Chronic Musculoskeletal Pain in Children and Adolescents

Educational Objectives

The goal of this program is to improve management of chronic musculoskeletal pain in children. After hearing and assimilating this program, the clinician will be better able to:

1. List risk factors for amplified musculoskeletal pain syndrome (AMPS) in the pediatric population.
2. Optimize management of AMPS in children.

Summary

Epidemiology of chronic musculoskeletal pain (CMP): CMP is a common issue among children and adolescents; orthopedic surgery and sports medicine are not designed to provide ongoing care for chronic conditions, and sports medicine fellowships rarely focus on chronic pain management, even though most patients in this field seek treatment for painful conditions; among children, chronic headaches, chronic abdominal pain, and CMP are the most prevalent painful conditions, and sports medicine clinics often encounter cases of CMP

Literature on chronic pain: a systematic review of literature (Chambers et al [2024]) assessing children <19 yr of age revealed that 1 in 4 children experienced chronic musculoskeletal pain, with girls affected more often than boys; in a study at Boston Children’s Hospital done by Stracciolini et al (2014), pain or “pain not otherwise specified” was the seventh most frequent diagnosis in pediatric sports clinics overall and ranking fifth in adolescents (13-17 yr)

Amplified musculoskeletal pain syndrome (AMPS): is an umbrella term for diffuse or localized noninflammatory musculoskeletal pain that is more intense than normal; AMPS primarily affects preteen and teenage girls (11-15 yr of age [≈80% of cases]) and often presents with diffuse or localized pain (eg, wrists, feet, ankles); allodynia, where nonpainful stimuli cause significant pain disproportionate to history, is a hallmark physical finding; autonomic signs (eg, swelling, discoloration) may also be present; other terms for the condition include complex regional pain syndrome (primarily used for adults), reflex sympathetic dystrophy, myofascial pain, juvenile fibromyalgia, and CMP; risk factors include stress, injury, illness, age, and genetic predisposition, with parents, particularly mothers, often reporting similar conditions

Management of AMPS: the hallmark treatment includes biofeedback, intensive physical and occupational therapy, and desensitization, which involves lightly touching the affected area with a feather to retrain the nerves; non-narcotic medications include gabapentin, pregabalin (Lyrica), and tricyclic antidepressants; coping strategies and wellness or psychologic counseling are advised; AMPS is not a diagnosis of exclusion; additional investigations are not indicated, as these tests may increase fear, anxiety, and depression, and worsen pain; AMPS can be diagnosed based on clinical history and examination; families often struggle to accept this diagnosis, fearing that the pain will not be taken seriously, while children wonder if their pain is “all in their head”; AMPS is not rare, with numerous personal stories published by children’s hospitals nationwide; books (eg, The AMPS Champ) offer a child’s perspective on the condition

Hypermobility arthralgia: is common in sports, and presents as joint pain associated with hypermobile joints; it can be linked to connective tissue disorders (eg, Ehlers-Danlos, Marfan syndrome); the primary treatment is physical therapy, which focuses on strengthening the surrounding muscles; options for ongoing care include pediatric physiatry or rheumatology

Scoring system: the Beighton scoring system helps assess hypermobility or flexibility in joints (eg, thumbs, fingers, knees, elbows); scores >6 or 7 out of 9 suggest generalized hypermobility; the parameters include the ability to touch the volar aspect of the forearm with the thumb, hyperextension of the fifth finger, recurvatum at the knee, hyperextension of the elbows greater than -15 degrees, and touching the palms to the floor; each test is worth one point per affected extremity, and touching the palms to the floor is worth one point

Vitamin D deficiency: limited sun exposure, especially in regions with long winters, exacerbates this issue; there is a link between vitamin D deficiency and CMP; a study in Iran found that children with chronic pain had significantly lower vitamin D levels compared with their asymptomatic peers

Role of mental health in chronic pain: Noel et al (2016) found that adolescents with multifocal joint pain experience elevated rates of mental health disorders; a study from Norway by Garnæs et al (2022) on ≈1000 patients with a mean age of 46 yr found that patients with CMP reported higher rates of anxiety, depression, fatigue, and insomnia

Management of chronic pain: the recommended workup for chronic pain includes a thorough history, physical examination, and limited investigations; screening radiography helps rule out serious conditions (eg, tumors, infections); the only blood work the speaker orders for chronic pain includes a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, and vitamin D levels; the speaker does not order antinuclear antibody, rheumatoid factor, or antineutrophil cytoplasmic antibody tests; mental health screening is beneficial, although orthopedic and sports clinics often lack the time to adequately address these issues, and parents are frequently resistant; referrals to physical therapy are advisable, and encouraging aerobic activities is beneficial; referrals to physiatry and rheumatology are also helpful; chronic pain management requires a multidisciplinary approach involving primary care, nutritionists, psychologists, alternative medicine practitioners, pain specialists, and physical and occupational therapists; coordinated care through a medical home is essential to prevent patients from becoming lost in fragmented systems

Readings

Chambers CT, Dol J, Tutelman PR, et al. The prevalence of chronic pain in children and adolescents: a systematic review update and meta-analysis. Pain. 2024;165(10):2215-2234. doi:10.1097/j.pain.0000000000003267; Garnæs KK, Mørkved S, Tønne T, et al. Mental health among patients with chronic musculoskeletal pain and its relation to number of pain sites and pain intensity, a cross-sectional study among primary health care patients. BMC Musculoskelet Disord. 2022;23(1):1115. doi:10.1186/s12891-022-06051-9; Malek S, Reinhold EJ, Pearce GS. The Beighton score as a measure of generalised joint hypermobility. Rheumatol Int. 2021;41(10):1707-1716. doi:10.1007/s00296-021-04832-4; Noel M, Groenewald CB, Beals-Erickson SE, et al. Chronic pain in adolescence and internalizing mental health disorders: a nationally representative study. Pain. 2016;157(6):1333-1338. doi:10.1097/j.pain.0000000000000522; Sherry DD. An overview of amplified musculoskeletal pain syndromes. J Rheumatol Suppl. 2000;58:44-48; Sherry DD, Sonagra M, Gmuca S. The spectrum of pediatric amplified musculoskeletal pain syndrome. Pediatr Rheumatol Online J. 2020;18(1):77. doi:10.1186/s12969-020-00473-2; Stracciolini A, Casciano R, Levey Friedman H, et al. Pediatric sports injuries: a comparison of males versus females. Am J Sports Med. 2014;42(4):965-972. doi:10.1177/0363546514522393.

Disclosures

For this program, members of the faculty and the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Riederer was recorded at Sports Medicine for the Primary Care Physician, held on October 2, 2024, in Ann Arbor, MI, and presented by the Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI. For information about upcoming CME activities from this presenter, please visit https://medschool.umich.edu/offices/cme. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

PD711002

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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