FEATURE | SHERRY WHENCHILDREN HURTTOOMUCH Diagnosis and Treatment of Amplified Musculoskeletal Pain BY DAVID D. SHERRY, MD 50 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
There are multiple forms of amplified musculoskeletal pain (chronic musculoskeletal pain out of proportion to the known stimulus) in children, ranging from Complex Regional Pain Syndrome (CRPS) in one limb to total body pain. The cause is unknown but may be related to trauma, illness, or psychological stress, and the incidence seems to be increasing. THERE IS A TYPICAL PRESENTATION, mostly among adolescent girls with allodynia, marked pain and dysfunction disproportionate to the known stimulus, and an incongruent affect. Con<strong>version</strong> symptoms are not uncommon. The treatment is intense exercise therapy focused on function, desensitization, and attention to concurrent conditions (psychological, mechanical, inflammatory). The outcomes are very good, with virtually all patients regaining full function and between 80 - 90% resolving all pain. These conditions present some of the greatest challenges in pediatrics but are also the most rewarding to treat because the child goes from being highly disabled to normal. Case Presentation BETTY WAS AN ATTRACTIVE, bright, athletic 14-year-old girl who stepped on a rock at the bottom of a swimming pool and hurt her right foot. The skin was not broken, but over the next two days her foot became progressively more painful, swollen, blue, and cool to the touch. In the emergency department a radiograph was normal and a splint was applied. Betty required crutches and developed marked tenderness to touch. She was put in a cast, but the cast caused so much pain that it had to be removed the next day. The pain spread to include her entire right leg and also the left foot (although she could bear weight on that side), and to both hands (presumably from using crutches). She was unable to move her right foot, or her toes, which occasionally went numb (although they still hurt). Today, she hurts too much to wash or shave her right leg. She cannot attend school, because she is fearful that the leg might get bumped, and she is unable to concentrate because of the intensity of her pain. She cannot sleep well and when she does sleep, she wakes frequently with pain. The pain in her right foot is greater than 10 out of 10, and her hands and left foot hurt 10 out of 10. The pain has taken over her life and the life of her family. She has seen multiple healthcare practitioners, has had numerous tests (all of which are normal), and has either failed to respond or has developed unacceptable side effects from a host of medications, treatments, and blocks. Betty’s symptoms are not unusual for a child with amplified musculoskeletal pain. There are multiple forms, usually defined T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 51