Recurrent Musculoskeletal Pain Research Articles

Patient values in physiotherapy practice, a qualitative study.

ObjectivesPhysiotherapy is, like all healthcare professions, relational and value‐laden. Patient‐centred care, evidence‐based practice and value‐based practices are concepts in which patient values lie at the heart of high‐quality healthcare practices. Nevertheless, physiotherapists have limited awareness of what patient values are in the physiotherapy encounter. The purpose of this study is to explore these patient values.MethodsA qualitative study design using content analysis was used involving 17 adult participants with chronic or recurrent musculoskeletal pain. Data were collected during July 2015–July 2016 in three primary care physiotherapy facilities in Rotterdam, The Netherlands. Two researchers analysed the interviews and derived relevant codes from the data. After an iterative process of comparing, analysing, conceptualizing, and discussing the data, a pre‐existing analytic framework was refined in which distinct values were delineated.ResultsEmerging patient values were encompassed in three themes, each consisting of two to four elements: (1) values about oneself (uniqueness and autonomy), (2) values regarding actions of the professional (technically skilled professional, conscientious professional, compassionate professional, responsive professional) and (3) values regarding interactions between patients and the professionals (partnership and empowerment).ConclusionThis study emphasizes the need for discussing patient values in the clinical encounter and helps physiotherapists to understand what deems to be important for patients with musculoskeletal pain in physiotherapy practice. The results of this study contribute to the existing body of knowledge of this important aspect of the quality of physiotherapy practice and may inspire clinicians and educators to actively implement patient values in clinical practice and the physiotherapy education.

Risk severity moderated effectiveness of pain treatment in adolescents

Background and aims A targeted pain program may prevent the progression and subsequent occurrence of chronic pain in adolescents. This study tested the effectiveness of a new acceptance and commitment therapy -based pain management intervention, using physical and psychological functions as the outcomes. The objective was also to determine whether Pediatric Pain Screening Tool risk profiles function as outcome moderator in the current sample. A valid screening tool would enable the program development. Methods Thirty-two consecutive adolescent patients (13-17 years old) with idiopathic recurrent musculoskeletal pain completed the study. The intervention comprised acceptance and commitment therapy-oriented multidisciplinary treatment. Pediatric Pain Screening Tool, pain frequency, functional disability, school attendance, physical endurance, depressive symptoms, and catastrophizing coping style were measured before treatment (baseline) and again at 6 and 12 months after the initiation of treatment. To test the effectiveness of the new program, we also determined whether the original risk classification of each patient remained constant during the intervention. Results The intervention was effective for high-risk patients. In particular, the pain frequency decreased, and psychosocial measures improved. In post-intervention, the original risk classification of seven patients in the high-risk category changed to medium-risk. PPST classification acted as a moderator of the outcome of the current program. Conclusions The categorization highlighted the need to modify the program content for the medium-risk patients. The categorization is a good tool to screen adolescent patients with pain. Implications The results support using the Pediatric Pain Screening Tool in developing rehabilitation program for pediatric musculoskeletal pain patients. According to the result, for adolescent prolonged musculoskeletal pain patients the use of ACT-based intervention program is warranted.

Approach to Growing Pains in Childhood in a Familial Mediterranean Fever Endemic Region

: Growing pain, still preserving its charm, is the most common form of recurrent musculoskeletal pain in childhood. Approach to diagnosis requires significant care in geographical regions with familial Mediterranean fever (FMF) endemicity. We discuss data and a current approach to growing pains in children in an FMF endemic region. The symptomatology may be confused with different diseases. Although unnecessary tests may be performed to reach diagnosis, sometimes patients may be misdiagnosed as having growing pain without revealing the primary underlying pathology. Definite algorithms are not developed for diagnosis of growing pains. Diagnosis is mainly based on typical clinical features of the condition. However laboratory tests and imaging methods may be used for diagnosis and differential diagnosis especially in atypical course suggesting diseases such as inflammatory ones or malignancies. Vitamin D deficiency should be investigated to give supplementation if necessary. Some helpful algorithms may be used in evaluation of patients. In order to evaluate myalgia as growing pain in areas where FMF is endemic, fever, abdominal pain, elevated acute phase reactants and history of FMF and/or amyloidosis in family should be carefully excluded. It is important to inform parents about the alarming symptoms of extremity pain and when to urge medical advice again.

Effect of vitamin D supplementation in chronic widespread pain: a systematic review and meta-analysis.

Chronic non-specific widespread pain (CWP) including fibromyalgia (FMS) is characterized by widespread pain, reduced pain threshold, and multiple tender points on examination, causing disability and decreased quality of life. Vitamin D has been proposed as an associated factor in CWP. This meta-analysis aimed to explore the benefit of vitamin D supplementation in the management of CWP. A comprehensive search of the CENTRAL, MEDLINE, and Embase databases was performed from inception through January 2017. The inclusion criterion was the randomized clinical trials' evaluating the effects of vitamin D treatment in adult subjects with CWP or FMS. CWP was defined as chronic recurrent musculoskeletal pain without secondary causes; FMS patients met the American College of Rheumatology criteria for FMS. Study outcome was assessed using visual analog scale (VAS) of pain intensity. Pooled mean difference (MD) of VAS and 95% confidence interval (CI) were calculated using a random-effect meta-analysis. Meta-regression analysis using a random-effects model was performed to explore the effects of change in vitamin D in the treatment group on difference in the mean of VAS. Sensitivity analysis was performed to evaluate the robustness of results. The between-study heterogeneity of effect size was quantified using the Q statistic and I 2. Data were extracted from four randomized controlled trials involving 287 subjects. Pooled result demonstrated a significantly lower VAS in CWP patients who received vitamin D treatment compared with those who received placebo (MD=0.46; 95% CI 0.09-0.89, I 2=48%). Meta-regression analysis revealed no significant relationship between the changes of vitamin D and VAS (coefficient=0.04 (95% CI -0.01 to 0.08), p=0.10). In this meta-analysis, we conclude that vitamin D supplementation is able to decrease pain scores and improve pain despite no significant change in VAS after increasing serum vitamin D level. Further studies need to be conducted in order to explore the improvement of functional status, quality of life, and the pathophysiological change that improves chronic widespread pain.

Hypermobility: A Cause of Joint Pain in Children and Adolescents

Hypermobility: A Cause of Joint Pain in Children and Adolescents

Associations between recurrent musculoskeletal pain and visits to the family doctor (GP) and specialist multi-professional team in 74 Norwegian youth with cerebral palsy.

Musculoskeletal pain in cerebral palsy (CP) is common, but probably undertreated. The aim of the study was to explore if recurrent musculoskeletal pain (RMP) related to the CP condition was associated with visits to the family doctor [general practitioner (GP)] and specialist habilitation centre in youth with CP. Seventy-four youth with CP (mean age 16.5 years, 40 boys) from the same geographical area were assessed by clinical examination, semi-structured interview on pain (adolescent and parent together), the two questions on pain from the Child Health Questionnaire (parents only) and a structured interview on health care services. Gross Motor Function Classification System was level I 39%, level II 23%, level III 8% and levels IV and V 30%. Thirty-five participants (47%) had visited their GP last year, and 49 (66%) had visited the specialist habilitation centre. The presence of RMP (n = 58; 78%) was not significantly associated with having visited the GP or the specialist habilitation centre. Still, in participants with RMP, increasing pain severity was associated with having visited the GP. Rest, massage, change of position and oral drugs were the most common measures taken to relieve RMP. Three adolescents with RMP did not take any measures to relieve pain. Youth with RMP do take measures to relieve pain, but usually not in the direction of consulting the health care services available unless the pain is severe. Both youth with CP and their caregivers should be encouraged to discuss RMP with their professional network of care.

When flexibility is not necessarily a virtue: a review of hypermobility syndromes and chronic or recurrent musculoskeletal pain in children.

Chronic or recurrent musculoskeletal pain is a common complaint in children. Among the most common causes for this problem are different conditions associated with hypermobility. Pediatricians and allied professionals should be well aware of the characteristics of the different syndromes associated with hypermobility and facilitate early recognition and appropriate management. In this review we provide information on Benign Joint Hypermobility Syndrome, Ehlers-Danlos Syndrome, Marfan Syndrome, Loeys-Dietz syndrome and Stickler syndrome, and discuss their characteristics and clinical management.

Self-reported mental health in youth with cerebral palsy and associations to recurrent musculoskeletal pain

Purpose: To explore self-reports on emotional, conduct, hyperactivity and peer problems and on prosocial behaviour in youth with cerebral palsy (CP), compare the reports to normative data and to mothers’ reports and to analyse if recurrent CP-related musculoskeletal pain (RMP) influence the self-reports. Methods: Eighty-one youth with CP (mean age 14.2 years, 40 boys) were assessed by clinical examination, interview and the questionnaire Strengths and Difficulties Questionnaire (SDQ) filled in by the youths and their mothers. Gross motor function (GMFCS) was: level I 43%, level II 41%, level III 12% and level IV–V 4%. Results: Compared to normative data, youth with CP reported similar levels of peer problems, less conduct problems (p < 0.01), less hyperactivity problems (p < 0.01) and more prosocial behaviour (p < 0.01). Compared to the mothers’ reports, youth with CP reported lower levels of peer problems (p < 0.01). Twenty-six boys (65%) and 28 girls (68%) had RMP. Girls, but not boys with RMP reported a higher level of peer problems (p = 0.02) than youth without RMP. Conclusion: Self-report on mental health in addition to parental proxy-report is important because it yields additional information. Peer acceptance and the impact of pain on peer problems and participation are candidate topics for further research.Implications for RehabilitationIn children and adolescents with CP, self-report on mental health and peer problems is warranted because they provide different information than proxy-report.Self-reported behaviour may be a starting point for counselling and interventions to improve peer acceptance in children and adolescents with CP.When exploring how pain related to CP influences the daily activities of the individual child or adolescent; health care providers should pay special attention to peer problems and female gender.

EMG Biofeedback and Exercise for Treatment of Cervical and Shoulder Pain in Individuals with a Spinal Cord Injury: A Pilot Study

Chronic or recurrent musculoskeletal pain in the cervical and shoulder region is a common secondary problem after spinal cord injury (SCI), reported by 30% to 70% of individuals. The purpose of this study was to investigate the effect of electromyographic (EMG) biofeedback training, in addition to a standard exercise program, on reducing shoulder pain in manual wheelchair users with SCI. Fifteen individuals with SCI, C6 or lower, who were manual wheelchair users with shoulder pain were randomly assigned to 1 of 2 interventions. The Exercise group (n = 7) received instruction on a standard home-based exercise program. The EMG Biofeedback plus Exercise group (n = 8) received identical exercise instruction plus EMG biofeedback training to improve muscle balance and muscle relaxation during wheelchair propulsion. Shoulder pain was assessed by the Wheelchair Users Shoulder Pain Index (WUSPI) at baseline, at posttest 10 weeks after the start of intervention, and at follow-up 16 weeks after posttest. The number of participants per group allowed only within-group comparisons; however, the findings indicated a beneficial effect from EMG biofeedback training. Shoulder pain, as measured by WUSPI, decreased 64% from baseline to posttest for the EMG Biofeedback plus Exercise group (P = .02). Shoulder pain for the Exercise group decreased a nonsignificant 27%. At follow-up, both groups showed continued improvement, yet the benefit of EMG biofeedback training was still discernible. The EMG Biofeedback plus Exercise group had an 82% reduction in shoulder pain from baseline to follow-up (P = .004), while the Exercise group showed a 63% reduction (P = .03) over the same time period. This study provides preliminary evidence that EMG biofeedback has value when added to an exercise intervention to reduce shoulder pain in manual wheelchair users with SCI. These findings indicate that EMG biofeedback may be valuable in remediating musculoskeletal pain as a secondary condition in SCI. This preliminary conclusion will need to be studied and verified through future work.

Parent‐reported participation in children with cerebral palsy: the contribution of recurrent musculoskeletal pain and child mental health problems

The aim of the study was to explore the contribution of recurrent musculoskeletal pain and mental health to aspects of participation in children with cerebral palsy (CP). A total of 105 participants (54 males, 51 females); mean age 14 y (SD 3) were assessed by clinical examination, interview, and parental questionnaires. CP type distribution was as follows: spastic unilateral, 37%; spastic bilateral, 56%; and dyskinetic, 7%. Motor function assessed using the Gross Motor Function Classification System was level I, 33%; level II, 40%; level III, 15%; and level IV/V, 11%. Parents reported child participation using the Assessment of Life Habits, child mental health problems using the Strengths and Difficulties Questionnaire, their own mental health using the General Health Questionnaire, and their socioeconomic status. Recurrent musculoskeletal pain was associated with reduced accomplishment of daily activities (B=-1.22, p=0.02) and social roles (B=-1.17, p=0.03), and with reduced parental satisfaction with the accomplishment of daily activities (B=-1.14, p=0.03) and social roles (B=-1.48, p<0.01). Increasing levels of child mental health problems was associated with reduced accomplishment of daily activities (B=-0.10, p=0.02) and social roles (B=-0.11, p<0.01), and with reduced parental satisfaction with the accomplishment of social roles (B=-0.21, p<0.01). Pain and child mental health should be considered in most participation models in CP. Regarding participation as an objective outcome measure is questionable.

Mental health, health related quality of life and recurrent musculoskeletal pain in children with cerebral palsy 8–18 years old

Purpose: To extend knowledge on mental health with children’s self-report and explore mental health and health related quality of life (HRQL) in a context of recurrent musculoskeletal pain in cerebral palsy (CP). Method: Eighty-three participants, mean age 14.2 ± 2.8 years, were assessed with clinical examination, interview and questionnaires. Gross motor function was GMFCS level I 42%, level II 42%, level III 12% and level IV–V 5%. Children self-reported mental health on SDQ (Strengths and Difficulty Questionnaire), HRQL on PedsQL (Pediatric Quality of Life), and pain on CHQ (Child Health Questionnaire). Mothers proxy-reported on the same questionnaires and reported own mental health on GHQ (General Health Questionnaire). Results: Both self-reported mental health and HRQL was better than proxy-reported. Recurrent musculoskeletal pain was associated with more mental health problems and reduced HRQL in self-reports, but not in proxy-reports. Conclusions: In CP, the importance of child-report on mental health and HRQL when possible, in addition to parent proxy-report, cannot be overstated. Close co-operation between (re)habilitation and child psychiatry is urgent. Further research on self-reported mental health and impact of mental health problems is warranted together with a focus on the impact of recurrent musculoskeletal pain on participation.Implications for RehabilitationChildren with cerebral palsy experience musculoskeletal pain that is associated with more self-reported mental health problems and lower HRQL.Because mothers tend to not recognise these associations, self-report (when possible) is essential.A bio-psycho-social perspective in both individual and family approach is important because of the associations mentioned and because parents report that their children have a high prevalence of mental health problems.Assessment of HRQL has the potential to capture both pain and mental health problems, and should be an integrated part of the systematic clinical follow-up.

Characteristics of recurrent musculoskeletal pain in children with cerebral palsy aged 8 to 18 years

The aim of this study was to explore the prevalence, predictors, severity, and impact of recurrent musculoskeletal pain in children and adolescents with cerebral palsy (CP). One hundred and fifty-three participants (81 males, 72 females) aged 8 to 18 years were assessed by clinical examination, interview, and questionnaires. CP type distribution was 38% unilateral spastic, 55% bilateral spastic, 6% dyskinetic, and 1% ataxic. Gross Motor Function Classification System (GMFCS) levels were as follows: level I, 54; level II, 56; level III, 20; level IV, 8; and level V, 15. Sixty-four children and 89 parents recorded pain on the Child Health Questionnaire, 56 children and 85 parents indicated impact of pain on 0 to 10 numeric rating scales, and 72 children indicated pain intensity on the Faces Pain Scale-Revised. Ninety-five (62%) children across all GMFCS levels experienced recurrent musculoskeletal pain. Age above 14 years was the only significant predictor (OR 2.90, 95% CI 1.22-7.80, p=0.02, adjusted for sex, CP type, gross motor function and mother's education). Children reported recurrent musculoskeletal pain to be moderate. Parents reported pain to be more severe and with higher impact on sleep than their children did. Children and parents reported similar impact of pain on general activity and walking. Recurrent musculoskeletal pain is the dominating pain problem in children and adolescents with CP. Monitoring of musculoskeletal pain should be part of the medical follow-up across the whole range of motor impairment.

Ergonomics related to seating arrangements in the classroom: Worst in South East Asia? The situation in Sri Lankan school children

Sri Lanka is a resource-poor country in the South-East Asian region with good health indices. Ergonomics of children in educational environments is still novel in the region. An exploration into such issues and dissemination of the scientific evidence will stimulate policy makers in both education and health sector. An important ergonomic issue of the classroom is the seating arrangement. Essential aspects of seating include location of the chair and desk in relation to the blackboard and features of the chair and desk. Musculoskeletal pain is considered to be the most important negative effect due to mismatched ergonomics. A school-based descriptive cross sectional study was carried out in a district of Sri Lanka to ascertain the distribution of selected ergonomic factors related to seating arrangements in the classroom of school-going early adolescents and to assess their relationship to musculoskeletal pain. A sample of 1607 school children of Grade 6,7 and 8 were selected using stratified multi-stage cluster sampling method. There were 52.1% (N=838) females and 47.9% (N=769) males. Many ergonomic aspects related to classroom seating arrangements are not conducive for children. Children were seated with a mean distance of 398.04 cm (SD=132.09) to the blackboard. Nearly 23% of children had to turn more than 45~degrees to see the blackboard. A prevalence of > 80% mismatch was found between body dimensions of children and measurements of furniture. Musculoskeletal pain may have resulted from efforts to maintain stability while seated in incompatible furniture. Nearly 36% children complained of recurrent musculoskeletal pain. Musculoskeletal pain may have resulted from efforts to maintain stability while seated in incompatible furniture. Mismatched seat depth - buttock-popliteal length posed 1.59 times risk recurrent musculoskeletal pain. Despite, children perceived a good chair comfort. Use of backrest lowered the risk of recurrent pain. Results shows that programme planners can utilize such evidence to provide simple ergonomic solutions at national and school level.

Reflex sympathetic dystrophy: a multidisciplinary approach.

Reflex sympathetic dystrophy (RSD) is a complex regional pain syndrome characterized by variable dysfunctions of the musculoskeletal, skin, and vascular systems. The most common features are severe persistent spontaneous pain in a limb, sensory and vascular alterations, and major associated disability, which often causes profound psychological dysfunction (1,2). RSD is characterized by spontaneous pain, swelling, dysaethesia, and allodynia usually of a distal site of the affected extremity (3,4). Other features relate to the autonomic nervous system and include cyanosis, mottling, sweating (which is less common in children), and reduction in temperature. In some cases, particularly if there is delay in recognition or treatment, more permanent or serious features may develop; these include muscle atrophy, demineralization of bone, and contractures of soft tissue around the affected joint. In the early stages of RSD, there are no specific laboratory tests available to help diagnose the condition, and the radiologic and bone scanning findings characteristic in adults are often not seen in children (5–9). The lack of diagnostic investigations, the relative lack of recognition of the condition, and the more variable clinical presentation present in children often result in a delay in diagnosis and treatment. This often is complicated by the diversity of medical opinions sought from the onset of symptoms. This may lead to a more severe and chronic presentation. Although a number of studies have reported RSD in childhood, a variety of approaches to its management have been suggested with variable or undetermined outcomes (10). RSDmay also occur in, or be associated with, a variety of other clinical conditions and may affect different areas of the body to a greater or lesser extent. There are also a variety of descriptive names that are used as synonyms for RSD, including algodystrophy, reflex neurovascular dystrophy, causalgia, Sudeck’s atrophy (although this refers to patients with the classic macular osteopenia, not often seen in children), and complex regional pain syndrome type 1 (2). In this article we prefer the older but perhaps still more commonly used term, RSD (11–13). Population studies in schoolchildren indicate that chronic or recurrent musculoskeletal pain is quite common, with back pain being the most frequent (20%), followed by limb pain (16%) and fibromyalgia (6%) (14–17). There is little work on the incidence of RSD, but 5–8% of new referrals to North American pediatric rheumatology centers have a diagnosis of idiopathic musculoskeletal pain syndromes, a small percentage of which are RSD (18,19). Idiopathic musculoskeletal pain syndromes have been described in patients as young as 3 years of age, though RSD has not been reported at this age. The majority of reports involve children in late childhood or early adolescence, with a mean age of onset of 12–13 years and a higher frequency in girls than boys ( 4:1) (3,4,13,20–22). There have been no reports of specific ethnic differences in the presentation of RSD. Currently, there is no single or specific biologic cause identified or pathogenetic pathway described for RSD, and it is clear that the clinical features may vary widely from children to adults. The etiology is likely to be multifactoral in some children. In many pediatric cases, however, there is no or only a very minor precipitating incident; psychological factors may have greater influence. This hypothesis is supported with the differences found between technetium bone scintigraphy in children compared with adults and by the fact that children respond more readily to physical therapies (4,23). However, it appears that the triggering factor in many children is related to injury, illness, or psychological distress in any combination (3–5,8,9,13–17,20,24–39), in contrast to adults in whom surgery or myocardial infarction often precedes the onset of RSD (31,32,40). Susan M. Maillard, MSc, SRP, MCSP, Karen Davies, MB, BS, MRCP, Patricia M. Woo, MB, BS, PhD, FRACP, Kevin J. MurrayMB, BS, FRACP (current address: Princess Margaret Hospital for Children, Perth, Western Australia): Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom; Raju Khubchandani, MD, FRACP: Jaslock Hospital and Research Centre, Mumbai, India. Address correspondence to Susan M. Maillard, MSc, SRP, MCSP, Juvenile Dermatomyositis Research Centre, Rheumatology Unit, Ground Floor, Philip Ullmann Wing, 30 Guilford Street, London, WC1N 1EH, United Kingdom. Email: S.Maillard@ich.ucl.ac.uk. Submitted for publication March 31, 2003; accepted in revised form September 15, 2003. Arthritis & Rheumatism (Arthritis Care & Research) Vol. 51, No. 2, April 15, 2004, pp 284–290 DOI 10.1002/art.20249 © 2004, American College of Rheumatology

Pain syndromes in children.

This review discusses the recent literature on pain conditions in children that should be of interest to rheumatologists. The focus of the review is therefore on musculoskeletal pains in children, particularly chronic or recurrent musculoskeletal pain. Articles that have a broader focus on pain are discussed when these are likely to be of general interest to rheumatologists. Chronic or recurrent pain in childhood is common and can be caused by a wide variety of conditions, several of which are discussed here. The importance of being able to measure pain in children has been emphasized repeatedly in the recent literature. With increased understanding of how to evaluate pain in children has come the recognition that pain in children is multifactorial and that even when there are obvious "organic" causes of the pain (such as arthritis), psychosocial factors are critical in how pain is perceived, and they influence the extent to which pain leads to dysfunction. There is also increasing evidence that cognitive-behavioral therapies are effective in managing chronic pain in children. The frequency of back pain in children is increasingly recognized, and the role of children's work and play, carrying heavy backpacks, and sitting for long periods of time at computers in causing back pain is of interest. The studies reviewed here add to an increasingly rich and informative literature on musculoskeletal and other chronic pain in children, and they help emphasize the importance of proper evaluation and management of pain in children.

Recurrent Musculoskeletal Pain in Professional Ballet Dancers in Sweden

In a six-year follow-up study, the self-reported musculoskeletal pain in professional ballet dancers was investigated. Fifty-one (72%) dancers, working in professional companies on both occasions participated in the study. The high prevalence of pain among the dancers was on both occasions dominated by problems in the back (69% and 82% respectively) and feet (73% and 82%). Pain reported some time during the preceding 12 months increased significantly only in the upper back region, while incapacitating pain decreased for the same region ( p &lt; 0.05). Recurrent pain was reported by 90% of dancers. Our results indicate that about every third dancer experiences recurrent incapacitating pain, with 75% set off by a previous major injury. In spite of an increased workload, and getting older, ballet dancers are not necessarily more prone to incapacitating pain, rather the opposite seems true. It is speculated that the right training facilities within the theater seem to be important to keep the dancers dancing.

Chronic musculoskeletal pain in childhood.

We studied 73 children with chronic or recurrent musculoskeletal pain of > or = 6 weeks' duration. Thirty-six children had no identifiable organic etiology for their pain, with a minimum follow-up of 2 years for ongoing symptoms. Thirty-seven children had an organic etiology for their pain. Use of an Inappropriate Symptom Checklist was helpful in distinguishing between children with chronic pain who were found to have an organic disease and those without an identifiable organic disease. Seventy-seven percent of children with no inappropriate symptoms had an organic diagnosis ultimately made. Conversely, 79% of children with two or more inappropriate symptoms ultimately had no organic diagnosis to explain their pain. Behavioral self-report measures testing could not differentiate between children with chronic pain with or without organic disease. Intervention by a psychologist skilled in pain management was helpful.

Evaluation and Management of Pain in Children with Rheumatic Diseases

The evaluation and management of pain in children with rheumatic diseases are still in the early stages of empirical development. Nevertheless, with the advent of the PPQ, systematic research efforts are now underway to develop the reliability and validity of the PPQ's measurement characteristics for pediatric rheumatic diseases. With these developments, the inclusion of pediatric pain measurement as an essential outcome variable in controlled clinical trials should be advocated. The major points to be advocated by professionals who care for these children are (1) Children can accurately report their pain when age-appropriate measures are used; (2) pharmacologic treatment is not a sufficient condition for adequate pain management; (3) cognitive-behavior therapy techniques can facilitate children's coping with "breakthrough" recurrent musculoskeletal pain with no known side effects; and (4) adequate pain control should be viewed as a quality assurance issue, considered as another indicator of the adequacy of pediatric health care.

Pain syndromes, disability, and chronic disease in childhood

Childhood disability and chronic disease are common, and their prevalence is increasing as children survive with conditions that were previously fatal. It is important that physicians in training learn about disability and handicap, and the functioning of multidisciplinary teams to manage these problems. Chronic ill-health is often very expensive to manage, and some serious and creative thinking about the best way to fund such health care is urgently needed. Pediatric rheumatologists are involved with the care of many children with chronic and recurrent musculoskeletal pain; however, they have not perhaps focused enough research effort on the investigation of pain and its management. Whether reflex neurovascular dystrophy, fibromyalgia, and chronic fatigue syndrome are part of a disease continuum is unclear, but it seems probable that psychosocial problems are often important contributing factors in all three conditions. Immunoglobulin subclass deficiencies are being increasingly delineated, occurring in chronic fatigue syndrome as well as many other disease states. Their clinical relevance still remains, for the most part, uncertain. Short stature occurs in many chronic illnesses, and the role of growth hormone treatment in these conditions is beginning to be investigated.