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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. Conversion 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
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