Pain Syndromes
Characteristics of Non-inflammatory Disease
 Ask yourself the following questions:
o Is this a systemic inflammatory rheumatic syndrome?
o Does this represent rheumatic symptoms of an endocrinopathy? (Patients with
hypothyroidism can present with diffuse and nonspecific arthralgias and myalgias. CKs may be
elevated)
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o Is this a toxic/drug reaction?
o Is this a generalized soft-tissue pain syndrome?
General PE is unremarkable
o Diffuse muscle tenderness is noted, but no objective muscle weakness
o Some tenderness around the joints, but no synovitis
o Normal neurologic examination
CBC, ESR, and chemistry profile are normal
Characteristics of Inflammatory Disease
 History
o Associated with significant morning stiffness (>45 min)
o Pain often better with movement
o Insidious onset of the pain
 Duration of symptoms is important for diagnosis
o <6 months = may be early rheumatic disease
o 1 year = diagnostic clinical signs and lab abnormalities usually present
o >2 years = abnormalities almost always present
 Physical exam
o Objective findings of inflammation (swelling, erythema, warmth, detectable joint
fluid)
o Muscle weakness and other focal neurologic abnormalities
 Laboratory studies
o ESR and C-reactive protein are indicators of generalized inflammation
o Autoantibodies can be helpful in selected cases
o Organ specific tests can suggest internal organ involvement (LFTs, renal function
tests, muscle-specific enzymes)
MECHANICAL PAIN SYNDROMES
LIMB PAINS OR “GROWING PAINS” OF CHILDHOOD
 Age 4 to 13 years
 Lower extremities>>upper
 Nocturnal>>daytime
 Calves, thighs or shins>>joints
 No pattern of recurrence, but ? association with daytime activity
 Girls>boys
 Respond to heat, massage or mild analgesia (tylenol, motrin)
 No lab or X-ray findings
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Fine in morning
PATELLO-FEMORAL SYNDROME
 Female>male
 Age at onset 11-13 years
 Knee pain--grating, catching, instability
 Pain increased with descending stairs, squatting, kneeling, running
 Unable to sit for long periods without extending knee
 Physical findings--crepitance, +patellar apprehension test, patellar compression test
BENIGN HYPERMOBILITY SYNDROME
• Carter and Wilkinson Score
– Extend little finger > 90 degrees (1 point each)
– Bring back thumb parallel to touch forearm
– Hyperextend elbow > 10 degrees
– Hyperextend knee > 10 degrees
– Touch floor with flat of hands, legs straight
• Score > 6 equals hypermobility (max = 9)
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Up to 10% of normal population
Arthralgias common
Injuries common (dislocation of affected joints, back pain, meniscal and tendon injuries)
Increased incidence of mitral valve prolapse
Genetically determined
?Generalized laxity of tissues?
Ehlers-Danlos syndrome type 3?
CENTRALLY MEDIATED PAIN SYNDROMES/
GENERALIZED SOFT TISSUE PAIN SYNDROMES
Evidence for central desensitization:
 Neurophysiologic testing reveals abnormal nociceptive processing
 Dysautonomia
 Increased (3X) substance P in CSF
 Regional modulation in CNS blood flow in hemithalami, caudate nuclei, pontine
tegmentum
 Abnormal summation of pain signals “wind-up”
 Abnormal somatomedin, prolactin and cortisol stress response
Fibromyalgia, Myofascial pain syndrome, Irritable bowel syndrome, Migraines, Tension
headaches, TMJ disorder, Irritable bladder, interstitial cystitis all related as a centrally mediated
pain syndrome
MYOFASCIAL PAIN
 Localized, muscular pain
 No generalized aching, stiffness of fatigue
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Responds to local therapy
COMPLEX REGIONAL PAIN SYNDROME (CRPS)
 Age: prepubertal through early to mid adolescence
 Females>males
 One or more extremities may be involved
 Diagnosis requires the presence of physical abnormalities including temperature and
color changes or swelling (autonomic signs)
 Diffuse exquisite pain to light touch (allodynia) and severe dysfunction are hallmarks
 Frequently see high-achieving, perfectionistic children with close (enmeshed?) family
units
FIBROMYALGIA SYNDROME
 Widespread musculoskeletal pain, aching, stiffness
 Decreased pain threshold and tolerance
 May have tenderness in specific regions (tender points)
 Associated fatigue, sleep, somatic complaints
 No objective inflammation seen on physical examination
 Normal laboratory findings
 Occurs in prepubertal, pubertal and adolescents
 Females>>>males
 Parasthesias, headaches, depression and anxiety
 Treatment
o active physical therapy/ conditioning exercises- to increase function in spite of
pain not to eliminate pain.
o NSAIDs, amitriptyline, but duration of response to pharmacological agents is
usually limited
Fibromyalgia Tender Points
 11 out of 18 tender points
 Control points – thumb-nail, mid-forearm, and forehead
MAJOR DEPRESSION WITH MUSULOSKELETAL PAIN
 Significant depression is seen in
o 49% of patients with chronic soft-tissue pain
o 37% of patients with rheumatoid arthritis
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o 33% of patients with osteoarthritis
Depression is associated with increased pain levels in arthritis
Depression is more prevalent with loss of valued activities
SOMATOFORM PAIN DISORDERS
 Chronic pain that cannot be explained by a known general medical condition
 These nonintentional symptoms cause significant distress and impairment of social,
occupational, and functional activities
 Psychological factors play a role in the onset, severity, or maintenance of the pain
 Somatoform disorders are commonly seen (15%) and nonrecognized (71%) in the
primary-care setting
Have a high index of suspicion for the presence of amplified musculoskeletal pain especially in:
 Adolescent girls who are mature beyond years, accomplished, perfectionistic pleaser
 Prolonged school absence due to pain
 Marked dysfunction
 Pain is continuing to worsen
 Normal examination except pain (no enthesitis or arthritis, normal neurological exam)
 Localized or widespread pain on examination
o Allodynia (variable border)
o Autonomic signs
o Incongruent affect (la belle indifference)
o Multiple painful points
o Nonorganic back signs
 Failure of all prior therapies
Once an amplified musculoskeletal pain syndrome is recognized
 Acknowledge the pain and explain that it is amplified, not indicative of underlying
damage or disease
 Stop further medical investigations and stop medications
 Restore function
o Aerobic exercise up to 5 h/day of intense tx focused on functional activities that
may take 2-3 weeks
o If allodynia is present, desensitize with tactile stimulation
o Resume full school attendance
o Resume social and recreational activities
 Have psychological dynamics evaluated and treated: stress management, coping skills
Key Points
 Early diagnosis—the pediatrician’s job
 Confidence of diagnosis
 Clear, concrete plan of treatment
 Patient/family/treating team/payer in full support of plan