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especially opioids. Opioids should be tapered about 10% per
day and, depending on the dose, gabapentin should be tapered
over two to three weeks. Tramadol binds to opioid receptors;
therefore, those children on a high dose of this medication
should have it tapered.
There are no controlled studies of the vast number of treatments
reported in the literature for the various forms of amplified
musculoskeletal pain. Treatments are legion and include
pain medications, antidepressants, gabapentin, transcutaneous
nerve stimulation, nerve blocks and sympathectomy (for
CRPS), epidural catheters for continuous drug infusion, pain
pumps, lidocaine and opioid patches, acupuncture, massage,
cognitive-behavior therapy, psychotherapy, and exercise therapy.
Most authors agree that exercise therapy is helpful in
achieving the best long-term outcomes in all forms of amplified
musculoskeletal pain. I have found it to be the most helpful
with the longest-lasting results (13, 14). The nature of the exercise
therapy, however, is different from what physical and occupational
therapists are accustomed to (15). The primary goal of
the program we use is to restore function, so the exercise program
is very intense and directed at doing normal and aerobic
activities (such as jumping, climbing stairs, building walking
speed and endurance, performing sports drills, and carrying
loads). Pain is not directly treated and is ignored as much as
possible during the exercise sessions. The vast majority will
gradually resolve all pain once full function has been restored.
Allodynia is treated by desensitization with rubbing, vibration,
and applying textures to the skin.
Some children can and do carry on this exercise program on
their own at home once they realize that even though exercising
hurts, it is not damaging and is, in fact, going to make them
better. For most children, however, the pain is too great for
them to exercise at home, so they need to come into the office
to participate in our program. We give them five hours of exercise
therapy daily for an average of three weeks. Most children
will also have improvement in their mood, sleep, and energy
level, and relief from other somatic complaints once they start
this intensive exercise program.
In addition to exercise therapy, the psychodynamics of
the child and family should be evaluated, since most families
and children will have significant psychological difficulties.
These may require individual, family, or marital therapy (or a
combination of these therapies) (16, 17).
Good sleep hygiene is helpful and should be mentioned
even though fixing the sleep problems does not resolve the
somatic symptoms. Frequently children with amplified musculoskeletal
pain have a sleep complaint (not a true sleep disorder)
and having a good night sleep is helpful. This includes going to
bed only when one is sleepy, not reading or watching television
while in bed, eliminating caffeine, practicing relaxation techniques,
eliminating napping, and having a routine for sleeping
and waking on weekdays and weekends.
Complementary treatments are frequently sought, but there
are no data regarding benefit. These treatments include herbal
therapy, massage, magnet therapy, homeopathy, reflexology,
aromatherapy, to name a few, but only rarely is any sustained
benefit reported. We cannot recommend any of these treatments
and, as with allopathic medications, we discontinue
them once the diagnosis is made.
Outcomes
MOST CHILDREN DO WELL with the described treatment
approach. The outcome may vary, depending on the form of
amplified musculoskeletal pain; however, long-term studies in
children are rare. Most children with CRPS (92% of 103 children
studied) who were treated with an intense exercise program
resolved all signs and symptoms and 88% were well after
five years (14). Less than half of 70 children with CRPS who
were treated with drugs, blocks, and moderate exercise resolved
all symptoms; no long-term outcomes were reported (18).
TABLE 2 | Key Points in the Recognition
and Treatment of Amplified
Musculoskeletal Pain in Children
1
There is a high index of suspicion
for the presence of amplified
musculoskeletal pain in patients
with these characteristics or
manifestations:
❥ Adolescent female
❥ Mature beyond years
❥ Accomplished
❥ Perfectionistic
❥ Anxious to please
❥ Prolonged school absence due to
pain
❥ Marked dysfunction
❥ Worsening of pain over time
❥ Normal examination except pain
❥ No enthesitis or arthritis
❥ Normal neurological exam
❥ Localized pain on examination
❥ Allodynia
❥ Autonomic signs
❥ Incongruent affect
❥ La belle indifference
❥ Widespread pain on examination
❥ Multiple painful points
❥ Normal laboratory studies
❥ Failure of all prior therapies
2
Once an amplified musculoskeletal
pain is recognized:
❥ Acknowledge the pain
❥ Explain that it is amplified,
and not indicative of
underlying damage or disease
❥ Stop further medical investigations
❥ Stop medications as appropriate
❥ Restore function
❥ Prescribe aerobic exercise, up to
5 hours daily of intense therapy
focused on functional activities
and continuing for 2-4 weeks
❥ If allodynia is present, desensitize
with tactile stimulation
❥ Advise child to resume full-time
school attendance
❥ Advise child to resume social
and recreational activities
❥ Evaluate the psychological
dynamics and treat if appropriate
❥ Anticipate total resolution
of symptoms
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