158 Pain Amplification Syndromes

Pain is a common presenting complaint in the pediatrician’s office. As many as 30% of children and adolescents experience significant muscular fatigue and chronic or recurrent musculoskeletal pain. The symptoms have many causes and the differential in children includes infectious and metabolic conditions, growing pains, overuse injuries, hyperextensibility, orthopedic problems, arthritis, and genetic syndromes. Pain Amplification Syndromes are rarely recognized or diagnosed in a timely fashion by the primary care physician. These syndromes are characterized by a lack of physical or laboratory findings. Typically the child describes the pain as maximal (on a pain scale of 10/10). There is disability out of proportion to the physical findings, a sensation of pain to non-painful stimuli, psychological distress, an inappropriate indifferent affect (La Belle indifference), a significant family history of disability or chronic pain, and the presence of multiple somatic complaints. Indeed, the degree of pain and disability in these groups is strikingly high compared to children with Juvenile Idiopathic Arthritis or other classical rheumatic conditions where joint disease is readily demonstrable. Given the lack of a diagnostic test and variability of presentation, as well as a large number of potential etiologies, Pain Amplification Syndromes have been called by many synonyms, despite the possibility that they all represent variations of a common process. Generalized pain syndromes include fibromyalgia, fibrositis, myofascial pain syndrome, pain amplification syndrome, and diffuse wide spread myofascial pain, while localized pain syndromes have been called reflex sympathetic dystrophy, reflex neurovascular dystrophy, causalgia, and Sudeck’s atrophy. Some authors suggest that the precise classification in children with pain and fatigue is not necessary because overlap in clinical presentation is frequent and all children with pain syndromes respond to a similar treatment programs.