MUSCULOSKELETAL PAIN AND CHILD ABUSE
Musculoskeletal pain in children is variable. Depending on age, and verbal and cognitive abilities, assessing pain in the pediatric patient may present additional challenges. Children under 5 years may have difficulty describing pain. A scale with faces illustrating different emotions may help children describe how they feel (401). The faces scale, has been in use for over a decade, continues to be used during assessment, and was recently used in a study published on pain in the pediatric population (402). At the age of 6 years, children can usually score their pain on a level between 0 and 10 by increasing severity (11).
COMPLEX REGIONAL PAIN SYNDROME
Complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy, is a condition that usually involves one limb and more commonly the lower extremity in children. There is a scarcity of data in the pediatric population. There are two types of CRPS. Type 1 follows an injury or illness to the region affected and type 2 occurs after a distinct nerve injury. CRPS is a complex condition characterized by dysesthetic sensory component. Motor and sensory cortexes are reportedly reorganized and there are inflammatory and neurologic changes peripherally (403).
Acute Phase Lasts up to 3 Months
Burning pain and increased sensitivity to touch are the common findings during this time. Joint stiffness, swelling, redness, and increased warmth follow typically (405). Other findings may include an increase in the rate of nail and hair growth as well as sweating. Stage IT. dystrophic, 3 to 12 months; swelling more constant. Stage III: after 1 year.
Unlike adults, who usually have an inciting event such as a fracture, surgery, prolonged immobilization, or vascular insult, children usually do not have a clear event that precipitates the condition (406). There appears to be a sympathetic nervous system reflex arc mechanism of action. The majority of children with this condition are teenage girls around 12 to 13 years of age. Radiographs are useful to rule out a fracture or osteomyelitis (407). Regional nerve blocks may be both diagnostic and therapeutic. The diagnosis should be considered with trauma and pain that is out of proportion to the stimulus and worsened with use.
A multidisciplinary approach is useful. The earlier the recognition and treatment, the more rapidly recovery is possible. Once contractures and atrophy set in, this is a much more difficult entity to treat. Some advocate medications such as calcium channel blockers, beta-blockers (propranolol), and tricyclic antidepressants such as amitriptyline. Relapse rates are high (408).
The etiology of fibromyalgia in children and adolescents is unclear.
Diffuse musculoskeletal pain involving the neck, back, and upper and lower extremities is common in fibromyalgia in children and adolescents. Sleep disturbance, headaches, fatigue, and problems with peer relationships (408) are common among those diagnosed. The diagnosis of juvenile primary fibromyalgia syndrome (JPFS) is given when the child or adolescent has muscle and join pain, and/or pain "all over" without any other illness.
Polysomnography is frequently positive while other tests are negative (409). There has been an increase in children whose mothers have the condition; this may be cultural rather than genetic. Females are more affected, and the onset ranges from around 11.5 to 15 years. Children with fibromyalgia can have fewer trigger points than adults, although the exact number is uncertain.
Education and psychological interventions are the first line of treatment. Those with JPFS are often treated by rheumatologists, as they may present similar to a child or adolescent who has lupus or arthritis (410).
There is a high prevalence of fibromyalgia in those adults who clinically had onset of fibromyalgia in adolescence. Furthermore, these individuals have been found to be the most impaired both emotionally and physically in adulthood. In one study, greater than 80% of patients who presented as juvenile-onset fibromyalgia continued to express symptoms of fibromyalgia in adulthood and approximately half of those met the criteria of the ACR. Additionally, the fibromyalgia group was more likely to marry at an earlier age and have children rather than move out of their homes and attend college compared to age-matched healthy peers (411).