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Audio-Digest FoundationPediatrics


Volume 56, Issue 14
July 21, 2010

The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program. If, after reviewing the summary, you would like to hear the contents and earn CME/CE credit, simply use your browser's back button to return to the order page and add this program to your cart.

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The Child in Pain

Educational Objectives

The goal of this program is to improve the evaluation and treatment of pediatric musculoskeletal pain syndrome. Af­ter hearing and assimilating this program, the clinician will be better able to:

1.   Distinguish between inflammatory arthropathies and musculoskeletal pain syndromes in children.

2.   Perform clinical evaluations for diagnosis of various pediatric musculoskeletal pain syndromes.

3.   Prescribe appropriate treatment for different musculoskeletal pain syndromes in children.

4.   List possible causes of musculoskeletal back pain in children.

5.   Recognize red flags that indicate serious underlying pathology in children with back pain.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Passo is a consultant to Pfizer. Dr. Bernstein and the planning committee reported nothing to disclose. In his lecture, Dr. Passo pres­ents information that is related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Passo spoke at Frontiers in Pediatrics, held December 4–6, 2009, in Charleston, SC, and sponsored by the Medical University of South Carolina. Dr. Bernstein spoke at Head to Toe: Orthopaedic Aspects of the Growing Child, held October 10, 2009, in Los Ange­les, CA, and sponsored by Cedars-Sinai Medical Center. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Musculoskeletal Pain Syndrome in Children    Pattern Recognition

Murray H. Passo, MD, Professor of Pediatrics, Director, Division of Rheumatology, Medical University of South Carolina, Charleston

Pattern recognition: listen to patient’s complaints; make informed guess as to correct diagnosis, then attempt to ver­ify it (or find an alternative)

Inflammatory diseases of connective tissue associated with musculoskeletal pain: juvenile idiopathic arthritis (JIA; currently preferred term for juvenile rheumatoid arthritis [JRA]); systemic lupus; dermatomyositis; sclero­derma; mixed connective tissue disease

Inflammatory arthropathy: distinguished by inactivity, stiffness, and swelling; aching and soreness; occasionally, severe pain; swelling is hallmark of inflammation (due to synovial thickening, tissue swelling, or effusion in joint); some loss of motion (with or without pain); warmth; occasionally, discoloration

Inflammatory enthesopathy: distinguished by pain and tenderness in insertion sites of ligament, tendon, and fascia; inactivity, stiffness, and gelling; can occur with joint swelling; cardinal features of enthesitis present in spondyloar­thropathies

Chronic Arthritis

Diagnosis: of 226 children referred for chief complaint (CC) of musculoskeletal pain (MSP), only one case of anky­losing spondylitis (AS) found, and no JRA; 64 of 76 JRA patients did not include MSP in CC; take-home points   most patients referred for MSP have either mechanical or overuse syndrome; MSP has negative predictive value for JRA; signs and symptoms predictive of JRA    joint swelling; disturbance of gait (limping); shorter duration of symptoms; elevated erythrocyte sedimentation rate (ESR) (helpful, although not diagnostic); positive antinuclear antibody (ANA), rheumatoid factor (RF) of limited utility

Arthralgia and positive ANA or RF: even with positive serology, must have objective findings (swelling of joint) to diagnose arthritis; comprehensive physical examination and review of systems may uncover lupus or other ANA-related diseases; re-evaluations may be necessary to confirm diagnosis; most often, patients with positive serolo­gies do not have autoimmune disease (3%-5% of normal children have positive ANA)

Growing Pains

Symptoms: prevalence 4% to 37% of normal children; more common in girls than boys; episodic, with symptom-free intervals; bilateral; more often in lower extremities; occurs at end of day or may awaken child from sleep; short duration; usually in muscles between joints, but occasionally in joints; no objective abnormalities (swelling or discoloration)

Etiology: related to “being a growing person,” rather than to growth itself; not observed in adults; theories    lower pain threshold; fatigue; faulty posture; emotional contribution; decreased bone strength with overuse syndrome; hypermobility; flexible flat feet

Diagnosis: pattern recognition of history; thorough negative physical examination; laboratory tests and imaging usu­ally unnecessary (occasionally, complete blood count [CBC] and ESR); x-rays and radionucleotide imaging rarely performed

Treatment: reassurance, heat, massage, analgesics, stretching and strengthening exercises, shoe insoles, occasion­ally, behavioral intervention and awareness of family environment

Benign Hypermobility Syndrome

Prevalence: occurs in 7% to 34% of normal children; underrecognized cause of joint pain in children; frequency in­versely related to age

Symptoms: associated with arthralgia, especially after activity; short-lived joint effusions can occur; if effusions per­sist, seek alternative explanation (may be associated with inflammatory arthritis); family history frequently positive for joint laxity (autosomal dominant inheritance)

Diagnosis: Beighton score    assessment of joint laxity; hypermobility of ankles, feet, shoulders, and hips excluded; 8 sites of hyperextension plus forward flexion with knees straight and hands flat on floor (ie, total of 9 possible points); major criteria    include Beighton score of ³4/9; Brighton criteria    newer scheme for diagnosing hyper­mobility syndrome; diagnosis requires 2 minor criteria plus one major criterion, or 4 minor criteria

Association between arthralgia and hypermobility of joints: 34% hypermobile; study found 50% of hypermobile patients had arthralgia, vs 20% of matched controls; suggests that hypermobility probably does cause transient postactivity arthralgia; not benign; associated difficulties    poor coordination; proprioceptive abnormalities; learn­ing difficulty; autonomic dysfunction of gastrointestinal tract; panic attacks; pain amplification syndromes; sleep disorders; hernias

Anterior Knee Pain

Patellofemoral compartment syndrome: formerly called chondromalacia patellae; pain in peripatellar area

History: insidious vague aching in peripatellar region; often bilateral; grating, clicking, or catching sensation; leg gives out; pain worse during and after activities that load knee in flexion; prolonged sitting aggravates pain

Pathophysiology: abnormal patellar tracking (usually valgus deformity); weakness of vastus medialis muscle; hyper­mobility of patella or knee joint; abnormal bony structure

Physical examination: look for    patellar apprehension sign; patellar mobility; tenderness of medial patellar facet; tenderness of inferior pole of patella; synovial plica; genu valgum (Q angle >20º); insufficiency of vastus medialis; tight hamstrings; weak hip flexors

Diagnostic tests: synovial fluid analysis if effusion present; x-rays (sunrise view, tunnel view)

Differential diagnosis: osteochondritis dissecans; Osgood-Schlatter disease; patellar tendonitis

Treatment: nonsteroidal anti-inflammatory drugs (NSAIDs); ice after activity; limitation of aggravating activities; strengthening of quadriceps; patellar stabilizing brace; hamstring stretching exercises; orthotic device for hypermo­bile or flat feet; surgery (rare)

Malignancy

Signs and symptoms: osteoarticular pain    common in malignancy; usually in long bones, though small joints may be involved; can be severe (often disproportionate to physical findings); other    effusions in joints; lytic lesions, meta-physeal rarefaction, or periosteal reaction on x-ray; cytopenia; positive RF and/or ANA

Malignancies presenting with osteoarticular pain: acute lymphoblastic leukemia; non-Hodgkin lymphoma; meta­static neuroblastoma; keys to diagnosis    CBC with differential; platelet count; serum lactase dehydrogenase (LDH); radiographs; bone scans; abdominal ultrasonography; bone marrow aspirate and biopsy; tissue biopsy

Musculoskeletal Pain Syndromes

Diffuse idiopathic pain syndromes: fibromyalgia; psychogenic rheumatism

Localized idiopathic pain syndromes: hypermobility syndrome; growing pains; reflex sympathetic dystrophy (RSD)

Amplified musculoskeletal pain syndromes: RSD (also called reflex neurovascular dystrophy [RND]); may have autonomic dysfunction, allodynia, and/or affective changes; exercise therapy key to recovery; psychologic inter­ventions may be necessary; long-term outcome good

Reflex Neurovascular Dystrophy

Signs and symptoms: usually distal extremity (upper or lower); in upper extremity, called shoulder-hand syndrome; severe pain; autonomic dysfunction with hyperesthesia or allodynia; paresthesias in nondermatome distribution; diffuse brawny swelling of limb (usually distally); pallor and coolness to touch; cyanosis; bizarre posturing (refusal to move limb); antecedent trauma; psychologic contribution implicated in most patients

Typical profile: compliant; overachieving; preadolescent female; undue stress from family psychodynamics or school; provoked by antecedent event of trauma or illness; serves functional role by allowing child to slow down and obtain parental attention; can turn into severe painful syndrome; requires expeditious diagnosis and treatment

Evaluation: must be sufficient to be confident of diagnosis

Diagnosis: x-rays to rule out occult bone abnormality or fracture; radionucleotide imaging; nerve studies if neuropa­thy suspected; Doppler vascular studies if ischemia suspected

Treatment: avoid immobilization; intense physical therapy (desensitization); graded stepwise re-utilization of the limb; psychologic intervention

Prognosis: dystrophic changes rare; most patients recover fully; recurrences common

Fibromyalgia Syndrome

History: chronic widespread musculoskeletal pain syndrome; diagnosis requires presence in ³3 sites (<3 sites con­sidered localized myofascial pain)

Signs and symptoms: hallmarks include tender points and nonrestorative sleep pattern; morning stiffness; subjective swelling that resolves in »1 hr; chronic fatigue; aggravated by sedentary lifestyle; modulated by weather, stress, and rest; headaches, irritable bowel syndrome, depression, and anxiety (sometimes panic attacks) common; reclas­sified as “central sensitivity syndromes”; female predominant; abnormal pain sensitivity in “nontender point” ar­eas; no objective arthritis or weakness; normal CBC, ESR, muscle enzymes, and thyroid function; subset may have positive ANA or Raynaud phenomenon

18 tender point examination: 9 points on 2 sides; occiput, trapezius, periscapular, gluteal, medial fat pad of knee, greater trochanter, lateral epicondyle of elbow, second intercostal space of anterior chest wall, and bottom of stern­ocleidomastoid muscles; 5 of 18 points sufficient for diagnosis in children; large proportion of patients with fibro­myalgia have coexistent joint hypermobility

Misdiagnoses: 30 patients referred for ongoing Lyme disease found to have fibromyalgia

Pathophysiology: unknown; sleep disorder common; disorder of serotonin metabolism likely

Treatment: reassurance; education; sleep modification (through use of amitriptyline or cyclobenzaprine); duloxetine and pregabalin (not approved by the Food and Drug Administration for fibromyalgia in children <18 yr of age); an­algesics (nonnarcotic; NSAIDs not beneficial); aerobic exercise (low impact; graded endurance training); stress management

Musculoskeletal Pain Syndrome in Children    Back Pain

Robert M. Bernstein, MD, Associate Clinical Professor of Surgery, David Geffen School of Medicine, Univer­sity of California, Los Angeles and Director of Pediatric Orthopaedics, Cedars-Sinai Medical Center, Los An­geles, CA

Background: back pain once thought to be rare in children, but now recognized as common; children rarely seek care or self-limit activities

Causes: mechanical abnormalities    trauma (eg, bruising, muscle strains, fracture [eg, spondylolysis]); developmental  —Scheuermann disease (growth abnormality of spine); inflammatory    infection (osteomyelitis, discitis), rheumatologic abnormalities (eg, JRA, juvenile ankylosing spondylitis [JAS]); neoplastic    spinal cord; bone (osteoid osteoma or osteoblastoma); muscle; metastatic

History: pain onset and chronicity; radiation of pain to legs; numbness; weakness; generalized symptoms (fevers and/or weight loss); bowel and bladder symptoms; medications (if child frequently taking NSAIDs, then back pain significant)

Presentation-oriented approach to evaluation: night pain    red flag (warrants immediate evaluation); pain that regularly awakens child from sleep could be tumor (eg, eosinophilic granuloma, leukemia); infections; look for as­sociated symptoms (fever, weight loss, or neurologic symptoms; self-limitation of activities); pain with generalized symptoms  —red flag; fever or weight loss (suggest tumor or infection [eg, vertebral osteomyelitis]); acute pain    patient having pain for 1 to 2 wk (eg, herniated discs, apophyseal fractures, spondylolysis, infections, muscle strains); chronic pain    Scheuermann disease; spondyloarthropathies (eg, JAS); psychologic problems (definite association in families where one or both parents complain of back pain); pain with recent-onset scoliosis    in children seen for scoliosis, pain not usually presenting complaint; back pain that predates curvature warrants more careful evaluation for tumor or disc herniation (scoliosis results from tendency to move away from side of tumor or herniation; in such cases, rotation of spine minimal)

Presentation to emergency department for back pain in children: most commonly for trauma, muscle strains, sickle cell crises, urinary tract infections, and viral syndromes; does not necessarily correspond with cases seen in office

Physical examination: inspection    alignment; ability to bend to touch toes; motion    pain worse with forward bending indicates increased pressure of discs (eg, disc herniation); pain worse with hyperextension indicates poste­rior element pain (eg, spondylolysis); pain worse with lateral bend to one side determines which side of spine has problem; palpation    tenderness on percussion (tapping over tumor produces pain); straight-leg raise and flip sign    looking for radicular signs or pain down leg; flexion, abduction, external rotation (FABER) test    stresses ipsilateral sacroiliac joint to assess for pain in this area; abdominal reflexes    should be even on both sides

Diagnostic algorithm: Journal of Family Practice    child presents with back pain; perform history and physical; if abnormal, get radiographs and laboratory studies; treat diagnosis; if tests negative, order magnetic resonance imag­ing and computed tomography; if physical examination normal, prescribe NSAIDs, teach home exercises, and pos­sibly refer patient to physical therapy; if patient improves, discharge

Red flags for pathologic problem: pain lasting >4 wk; self-imposed limitations; increasing pain; neurologic symp­toms; recent-onset scoliosis; systemic symptoms (fever and/or weight loss); in absence of these symptoms, can still have pathologic problem; make sure not missing tumor or infection

Encourage good body mechanics: meet with coaches; make sure    coaches understand good body mechanics; pa­tient doing preactivity stretching (talk to parents) and performing core strengthening exercises

Suggested Reading

Adib N et al: Joint hypermobility syndrome in childhood: a not so benign multisystem disorder? Rheumatology (Oxford). 2005 Jun;44(6):744-50; Arroyo IL et al: Arthritis/arthralgia and hypermobility of the joints in schoolchildren. J Rheumatol. 1988 Jun;15(6):978-80; Brace MJ et al: Family reinforcement of illness behavior: a comparison of adolescents with chronic fatigue syn­drome, juvenile arthritis, and healthy controls. J Dev Behav Pediatr. 2000 Oct;21(5):332-9; Cabral DA, Tucker LB: Malignancies in children who initially present with rheumatic complaints. J Pediatr. 1999 Jan;134(1):53-7; Clinch J, Eccleston C: Chronic musculo­skeletal pain in children: assessment and management. Rheumatology (Oxford). 2009 May;48(5):466-74; Gedalia A et al: Joint hy­permobility and fibromyalgia in schoolchildren. Ann Rheum Dis. 1993 Jul;52(7):494-6; Grahame R et al: The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS). J Rheumatol. 2000 Jul;27(7):1777-9; Lowe RM, Hashkes PJ: Growing pains: a noninflammatory pain syndrome of early childhood. Nat Clin Pract Rheumatol. 2008 Oct;4(10):542-9; McGhee JL et al: Identifying children with chronic arthritis based on chief complaints: absence of predictive value for musculosk­eletal pain as an indicator of rheumatic disease in children. Pediatrics. 2002 Aug;110(2 Pt 1):354-9; Schneider R, Passo MH: Juve­nile rheumatoid arthritis. Rheum Dis Clin North Am. 2002 Aug;28(3):503-30; Sherry DD: Pain syndromes in children. Curr Rheumatol Rep. 2000 Aug;2(4):337-42; Sherry DD: An overview of amplified musculoskeletal pain syndromes. J Rheumatol Suppl. 2000 Apr;58:44-8; Sherry DD, Weisman R: Psychologic aspects of childhood reflex neurovascular dystrophy. Pediatrics. 1988 Apr;81(4):572-8; Sigal LH, Patella SJ: Lyme arthritis as the incorrect diagnosis in pediatric and adolescent fibromyalgia. Pediatrics. 1992 Oct;90(4):523-8; Stanton-Hicks M et al: Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain. 1995 Oct;63(1):127-33; Uziel Y et al: Decreased pain threshold in children with growing pains. J Rheumatol. 2004 Mar;31(3):610-3; Uziel Y, Hashkes PJ: Growing pains in children. Pediatr Rheumatol Online J. 2007 Apr 19;5:5.

 


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