Pain Syndromes

Question 1

What is the most common cause of recurrent limb pain in children?

Answer 1

Benign nocturnal limb pain of childhood (AKA “growing pains”)

Question 2

What are the classic characteristics of growing pains?

Answer 2

They are characterized as a deep aching located in nonarticular areas, generally within muscle groups. Pain is bilateral and typically occurs late in the day or evening. The pain commonly wakes children from sleep.

Question 3

Is morning pain a common finding with growing pains?

Answer 3

No. Pain in the evening is characteristic.

Question 4

Are unilateral findings common in growing pains?

Answer 4

No. Unilateral symptoms require further evaluation.

Question 5

What other etiology for pain should be considered in patients who are being evaluated for growing pains?

Answer 5

The other diagnosis that causes nighttime bone pain is malignancy. The clinician should perform a thorough ROS to rule out the presence of concerning “B symptoms”.

Question 6

When is laboratory evaluation indicated in a child presenting with likely growing pains?

Answer 6

Laboratory evaluation is not indicated in situations where the clinical picture is compatible with growing pains, except to rule out other etiologies. Labs should be normal in children with growing pains.

Question 7

What is the recommended treatment for growing pains?

Answer 7

Treat with heat, massage, and acetaminophen/ibuprofen for pain. For patients with frequent episodes, a dose of acetaminophen/ibuprofen before bed may decrease the severity of the spells.

Question 8

Within what age range are growing pains most common?

Answer 8

They occur most commonly in preschool and elementary aged children and generally disappear by 12-13 years of age.

Question 9

Describe some (5) of the tasks that can be attempted to determine if a child has hypermobility syndrome.

Answer 9

Extend the wrist and MCP joints so that the fingers are parallel to the dorsum of the forearm (bilateral); passively oppose the thumb to the flexor aspect of the forearm (bilateral); hyperextend the elbows ≥10° (bilateral); hyperextend the knees ≥10° (bilateral); flex the trunk with the knees fully extended so the palms rest on the floor.

Question 10

What is benign hypermobility joint syndrome?

Answer 10

It is a fairly common joint hypermobility syndrome seen more commonly in girls. Most affected children are asymptomatic.

Question 11

How does one diagnose benign hypermobility joint syndrome?

Answer 11

The ability to perform the 5 hypermobility tasks in ≥5 locations (a point for each side of the body + flexing the trunk) confirms hypermobility. There should be no other signs/symptoms consistent with a more severe inherited diseases of connective tissues.

Question 12

If you find hypermobility syndrome, which traits do you look for to determine if a hereditary syndrome might be present?

Answer 12

High-arched palate, ocular/cardiac lesions, skin hyperelasticity, arachnodactyly, and velvety skin texture.

Question 13

What symptoms are most common in symptomatic patients with benign hypermobility joint syndrome?

Answer 13

Joint and muscular pain, as well as transient joint effusions. Knees and hands are most commonly affected.

Question 14

How should symptomatic patients with benign hypermobility joint syndrome be treated?

Answer 14

Treat with NSAIDs or acetaminophen.

Question 15

What is a recommended exercise activity for hypermobility syndrome?

Answer 15

Swimming and other low-to-no impact sports.

Question 16

What characterizes the amplified musculoskeletal pain syndromes in children?

Answer 16

These syndromes cause noninflammatory musculoskeletal pain.

Question 17

What are the four different amplified musculoskeletal pain syndromes?

Answer 17

Juvenile fibromyalgia, complex regional pain syndrome, localized pain without autonomic changes, and intermittent pain.

Question 18

What are the clinical findings in patients with amplified musculoskeletal pain syndromes (AMPs)?

Answer 18

Patients can present with one affected limb but can be anywhere in the body and can also be diffuse. Most children describe the pain as being constant, but it can be intermittent in some. The pain these patients experience is real.

Question 19

What is juvenile fibromyalgia?

Answer 19

It is a subset of the amplified musculoskeletal pain syndromes with similar features as adult fibromyalgia (chronic pain of at least 3 months’ duration without another identified cause). Children often fail to meet full adult diagnostic criteria, but they do have tender points with digital palpation. They do not have evidence of articular swelling, loss of motion, or muscle weakness.
*** Include figure 20-1

Question 20

What is complex regional pain syndrome?

Answer 20

It is a subtype of the amplified musculoskeletal pain syndromes. Characteristic features include allodynia (pain aggravated by light touch) and/or hyperalgesia. They have localized autonomic dysfunction with edema, coolness or excess warmth, mottling, and/or sweatiness.

Question 21

What is the recommended treatment for complex regional pain syndrome?

Answer 21

Aggressive physical and occupational therapy with therapists experienced in treatment of this diagnosis. The addition of concurrent psychological support can improve results.

Question 22

How might one be able to use school attendance history to differentiate between inflammatory/autoimmune diseases and amplified musculoskeletal pain syndromes?

Answer 22

Patients with AMPs often have a history of problematic school absenteeism, whereas patients with autoimmune/inflammatory diseases don’t tend to miss school as frequently.

Question 23

What is the role of laboratory testing in the diagnosis of amplified musculoskeletal pain syndromes?

Answer 23

Because fatigue and pain can be seen in some patients with autoimmune disorders, be sure to check appropriate laboratory tests (CBC, ESR, RF, ANA, anti-SSA/SSB antibodies, CPK, and thyroid function tests) to rule out these conditions prior to confirming a diagnosis of an AMP syndrome.