Prognosis of non-specific musculoskeletal pain in preadolescents: a prospective 4-year follow-up study till adolescence

Musculoskeletal pain is common in children but studies on the outcome and predictive factors for persistence/recurrence of these symptoms are scarce. A baseline cross-sectional survey of 1756 schoolchildren (mean age 10.8) identified 564 (32.1%) children with musculoskeletal pain. At baseline, these children were evaluated using a structured questionnaire and examined for hypermobility and physical fitness. The children were re-evaluated after one year, and four years (at adolescence) using the same pain questionnaire. At 1-year follow-up, 53.8% (95% CI 48.8–58.8) of the children reported pain persistence (persistent preadolescent musculoskeletal pain). At 4-year follow-up, 63.5% (95% CI 58.7–68.1) of them had musculoskeletal pain. Neck was the site with most persistent/recurrent musculoskeletal pain. Those with persistent preadolescent musculoskeletal pain had approximately three times higher risk of pain recurrence (OR=2.90 [95% CI 1.9–4.4]). In the univariate analysis, female gender, older age group (11+), hypermobility, co-existence of psychosomatic symptoms, having high disability index, and reporting combined musculoskeletal pain at baseline predicted pain recurrence at adolescence. In the multivariate analysis, age, headache, hypermobility and having combined musculoskeletal pain were found as independent predictors. Statistically significant sex interactions were found for age, depressive feelings, waking up during nights and hypermobility. More psychosomatic symptoms predicted pain recurrence in girls than in boys, and hypermobility was a strong predictor in females only. Musculoskeletal pain in preadolescents is not a self-limiting phenomenon and more studies are still warranted to explore its determinants aiming to improve the long-term outcome of these symptoms.     

The effect of standard care, ibuprofen, and distraction on pain relief and patient satisfaction in children with musculoskeletal trauma.

INTRODUCTION: The purpose of this study was to determine the effectiveness of nursing interventions in decreasing pain for children with minor musculoskeletal trauma and moderate pain and to examine patient satisfaction. METHODS: Children were assigned to 1 of 3 intervention groups: (1) standard care (ice, elevation, and immobilization) only; (2) standard care and ibuprofen; or (3) standard care and distraction. Children were monitored for pain ratings for 60 minutes. Children who sustained minor musculoskeletal trauma within the past 24 hours and presented with pain ratings of 2 or greater using the 0-5 Wong/Baker faces scale were included. Two patient satisfaction questions were asked of parents upon their child's discharge from the emergency department. RESULTS: A statistically significant decrease in pain for all patients (76) occurred at 30 minutes (F = 4.39, P <.05) and was maintained at 60 minutes. The distraction group demonstrated a statistically significant reduction in pain compared with the other groups at 30 minutes; this reduction was maintained at 60 minutes (F = 47.07, P <.05). Parents of only 6 children expressed dissatisfaction with overall pain management. Twelve percent of children who were not in the group receiving medication received analgesics while in the emergency department. At discharge, only 37% of children with fractures and/or sprains had received medications for pain. DISCUSSION: Children with musculoskeletal trauma may be under-medicated. Distraction techniques can be an effective adjunct to analgesia for children with musculoskeletal pain in the emergency department and should be made available. Ibuprofen may not be an effective analgesic for children with these injuries; stronger analgesics may be required.     

The ergonomics of caring for children: an exploratory study.

BACKGROUND: Caring for one's children is among the most ubiquitous of occupations. However, few studies have examined the ergonomic risks involved in parents caring for children at home. PURPOSE: The purpose of this study was to identify the frequency, type, and severity of musculoskeletal symptoms in parents of children less than 4 years old. The study further examined the factors that contribute to musculoskeletal pain in this sample. METHODS: A convenience sample of 130 parents with children younger than 4 years old completed a seven-page survey that included questions related to the parents' demographics, their musculoskeletal discomfort, their performance of child-care tasks with high biomechanical risks (such as carrying a child in a car seat), and parents' perceived psychological strain related to caring for their children. RESULTS: Ninety-two percent (92%) of the providers were mothers. Sixty-six percent (66%) of the sample reported the presence of musculoskeletal pain. The parts of the body most affected were the low back (48%), neck (17%), upper back (16%), and shoulders (11.5%). Factors associated with musculoskeletal pain were performing child-care tasks defined as having high biomechanical risks (p = .001), the perception that caring for children is highly demanding (p = .003), and performing hobbies less than 1 hour per week (p = .04). Parents' working status, age, and participation in other daily activities were not significantly related to musculoskeletal discomfort. CONCLUSION: This study demonstrates the high prevalence of musculoskeletal pain in parents of children under the age of 4 years. It underscores the association between physical and psychological factors in the development of musculoskeletal discomfort. It suggests the need for occupational therapy wellness programs that focus on preventing musculoskeletal discomfort and providing support for the parenting role.     

Musculoskeletal complications of neuromuscular disease in children

A wide variety of neuromuscular diseases affect children, including central nervous system disorders such as cerebral palsy and spinal cord injury; motor neuron disorders such as spinal muscular atrophy; peripheral nerve disorders such as Charcot-Marie-Tooth disease; neuromuscular junction disorders such as congenital myasthenia gravis; and muscle fiber disorders such as Duchenne's muscular dystrophy. Although the origins and clinical syndromes vary significantly, outcomes related to musculoskeletal complications are often shared. The most frequently encountered musculoskeletal complications of neuromuscular disorders in children are scoliosis, bony rotational deformities, and hip dysplasia. Management is often challenging to those who work with children who have neuromuscular disorders.     

Depression and functional disability in chronic pediatric pain.

OBJECTIVES: The primary aim of this study was to describe pain characteristics, coping strategies, depression, and functional disability in children and adolescents with chronic pain and to examine potential factors that are associated with functional disability in a pediatric pain population. The secondary aim of this study was to compare functional disability in two chronic pain conditions: localized musculoskeletal pain and chronic daily headaches. SUBJECTS: The participants in this study were 73 pediatric pain patients with a variety of chronic pain conditions. Subjects in the second part of the study were a subset of patients (N = 44) from the pain clinic sample with chronic localized musculoskeletal pain and a subset of patients (N = 38) from the headache center of the same hospital who had chronic daily headaches. DESIGN: Patients completed self-report measures of pain intensity, depression, coping strategies, coping efficacy, and functional disability. RESULTS: Results indicated that chronic pain had a substantial impact on the children's lives and that depression was strongly associated with functional disability. Maladaptive coping was correlated with depression and disability; however, maladaptive coping was not independently associated with functional disability. A comparison between the two groups found significant differences in pain intensity and functional disability. The localized musculoskeletal pain group reported higher levels of disability and more difficulty coping than the chronic daily headache group. CONCLUSIONS: The implications for treatment of chronic pain in children are discussed with an emphasis on greater attention to developmental issues and their relation to coping, emotional functioning, and disability in pediatric pain. Further research examining differences in coping and disability between different pediatric pain groups is also warranted.     

Myofascial low back pain: a review

Myofascial pain syndrome is a common nonarticular local musculoskeletal pain syndrome caused by myofascial trigger points located at muscle, fascia, or tendinous insertions, affecting up to 95% of people with chronic pain disorders. Clinically, myofascial pain syndrome can present as painful restricted range of motion, stiffness, referred pain patterns, and autonomic dysfunction. The underlying cause is often related to muscular imbalances, and following a thorough physical examination the condition should be treated with a comprehensive rehabilitation program. Additional treatment options include pharmacologic, needling with or without anesthetic agents or nerve stimulation, and alternative medicine treatments such as massage or herbal medicines. Repeated trigger point injections should be avoided, and corticosteroids should not be injected into trigger points.     

Botulinum toxin A and musculoskeletal pain]

INTRODUCTION: Relaxant muscle properties and pain relieve effectiveness in neurological spasmodic disorders of botulinum toxin A (BTXA) suggested its relevance to relieve musculoskeletal pain. The aim of this article was to collect literature data and to assess the different analgesia indications of BTXA proposed in the treatment of musculoskeletal pains. METHOD: The international literature was carried out with the Medline data bank using keywords toxin and pain. Only clinical trials have been analysed. RESULTS: Three hundred and seventeen articles were collected and 12 clinical trials were retained. They are focused on 4 chronic diseases, neck pain, tennis elbow, Piriformis syndrome and low back pain. Results of the 6 chronic neck pain studies are contradictory and emphasize the difficulty to display a satisfactory analgesia effect of BTXA in this indication. Results of the studies concerning other indications (tennis elbow, Piriformis syndrome and low back pain) seem to be more effective and clinically pertinent. DISCUSSION: Analgesia BTXA effect seems to be conditioned by the presence of an objective muscular spasm or stringy disease inducing musculoskeletal pain. CONCLUSION: The first data concerning use of BTXA to treat musculoskeletal pains are few and are worth specifying by other studies.     

A systematic review of posture and psychosocial factors as contributors to upper quadrant musculoskeletal pain in children and adolescents

Musculoskeletal pain has become a major symptomatic complaint among children and adolescents and is increasingly occurring at a younger age. This systematic review was done to evaluate the evidence for the contribution of posture and psychosocial factors to the development of upper quadrant musculoskeletal pain in children and adolescents. The review describes the measurement tools used to assess musculoskeletal pain, sitting posture, and psychosocial factors. Two independent reviewers searched seven databases for observational studies that included prospective and cross-sectional study designs. Ten studies were extracted and assessed by two reviewers using the Critical Appraisal Form-Quantitative Studies (Law et al, 1998). The studies measured upper quadrant musculoskeletal pain as an outcome measure. Five studies evaluated sitting posture and found an association between the duration of static sitting and upper quadrant musculoskeletal pain. Six studies measured psychosocial factors of which depression, stress, and psychosomatic symptoms were the factors most commonly found to influence the development of upper quadrant musculoskeletal pain. The eligible studies used different pain measurement tools and different measurement tools to assess sitting posture and psychosocial factors. This review concludes that the duration of sitting posture and psychosocial factors may influence the experience of musculoskeletal pain among children and adolescents.     

Botulinumtoxin A in der orthopädischen Schmerztherapie

Botulinum toxin A (BTX A) has been used for more than 20 years as a safe and effective treatment for numerous diseases characterized by pathological muscle hypertension. In patients suffering from dystonia or spasticity, it has been observed that use of BTX A results not only in muscle relaxation but also frequently relieves associated pain. This pain relief is often seen earlier and to a much greater extent than the muscular relaxation itself. This has led to extending the use of BTX A to treat various focal pain syndromes. The results of initial studies in specific musculoskeletal pain therapy suggest that BTX A infiltrations are effective in the treatment of chronic, therapy-resistant pain of the shoulder and back region. Furthermore, BTX A has been found to be a less invasive option for the treatment of chronic epicondylitis and similar tendonitis conditions. The healing process following rupture of tendons or muscle transfer operations may be improved. In adults with increased muscle tone and endoprostheses, the targeted relaxation of spastic muscles might increase the lifetime of the implant and diminish aseptic loosening. In children with cerebral palsy, prophylactic treatment of hip luxation appears possible. The doses used in pain therapy are low; if correctly applied, the tolerance and safety are high and the effect lasts for a number of weeks.     

Bilateral dorsal foot pain in a young tennis player managed by neurodynamic treatment techniques

Exercise-related lower limb pain represents one of the most common presentations in sports medicine practice. This is usually caused by musculoskeletal overuse injuries but not uncommonly, a neuropathic cause may be suspected. A review of the literature revealed that peripheral neuropathic pain has never been documented in a child. It is possible that peripheral neuropathic pain of spinal origin may be more prevalent in children than previously recognized. This case report describes the presentation of a 12 year old tennis player with bilateral dorsal foot pain, who presented with positive findings of peripheral nerve sensitization which was successfully managed using neurodynamic treatment techniques. Differential diagnoses are considered and treatment and management described. A discussion of the clinical reasoning which led to the patient’s diagnosis is included. This case report suggests the effectiveness of neurodynamic treatment in a child with bilateral foot pain who fulfilled published criteria for peripheral nerve sensitization. However, the single case methodology employed in this study limits generalization of its findings. Further studies are warranted to investigate the role of neurodynamics in musculoskeletal pain disorders in children.     

Extracephalic tenderness and pressure pain threshold in children with headache

Background Sensitisation of the pain detection system has been suggested to be involved in the pathogenesis of recurrent headache. In adults, increased sensitivity to pain has been found in patients with chronic tension type headache. Children with migraine or with unspecific headache report non‐headache pains and interictal pericranial muscular tenderness more often than headache‐free children. Objective To study if children with different types of headache report non‐headache pain more often than children with no headache and if extracephalic muscular tenderness is different in children with headache in comparison to headache‐free children. To find out if interval to the headache episode has influence on the extracranial muscular tenderness. Design A population‐based sample of 13‐year‐old children with migraine (n = 48), episodic tension type headache (61) or no headache (59) were interviewed for the occurrence and characteristics of headache and fulfilled a questionnaire on non‐headache pain. A structured manual palpation test on muscular tenderness and a pain threshold measurement were done on seven cephalic and three extracephalic points. Results Children with migraine reported other pains, especially stomach pain and limb pain more often than children with episodic tension type or no headache. There were no significant differences in the extracephalic muscular tenderness or in the pressure pain thresholds between the three groups. Conclusions Children with migraine experience more non‐headache pains than children with episodic tension type headache and with no headache. However, neither children with migraine nor children with episodic tension type headache show increased interictal extracephalic muscular sensitivity for palpation.     

Preliminary evaluation of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain

Purpose. To describe the outcome of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain.

Methods. Study design: exploratory retrospective cohort study. The study sample consisted of a cohort of 70 children and adolescents (age: 8 - 21 years) with chronic musculoskeletal pain who completed a 3-month inpatient multidisciplinary pain management program. The program consisted of graded physical exercises, graded activities and counseling of the children and their parents. Assessed were motor and social activities, pain intensity, global assessment of physical functioning and psychosocial well-being (by patient and physician), understanding of the pain process and reduction of medical consumption. Assessments were performed at pre-admission, day of admission, day of discharge and at three months after discharge. Data collection took place over a 10-year period.

Results. Compared to admission, at discharge there were significant improvements in motor performances, school attendance, reduction of pain scores, understanding of the chronic pain process and reduction of medical consumption. Results remained stable at follow-up after three months.

Conclusion. The results of this study indicate that a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain may be effective.     

Chronic musculoskeletal pain and functional status in juvenile rheumatoid arthritis: an empirical model

An empirical model is proposed and tested on variables hypothesized to influence functional status in 23 children with juvenile rheumatoid arthritis experiencing chronic musculoskeletal pain. Child psychological adjustment, family psychosocial environment, chronic musculoskeletal pain, and disease activity were entered into multiple regression analyses to statistically predict 4 functional status criterion variables: activities of daily living (ADL), activities involvement, school functioning, and social functioning. Predictor variable relationships were found for all 4 functional status criterion variables, suggesting initial support for this empirical model of functional status in children with juvenile rheumatoid arthritis experiencing chronic musculoskeletal pain.     

Posturale Aspekte der Schmerztherapie des Bewegungssystems

In pain therapy of the musculoskeletal system postural cybernetics do not always receive the necessary attention. The functional muscular pathology which presents in the clinical practice is accompanied by painful muscle imbalance and functional movement limitations. The most common cause of pain can be observed in a change of intensity of stabilizing synergistic muscle activation in postural reactions. These stabilizing activities, which serve as suitable benchmark settings, develop according to systematic laws of postural ontogenesis. Insufficient benchmark settings of the target motor activity within the scope of postural dysfunction reveal the causality of the painful functional pathology of muscle tone. Knowledge of postural ontogenesis is a requirement for each form of therapy for pain of the locomotor system. If the reason for painful strains of muscle fibers is not known, structural or psychogenic causes are suspected of being the underlying mechanism behind many painful conditions. The lack of attention to postural stabilization often causes treatment failure and may promote chronic manifestation of the pain.     

Physical therapy in the treatment of chronic headache

Careful evaluation of the chronic headache patient can reveal the presence or absence of musculoskeletal factors to be causative or contributory to the headache condition. This article presents a review of the literature surrounding physical findings in patients with cervicogenic and musculoskeletal sources of pain and specific treatment with physical therapy. Included in the discussion is the identification of muscular and joint involvement in a given headache, the relevance of postural, range of motion, and strength deficits, and appropriate individualized treatment strategies with a review of relevant outcome studies. Possible mechanisms for treatment effects also are considered.     

Douleurs chroniques de l’enfant: les pièges à éviter

Chronic pain in children or adolescents (abdominal, muscular or articular pains and chronic daily headaches) are frequently associated with a major handicap, school absenteism and isolation, at the very moment when they do not receive organic explanation. The classic medical approach, seek for diagnosis with explorations and treatment of the cause is not successful. It is necessary to clearly establish the diagnosis of unexplained pain, and to approach at once with the child and its family the psychological investigation (context of life, concerns and conflicts) at the same time as the physical exam. The objective is to obtain the beginning of activities, in spite of the pain. The psychological therapies, such as hypnosis, are the most effective.     

Chest pain in children

Although chest pain in children is usually not due to serious organic pathology, its association with heart disease is a source of concern for patients and their families. Most cases of pediatric chest pain are of unknown etiology. Common diagnoses include musculoskeletal disorders, cough, costochondritis, psychogenic disturbance and asthma. A thorough history and a careful physical examination will determine the diagnosis in most children.     

Central mechanisms in the maintenance of chronic widespread noninflammatory muscle pain

Chronic widespread pain (CWP) conditions such as fibromyalgia and myofascial syndromes are characterized by generalized pain, tenderness, morning stiffness, disturbed sleep, and pronounced fatigue. However, CWP pathophysiology is still unclear. A number of hypotheses have been proposed as the underlying pathophysiology of CWP: muscular dysfunction/ischemia, central sensitization, and a deficit in endogenous pain-modulating systems. This article reviews the current and emerging literature about the pathophysiology and neurobiology of chronic widespread musculoskeletal pain. Widespread musculoskeletal pain results in changes in the central nervous system in human subjects and animal models. These changes likely reflect alterations in supraspinal modulation of nociception, and include increases in excitatory and decreases in inhibitory modulation pathways. These alterations in excitation and inhibition likely drive changes observed in the spinal cord to result in central sensitization, and the consequent pain and hyperalgesia.     

Besteht ein Zusammenhang zwischen Rückenschmerz und der Stabilit?t der lumbalen Wirbels?ule in der Schwangerschaft?

During pregnancy approximately 50% of women suffer from low back pain (LBP), which significantly affects their everyday life. The pain could result in chronic insomnia, limit the pregnant women in their ability to work and produce a reduction of their physical activity. The etiology of the pain is still critically discussed and not entirely understood. In the literature different explanations for LBP are given and one of the most common reasons is the anatomical changes of the female body during pregnancy; for instance, there is an increase in the sagittal moments because of the enlarged uterus and fetus and the occurrence of hyperlordosis.The aim of this study was to describe how the anatomical changes in pregnant women affect the stability and the moments acting on the lumbar spine with the help of a simplified musculoskeletal model.A two-dimensional musculoskeletal model of the lumbar spine in the sagittal plane consisting of five lumbar vertebrae was developed. The model included five centres of rotation and three antagonistic pairs of paraspinal muscles. The concept of altered acting torques during pregnancy was explored by varying the geometrical arrangements. The situations non-pregnant, pregnant and pregnant with hyperlordosis were considered for the model-based approach. These simulations were done dependent on the stability of the erect posture and local countertorques of every lumbar segment.In spite of the simplicity of the model and the musculoskeletal arrangement it was possible to maintain equilibrium of the erect posture at every lumbar spinal segment with one minimum physiological cross-sectional area of all paraspinal muscles. The stability of the musculoskeletal system depends on the muscular activity of the paraspinal muscles and diminishing the muscular activity causes unstable lumbar segments.The relationship between the non-pregnant and the pregnant simulations demonstrated a considerable increase of acting segmental countertorques. Simulating an increased lordosis for the pregnant situation in the sagittal plane substantially reduced these acting countertorques and therefore the demand on the segmental muscles.It is assumed that hyperlordosis is a physiological adaptation to the anatomical changes during pregnancy to minimize the segmental countertorques and therefore the demand on the segmental muscles.Further, it can be expected that an enhanced muscle activity caused by selective activity of lumbar muscles increases the stability of the lumbar spine and may improve the situation with LBP during pregnancy.