A multidisciplinary approach to managing chronic pain in children
“Everything hurts.” This was the chief complaint of ʻAʼ, a teenage girl with oligoarticular juvenile arthritis. On examination, she had no signs of arthritis, and no fibromyalgia tender points. She was unable to attend school because of the chronic pain. The problem I was facing was one that pediatric rheumatologists face quite often: What to do for a child with pain?
Pain is one of the most common complaints in pediatric rheumatology [1,2]. Chronic pain associated with rheumatic disease is a significant stressor to children and their caregivers. For instance, children with chronic or recurrent pain have been shown to have decreased coping skills, and increased anxiety, sleep disturbance, and social withdrawal, and parents report severe stress and dysfunctional family roles . Interestingly, pain does not always correlate with inflammation, and pain assessment can be challenging . In a study of children and adolescents with juvenile idiopathic arthritis, there was no difference in distress between children with elevated inflammatory markers compared with those with well controlled disease .
Treating pain in children can be quite challenging. If we can identify the cause, such as a swollen joint from arthritis, we can start medication to control the underlying disease, which in turn, should help treat the pain. The more challenging situation is when no specific cause of the pain can be identified, as in my patient. In these cases, thinking about pain as its own entity can be helpful. Amplified musculoskeletal pain syndrome (AMP) is thought to be due to abnormal pain signaling reflex, and can cause pain in any part of the body.
The good news is that we were able to diagnose A with AMP. The challenging news is that treatment would be complicated.
Children with AMP often need multidisciplinary support. Specialized clinics that focus on keeping children mobile through physical and occupational therapy, and dealing with stressors by working with a psychology team have been shown to be beneficial. For A, this multidisciplinary approach was critical. Over many months, A started increasing her physical activity. Her sleep improved and she started talking to the psychology team about some of the stressors she was facing in school and at home. I am happy to say that A is now back full-time in school and doing great, with no pain!
For me, working with A was challenging because there was no “quick fix” – it was hard work for A, her family, and me. It is difficult to watch children be in pain. But, as the opioid epidemic has shown, throwing medications at the problem can sometimes cause more harm than good. Working with A and other children with chronic pain has taught me about the importance of multidisciplinary teamwork. We are all working together to help our patients thrive.
Eccleston C, Malleson P. Managing chronic pain in children and adolescents. BMJ 2003; 327: 1408–1409.
Bromberg MH, Connelly M, Anthony KK, Gil KM, Schanberg LE. Self-reported pain and disease symptoms persist in juvenile idiopathic arthritis despite treatment advances: an electronic diary study. Arthritis Rheumatol 2014; 66: 462–469.
Carter BD, Threlkeld BM. Psychosocial perspectives in the treatment of pediatric chronic pain. Pediatr Rheumatol Online J 2012; 10: 10–15.
Giancane G, Alongi A, Rosina S et al. Open issues in the assessment and management of pain in juvenile idiopathic arthritis. Clin Exp Rheumatol 2017; 107: 123–126.
Noll RB, Kozlowski K, Gerhardt C et al. Social, emotional, and behavioral functioning of children with juvenile rheumatoid arthritis. Arthritis Rheum 2000; 43: 1387–1396.