at pre-admission, day of admission, day of discharge and at three months after discharge. Data collection took place over a 10-year period.

RESULTS

Compared to admission, at discharge there were significant improvements in motor performances, school attendance, reduction of pain scores, understanding of the chronic pain process and reduction of medical consumption. Results remained stable at follow-up after three months.

CONCLUSION

The results of this study indicate that a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain may be effective.

[Risk factors for back pain in children and adolescents]

Factors that have led to the increasing prevalence of back pain amongst children and adolescents living in industrialized nations are mostly unknown. The following literature review was aimed at determining the risk factors for back pain amongst children and adolescents. We searched both PUBMED and MEDLINE between the years 1985 and 2003 for the keywords "children or adolescents" and "back pain". Only data published in original articles were used. The risk for suffering back pain is influenced by physical, behavioural, emotional and social factors. The effects of physical activity, sitting, muscle status, weight of schoolbags, exercise, television and computer use, as well as age and gender on the development of back pain in children and adolescents were examined. Associations between continuous or recurring back pain and psychosocial factors (lifestyle, emotional factors, social relationships) could be demonstrated. There was no relationship between changes of the spine seen by radiological tests and the development of chronic back pain. Longitudinal epidemiological studies are urgently needed to delineate the risk factors for the development as well as the natural history of chronic back pain in the young.

Prognosis of non-specific musculoskeletal pain in preadolescents: A prospective 4-year follow-up study till adolescence

Musculoskeletal pain is common in children but studies on the outcome and predictive factors for persistence/recurrence of these symptoms are scarce. A baseline cross-sectional survey of 1,756 schoolchildren (mean age 10.8) identified 564 (32.1%) children with musculoskeletal pain. At baseline, these children were evaluated using a structured questionnaire and examined for hypermobility and physical fitness. The children were re-evaluated after one year, and four years (at adolescence) using the same pain questionnaire. At 1-year follow-up, 53.8% (95% CI 48.8-58.8) of the children reported pain persistence (persistent preadolescent musculoskeletal pain). At 4-year follow-up, 63.5% (95% CI 58.7-68.1) of them had musculoskeletal pain. Neck was the site with most persistent/recurrent musculoskeletal pain. Those with persistent preadolescent musculoskeletal pain had approximately three times higher risk of pain recurrence (OR=2.90 [95% CI 1.9-4.4]). In the univariate analysis, female gender, older age group (11+), hypermobility, co-existence of psychosomatic symptoms, having high disability index, and reporting combined musculoskeletal pain at baseline predicted pain recurrence at adolescence. In the multivariate analysis, age, headache, hypermobility and having combined musculoskeletal pain were found as independent predictors. Statistically significant sex interactions were found for age, depressive feelings, waking up during nights and hypermobility. More psychosomatic symptoms predicted pain recurrence in girls than in boys, and hypermobility was a strong predictor in females only. Musculoskeletal pain in preadolescents is not a self-limiting phenomenon and more studies are still warranted to explore its determinants aiming to improve the long-term outcome of these symptoms.

Epidemiology of musculoskeletal pain in primary care

AIMS

(1) To determine the proportion of children evaluated for musculoskeletal pain in a paediatric primary care clinic over a three year period; (2) to describe the number of office visits due to musculoskeletal pain; (3) to categorise the more common presenting complaints; and (4) to characterise the aetiology of musculoskeletal pain in a paediatric primary care clinic.

METHODS

Retrospective chart review of all children > or =3 and <15 years of age evaluated in an urban paediatric primary care clinic in Madrid between 1 January 1997 and 31 December 1999.

RESULTS

(1) A total of 317 children were evaluated for musculoskeletal pain throughout the study. The prevalence of musculoskeletal pain increased as children grew older, from 2.4-5.7% at age 3 to 27.5-36% at age 14. Regression analysis showed that age (OR 1.20) and gender (OR 0.75) were associated with MSP. (2) Musculoskeletal pain was reported in 397 of 6500 office visits (6.1%; 95% CI 5.5 to 6.7%). (3) Arthralgias and soft tissue pain represented 65% of the presenting musculoskeletal complaints. (4) Trauma was the most common aetiology, responsible for 44% of all musculoskeletal pain related office visits. Mechanical/overuse pathology (23.9%) and osteochondroses (10.3%) represented the second and third leading aetiologies.

CONCLUSIONS

Musculoskeletal pain is a common presenting complaint in primary care. The number of children presenting with musculoskeletal pain increases as they grow older, being particularly frequent among the adolescent population. The spectrum of aetiologies involved is limited, to the extent that three are responsible for almost 80% of cases.

The association between psychological distress and musculoskeletal symptoms experienced by Chinese high school students

STUDY DESIGN

A cross-sectional nonexperimental study.

OBJECTIVES

To determine the prevalence of musculoskeletal symptoms during a 6-month period and explore the contributing factors associated with these symptoms in Chinese senior class high school students. We also explored the relationship between psychological distress and musculoskeletal symptoms in this population.

BACKGROUND

Musculoskeletal symptoms with no underlying identifiable pathology are a management puzzle to medical professionals. Finding the prevalence of musculoskeletal symptoms is the first step in the prevention of further chronic pain syndromes in young adults. No study, however, has directly measured the prevalence of musculoskeletal symptoms in this population. Investigations of the contributing factors to these symptoms, though rare, can provide information to assist in the prevention of further injuries.

METHODS

The Musculoskeletal Symptom Questionnaire (MSQ) and the 12-question version of the Chinese Health Questionnaire (CHQ-12) were randomly distributed to students (n = 550) in 4 different high schools in the Tainan area of Taiwan. Of these, 471 students returned the questionnaires for analysis. Descriptive statistics were computed for means, standard deviations, and frequencies. Chi-square statistics were used for analysis of the association between psychological distress and musculoskeletal symptoms.

RESULTS

The most frequent complaints of musculoskeletal symptoms among the adolescent Chinese student population were reported as being located in the following anatomical areas: neck (56%), shoulder (45%), and back (37%). Based on the results from the CHQ-12, all of the participants were divided into 2 groups: a high psychological (CHQ-12 score > or = 5) and a low psychological (CHQ-12 score < 5) distress group. There were significant differences of prevalence of musculoskeletal symptoms between these 2 groups (P < .05), especially for the neck region (P = .003).

CONCLUSION

The results showed that the prevalence of musculoskeletal symptoms was high in this adolescent population and demonstrated a certain association with psychological distress. We suggest that surveys of this type may serve as preclinical detectors of future musculoskeletal disorders and may permit early interventions. Developing an intervention that addresses both physical and psychological problems may be beneficial for this population.

Back pain reporting in children and adolescents: the impact of parents' educational level

BACKGROUND

Social class, including educational level, is a strong predictor for health-related perceptions and behavior and for health outcomes in general. It is not known whether parental education has an effect on back pain in their offspring.

OBJECTIVES

To establish whether parents' educational level is associated with back pain reporting and consequences of back pain in their children.

DESIGN

A cross-sectional survey.

DATA COLLECTION

Information on parental education was obtained through questionnaires to parents and back pain information through standardized interviews with the children.

PARTICIPANTS

Children aged 8 to 10 years (n = 481) and adolescents aged 14 to 16 years (n = 325) obtained through a proportional 2-stage cluster sample.

SETTING

Local schools in Odense, Denmark.

MAIN OUTCOME MEASURES

The strength of association and dose-response connection were studied between parental educational level (high/medium/low) and the outcome variables (back pain in the preceding month, and consequences of back pain) in their children.

RESULTS

There was a significant modest negative association between the level of parental education and back pain in children but not in adolescents. There was no significant association between parental educational level and back pain consequences.

CONCLUSIONS

Further research in this area requires a more ingenious approach such as use of more socially heterogeneous study populations than those usually found in Denmark.

Widespread pain among 11-year-old Finnish twin pairs

OBJECTIVE

To examine the prevalence of widespread musculoskeletal pain (WSP) symptoms in 11-year-old Finnish twins and to determine the relative role of genetic and environmental factors in the etiology of WSP.

METHODS

Data on current pain items were collected from 1995 to 1998 from a national sample of Finnish families with 11-year-old twins born between 1984 and 1987. The presence of WSP was determined using a validated questionnaire method. Pairwise similarity was computed for 583 monozygotic (MZ) pairs, 588 same-sex dizygotic (DZ) pairs, and 618 opposite-sex DZ twin pairs. Variance components for genetic and environmental factors were estimated using biometric structural equation modeling techniques.

RESULTS

The prevalence of WSP was 9.9%, with no sex difference. The majority of twin pairs with WSP were discordant. The tetrachoric correlations for male MZ (r = 0.38), male DZ (r = 0.37), female MZ (r = 0.59), female DZ (r = 0.54), and opposite-sex pairs (r = 0.43) showed little difference by zygosity. Female pairs were more concordant than male pairs among both MZ and DZ twins. Biometric model-fitting indicated that genetic factors did not account for the pattern of twin similarity. Among boys 35%, and among girls 56%, of the variation in liability to WSP could be attributed to shared familial environmental effects. The remainder was attributed to unshared environmental effects.

CONCLUSION

Genetic factors seem to play at most a minor role in WSP in 11-year-old twins, and environmental factors shared by family members account for a substantial proportion of the variability in WSP.

Stress and rheumatic diseases

This study was done to review the literature concerning the influence of minor and major stress factors on onset and course of rheumatoid arthritis (RA), juvenile chronic arthritis (JCA), systemic lupus erythematosus (SLE), and fibromyalgia syndrome (FS). Major life events and chronic minor stress seem to be very important factors in JCA and are significantly associated with the onset of the disease. With respect to RA and FS, stress may be a provoking factor but the data in the literature are equivocal. However, during the course of the disease, minor stress aggravates SLE, FS, JCA, and RA. Patients with FS and RA may profit from psychological therapies. Optimistic and confronting coping strategies were found most frequently and perceived to be most effective. Very important for psychological function is the social background, especially the functioning of the family is of outstanding importance for clinical and psychological outcome.

Pain syndromes in children

The pediatric rheumatologist cares for children who may have a wide variety of causes of musculoskeletal pain. These include such diverse conditions as arthritis, low-back pain, hypermobility, metabolic bone pain, and amplified pain syndromes such as complex regional pain syndrome and fibromyalgia. This review examines the recent literature on these and other conditions causing musculoskeletal pain in children and adolescents. Overall, headway is being made, but differentiating soma from psyche remains a problem. This is perhaps due to the marked and unique effect pain brings to each of us. Children are different from adults in causes, presentations, and outcome. Vigilance in history, physical examination, and judicious use of laboratory investigations are usually sufficient in establishing a diagnosis, as well as an appreciation for the variety of presentations each condition can manifest.

Pain in fibromyalgia

Just as our caveman forebears were frail in the face of predatory animals, we are frail in today's society of childhood neglect or abuse, bumper-to-bumper traffic, frustration at work, and multiple daily hassles. The same neuroendocrine systems and pain regulatory mechanisms that protected early man during acute stress are still encoded in our genome, but may be maladaptive in psychologically and physiologically vulnerable people faced with chronic stress. Many patients with fibromyalgia become vulnerable because of the long-lasting psychological and neurophysiological effects of negative experiences in childhood. Ill-equipped with positive cognitive, emotional, and behavioral skills as adults, they display maladaptive coping strategies, low self-efficacy, and negative mood when confronted with the inevitable stressors of life. Psychological distress ensues, which reduces thresholds for pain perception and tolerance (already relatively low in women) even further. Converging lines of psychological and neurobiological evidence strongly suggest that chronic stress-related blunting of the HPA, sympathetic, and other axes of the stress response together with associated alterations in pain regulatory mechanisms may finally explain the pain and fatigue of fibromyalgia. Vulnerable people who can be classified by the ACR criteria as having fibromyalgia do not have a discrete disease. They are simply the most ill in a continuum of distress, chronic pain, and painful tender points in the general population.

Musculoskeletal pain in primary pediatric care: analysis of 1000 consecutive general pediatric clinic visits

OBJECTIVES

1) To determine the number of primary care clinic visits attributable to musculoskeletal pain (MSP) in children >/=3 and <15 years of age. 2) To describe the demographic characteristics of this population assessed for limb/back pain. 3) To characterize the etiology of musculoskeletal pain in an urban general pediatric clinic in Madrid, Spain.

METHODS

Prospective evaluation of 1000 consecutive clinic visits to an urban general pediatric clinic. Inclusion criteria were 1) age >/=3 and <15 years and 2) musculoskeletal evaluation requested by the family or patient. All consultations related to MSP were recorded via standard protocol and data record form.

RESULTS

During the study period, 61 of 1000 (6.1%; confidence interval: 4.6-7.5) clinic visits for children >/=3 and <15 years were related to MSP. Patients' age, mean +/- SD, was 9.7 +/- 3.3 years. Musculoskeletal complaints were more frequent in boys (57.4%), although there was no statistical difference. The presenting complaints included knee arthralgias in 33%; other joint (eg, ankles, wrists, elbows) arthralgias in 28%; soft tissue pain in 18%; heel pain in 8%; hip pain in 6%; and back pain in 6%. Symptoms were attributable to trauma in 30%; overuse syndromes in 28% (eg, chondromalacia patellae, mechanical plantar fasciitis, overuse muscle pain); and normal skeletal growth variants (eg, Osgood-Schlatter syndrome, hypermobility, Sever's disease) in 18% of patients.

CONCLUSION

MSP represents a frequent presenting complaint in general pediatric practice. A new heightened awareness of the frequent occurrence of MSP should be adopted when designing pediatrics continuing medical education and training programs. musculoskeletal pain, limb pain, arthralgia, children, general pediatrics, pediatric primary care.