Pediatric pain syndromes and management of pain in children and adolescents with rheumatic disease

Increasingly, pediatric rheumatologists are faced with the challenge of assessing, diagnosing, and managing pain in children and adolescents. Recent research suggests that musculoskeletal pain may be the most corm-non complaint for which children are referred to a pediatric rheumatologist and is present in approximately 50 % of all new patients [1]. A small percentage of these patients will be diagnosed with a form of juvenile idiopathic arthritis (JIA), which is marked by clinically significant pain. A larger percentage will be diagnosed with a musculoskeletal pain syndrome. Research indicates that approximately 25 % of new patients presenting to pediatric rheumatology clinics are diagnosed with a pain syndrome such as fibromyalgia, complex regional pain syndrome, localized pain syndrome, or low back pain. Given the frequency of musculoskeletal pain as a presenting complaint, understanding the nature of chronic musculoskeletal pain in children is advantageous for both the general pediatric practitioner and the subspecialist. This understanding includes familiarity with the pain experience of healthy children and with the range of factors that influence pain reporting in healthy children and in children with chronic disease. In addition, a clinician should understand how to use pain-assessment instruments and be able to recognize and treat pain syndromes and disease-related pain. It is now well recognized that pain is multidimensional and is best understood within the context of a biopsychosocial model that incorporates biologic, environmental, and cognitive behavioral mechanisms in the development and maintenance of pain (Fig. 1). Awareness of this model enhances a clinician's ability to manage pain in children by increasing recognition of the factors influencing pain perception and highlighting the full range of pharmacologic and nonpharmacologic treatment methods available to treat pediatric pain. This article introduces important issues related to pain in children with musculoskeletal pain syndromes and rheumatic disease, using juvenile primary fibromyalgia syndrome (JPFS) and JIA as models. A brief summary of the prevalence of pain in healthy children is followed by a summary of existing pain-assessment techniques. The remainder of the article describes the pain experience of children with JPFS and JIA and discusses issues related to pain management.