Non inflammatory musculoskeletal pain in a childby Nachiket Kulkarni
A child brings to our mind thoughts of cheerfullness, fun and spontaneity. Filled with overzealous energy these tiny tots are constantly active. As much may be their playfulness these angels are delicate too. Any discomfort can make a child restricted and gloomy. Musculoskeletal pain which has been reported to be common in childhood is a major source of discomfort for children.
Musculoskeletal pain has been reported to be present in range from 16 to 80 % of school children in various studies. More common in girls these pains have been reported to peak at around 14 years of age. This is the time when a child is evolving into adulthood and starts to face world on educational and social front. Any problem during this period is bound to have a long lasting impact if not permanent. Persistent or recurrent chronic pain brings persistent and recurrent distress, disability, adult attention and widespread family disruption. Most families have relatively successful mechanisms for dealing with short-lived demands or disruption. However, a young person with chronic pain typically demands sustained physical, emotional and financial resource. Young people with chronic pain report sleep disturbance, disordered mood, appetite disruption, low feelings (depression is often masked in this population), social isolation and unwelcome dependency on parents. All of these are experienced chronically and can serve to maintain pain and disability. They are also difficult to manage in isolation from other symptoms. It is imperative hence that we are prepared to handle this menace.
Musculoskeletal pain is not a single entity. It wide spectrum with inflammatory disorders at one end to non inflammatory disorders at other. Through various mediums and also through MAI we have had a fare access to information regarding inflammatory conditions. Its the non inflammatory conditions ironically more common and hence more distressing which remain in shadow and many times remain undetected.
Children provide a unique scenario for evaluation of musculoskeletal pain. With all their innocence they are not able to aptly describe their pain. Sometimes even exact localisation is a problem. In such times we depend on the parent's observation of discomfort. Chronic pain also incites anxiety in children making evaluation and assessment even difficult. The table 1 guides on some simple ways to be aware of which pains to be given more heed to. A point of caution - irrespective of any pain appearing as a benign pain if the duration is more than few weeks then it must be assessed by a rheumatologist or a paediatrician.
Most non inflammatory pains fall in the chronic benign category. But please do not be complacent as some of these can have long term impact. Lets go through a few common ones:
|Pain relieved by rest and worsend by activity||Pain not relieved by activity or not relieved by rest|
|Pain at the end of the day||Pain or stiffness in morning|
|Nocturnal pain relieved by simple analegesics & massage of painful areas||Nocturnal Pain not relieved by analgesics|
|No objective joint swelling||objective joint swelling|
|Hypermobile joints||Stiff Joints|
|No bony tenderness||Bony tenderness|
|Normal Strength||Muscle Weakness|
|Normal Growth Pattern||Poor Growth, Weight loss|
|No constitutional Sympton||Fever Malaise|
|Normal CBC, ESR||Abnormal CBC, elevated ESR|
|Normal Radiographic findings||abnormal Radiographic findings|
<center> Table 1- Characteristics of Benign & Serious MSK condition in Childern</center>
- Growing pains : Benign nocturnal limb pains of childhood (formerly known as “growing pains”) are cramping pains of the thigh, shin, and calf; they affect approximately 35 percent of children four to six years of age, although they may occur up to age 19. The pain typically occurs in the evening or at night, may awaken the child from sleep, and disappears by morning. The pain is thought to be associated with growth of tissues. On reassurance it just requires analgesics on and off or massage. It abates as the child grows.
- Diffuse Idiopathic Pain Syndromes (Juvenile Fibromyalgia) : The onset is often gradual. Initial insult like infection, trauma or hypermobility has been recounted in some. Widespread diffuse pain is described. This condition is more frequently associated with depression as compared to adult counterpart but is associated with better outcome to treatment. Treatment is on similar involvement as Adult Fibromyalgia but children would need psychologist's help to tackle this menace. Complete emotional support must be extended by care takers.
- Benign hypermobility syndrome : More common in adolescent girls, it is characterised by generalised musculoskeletal pain with hypermobility of joints. Its benign in nature. Only rarely it requires altering physical activities temporarily. Instituting monitored exercise programmes ensures improvement in most.
- Localised soft tissue pains : similar to adult counterpart all arrays of features of tendinitis, enthesitis, complex regional pain syndrome are seen in children. Enthesitis such as heel or peri-elbow pains can sometimes be associated with inflammatory arthritis and hence warrants evaluation by Rheumatologist. Complex Regional Pain syndrome can be a very troublesome. It is a localised problem common in upper limbs characterised by diffuse pain, swelling, occasional redness and sometimes tropic changes of skin and muscle. Needs early detection and treatment.
- Back pain : though not a syndrome in itself it has been increasingly observed in young children. Postural habits, load bearing (heavy school bag) and sedentary lifestyle (computers) are postulated as culprits. Timely correction, regular exercises are keys for treatment.
- Congenital Disorders : Some children are born with abnormalities of skeletal system. Commoner are club foot (A congenital abnormality in which the foot is twisted out of its normal position), hip dysplasia(The head of the femur is improperly seated in the acetabulum of the pelvis), scoliosis(lateral curvature of spine), cleft palate. These require sequential physiotherapy and in most cases surgery. Some abnormalities may develop later in life such as Perthe's disease, storage disorders. It's important hence any dismorphism on skeletal structure must be brought to notice of doctor. Some can be transient growth related features.
- Cancer : Cancer occurs in about one in 6,400 children annually. Malignant musculoskeletal tumours account for 5 to 10 percent of malignant neoplasm's of childhood. Other organ cancers can also affect musculoskeletal system. Cancer should be considered in a child who has pain out of proportion to clinical findings, or suggestive laboratory or radiologic test results. Pain is the most common presenting symptom of malignancy, with swelling and reactive arthritis over the involved bone occurring a few weeks or months after onset of pain.
A basic knowledge about these conditions should help allay fears associated with them. Though categorised as non inflammatory, these conditions can have widespread symptoms and sometimes life-long impact. When detected timely most can be attended to near cure.