chronic musculoskeletal pain syndromes: …chronic musculoskeletal pain syndromes: occupational...

CHRONIC MUSCULOSKELETAL PAIN SYNDROMES:

OCCUPATIONAL THERAPY EVALUATION AND INTERVENTIONS

FOR THE CHILD AND ADOLESCENT PATIENT

Ashley Binkowski, MS, OTR/L, CKTP

Rachel Bambrick, MS, OTR/L

The Center for Rehabilitation

LEARNING OBJECTIVES

• Define chronic pain

• Understand the OT evaluation process for children with AMPS

• Identify client factors in creating an evidence-based treatment plan for AMPS

• Implement OT treatment interventions including desensitization, self-care re-training, and therapeutic activities

DEFINITION AND SIGNIFICANCE OF CHRONIC PAIN

• https://vimeo.com/user8989405/review/346551813/482674a293

DEFINING PAIN

• “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

• Subjective experience

• May be present without any specific, identifiable injury or disease

International Association for the Study of Pain. Pain, IASP Pain Terminology. 1994.

DEFINITION OF CHRONIC PAIN

• Recurrent or persistent pain lasting longer than the normal tissue healing time

• Pain ≥ 3 – 6 months*

* Not required for AMPS

American Pain Society Task Force on Pediatric Chronic Pain Management, 2012

IMPACT OF PEDIATRIC CHRONIC PAIN

• Affects 2-6% of school-aged children

• Increased healthcare utilization

• Psychosocial problems

• Economic costs

• Increased risk of continued chronic pain into adulthood

Sherry DD, et al. J Pediatr, 2015. King S, et al. Pain, 2011.Hoffart CM, Wallace DP. Curr Opin Rheumatol, 2014. Sleed M, et al. Pain, 2005.

AMPLIFIED MUSCULOSKELETAL PAIN SYNDROME

• Umbrella term for chronic non-inflammatory musculoskeletal pain conditions

• Descriptive

• Does not assume an etiology

• Body amplifies the pain• Child is not willfully exaggerating the pain

Amplified Musculoskeletal Pain Syndrome

Chronic Pain Syndrome

Primary pain disorder

Chronic Non-inflammatory

Musculoskeletal Pain Syndrome

Juvenile Fibromyalgia

Syndrome

Myofascial Pain

Syndrome

Neuropathic pain

Chronic Fatigue

Syndrome

Sudekatrophy

Complex Regional

Pain Syndrome

Reflex Neurovascular

Dystrophy (RND)

Reflex Sympathetic

Dystrophy (RSD)

Causalgia

Algodystrophy

Shoulder-hand

syndrome

Chronic Widespread

Fibrositis

TERMINOLOGY

EPIDEMIOLOGY

• Median age at diagnosis 14 years (IQR: 12-16)

• More common in females

• Predominantly non-Hispanic Caucasians

• Median duration of pain: 12 months (IQR: 7-30)

MEASURES OF PAIN

• Verbal pain score (0-10)

• Visual analog scale

Zompo F, Mangiola et al. 2016

PAIN INTERFERENCE

• Functional disability inventory (FDI)

• Scores range from 0 – 60

• Higher scores indicate worse function

Level of disability FDI Score

No/minimal 0-12

Moderate 13-29

Severe ≥ 30

Flowers and Kashikar-Zuck 2011

≤ 2 body regions

CRPS 1Localized

≥ 3 body regions

Diffuse AMPS

autonomic dysfunction?

YES NO

Pain frequency: Constant vs. Intermittent

*All subjects were treated between February 2001 and October 2015 at CHOP or Seattle Children’s.

COMPLEX REGIONAL PAIN SYNDROME, TYPE 1

• Pain accompanied by ≥ 1 sign of autonomic dysfunction

• Type 1 occurs without a definable nerve lesion

• Leg is usually involved

AUTONOMIC SIGNS

• Cold

• Cyanotic

• Clammy

• Decreased pulse

• Dystrophic skin

• Increased perspiration

• Edema

Courtesy of Dr. David D. Sherry

KEY POINTS FROM THE HISTORY

• Pain for extended period of time

• No improvement with medicine

• Pain with hugging, light touch, etc.

• History of concussions, fractures, hospital stays and “poor healing”

• Pan-positive review of systems

• Very detailed descriptions and ratings of pain

SOCIAL HISTORY THEMES

• Tendency to identify stress as a pain trigger

• Recent major life events

• Family members with chronic pain

• Personality: mature, people-pleaser, high-achieving, perfectionist

• Withdrawal from activities – school, sports, etc.

CLUES FROM PHYSICAL EXAM

• Incongruent affect• Smiling despite pain

• La belle indifference

• Allodynia with variable borders• Not a dermatomal distribution

OVERARCHING TREATMENT APPROACH

• Non-pharmacologic

• Multi-disciplinary

• Emphasis on restoring function

• Counter-intuitive to typical approach to pain• Push through the pain

• May get worse before it gets better

• Providing reassurance that pain is not damaging

THE A-B-C’S OF TREATMENT

• Aerobic Exercise including PT/OT

• Behavioral Health Referral• Psychological Counseling

• Curbing over-medicalization and discontinuing medications

• Desensitization techniques

• Education

TREATMENT SUCCESS WITH MULTIDISCIPLINARY APPROACH

• Cognitive behavioral therapy (CBT) alone does not increase physical activity

• CBT + exercise found to have greater decreases in pain than CBT alone, as well as improvements in disability

Kashikar-Zuck, Black et al. J Pain. 2018

Kashikar-Zuck, S., et al. Arthritis Care Research, 2013

CONCLUSIONS

• Multi-disciplinary, non-pharmacologic approach is key to long-term success

• Focus on restoring function > pain reduction

• Empower patients and their families to take ownership over their own treatment plan

THERAPY EVALUATION PROCESS

CHOP OT/PT EVALUATION

• Specific blocks in OP schedule• 1-2 days a week at various sites

• 90 minute co-evaluation

• Often 1st time getting evaluated and provided education

• By end of evaluation, a clinical decision made by OT/PT on plan of care

WHY A CO-EVALUATION?

• Limits repetitive intake process

• Allows for two trained professionals to come together on a holistic clinical decision

Examination

Fin e motor

Fu n ctional Mobility

A DL’s

Gr oss Motor

REFERRAL SOURCE

• Script from MD/CRNP/PA• PCP vs. Specialist

• May or may specify AMPS diagnosis

• Direct Access (PT only)• Can be a tricky diagnosis to differentiate

INTAKE

https://dharmacomics.com/dharma-comics/tell-me-where-it-hurts/

PAST MEDICAL HISTORY

• Review of previous injuries, illnesses, and/or diagnoses

• Thorough review of potential comorbidities• EDS, POTS, concussion, Lyme, CP

CO-EXISTENCE/COMORBIDITIES

Ca n be seen with a n other

dia gnosis

S/p su rgery

S/p fr a cture/

or thopedic in jury

POTs (Postural

Or thostatic Ta chycardia Sy ndrome)

S/p con cussion

Ca n cer

Con v ersion

HISTORY OF PRESENT ILLNESS

• Date of onset• Coinciding with triggering event?

• History of progression

• Services received/receiving• Physicians, specialists, PT/OT, etc.

• Counseling• Type

• Frequency & Length

PRECAUTIONS

• Usually see a large variation

• Any general concerns• BMI

• Hypermobility

• Previous or current• Changes in weight bearing status over time

• Major Surgeries

• Medications

• Asthma

PAIN ASSESSMENT

Location Level Quality

FrequencyAggravating

FactorsAlleviating

Factors

Current, Best, Worst

Descriptors

HotTu gging

Piercing

A ching

Gloom y

Splashing

Squ eezing

Freezing

Extreme

ColdCu tting

Cru shing

Bu rning

stinging

pu l ling

stabbing

shooting

PAIN ASSESSMENT

Assess Allodynia

Light Touch

Deep Touch

Vibration

SOCIAL HISTORY

• Housing environment

• School environment

• Activity level

• Other Therapies?

• Any Counseling?

• Sleep

• Appetite

SOCIAL HISTORY - HOUSING

• Type

• Layout• Bathroom

• Bedroom

• Stairs

• Who lives with them

• Modifications secondary to pain?

SOCIAL HISTORY - SCHOOL

• Missed Days due to pain

• Leaving Early/Going Late

• Able to write in school

• Able to keep up with peers

• Transportation to/from

• Nurse visits

• Any specific accommodations?• How often are they used?

SOCIAL HISTORY- ACTIVITY LEVEL

Current

GoalPrevious

PATIENT GOALS

• Encourage patient to focus on function

• 3 most difficult activities to complete due to pain

• Goal activity level• What do they want to return to?

SOCIAL HISTORY

• Sleep• Difficulty staying/falling

• Average sleep nightly

• Appetite• Meal schedule

• Nausea

• Vomiting

EXAMINATION

http://bestptbilling.com/funny-physical-therapy-cartoon-its-a-stretch/

SYSTEMS REVIEW

• Cardiopulmonary screen• Asthma?

• Integumentary screen• Color/temperature/skin changes

• Abrasions indicating self harm?

• Neuromuscular screen• Balance, motor control

MUSCULOSKELETAL EXAM

• Range of Motion• Cervical

• Trunk

• Bilateral UE/LE

• Screening for muscle tightness

• Tone• Quick screen if necessary

• Can be helpful with screening out conversion symptoms

• Strength testing• MMT bilateral UEs

• Gross grasp

• Pinch• Lateral

• Tripod

• Tip to tip

• MMT bilateral LEs

• Be aware of true muscle weakness vs. “breaking” for pain or conversion

JOINT LAXITY – BEIGHTON SCALE

Transition Pain level Form

Supine <> Sit

Sit <> Stand

Squat <> Stand

Floor <> Stand

Heel sit

Tall kneel

Half kneel

Side sit

Tailor sit

• Balance • Sitting

• Posture

• Standing• Posture

• Rhomberg

• Tandem

• Single leg• Eyes open, eyes closed

• Mobility• Gait assessment

• Mechanics & speed

• Question ability to ambulate community distances

• Stair assessment• Mechanics & speed

• Note use of handrail

• Question typical pattern at home

MUSCULOSKELETAL EXAM - FUNCTIONAL STRENGTH

Activity Pain Level Form

Double & single leg squat

Step down

Double & single leg hop

Running

Skipping

Push up

Plank & side planks

Double & single leg bridging

• Fine Motor Assessment• Reach

• Grasp

• Pinch

• Release

• Manipulation

• Writing

• Standardized Assessments• Bruce Treadmill Protocol

Stage Time (Min) Incline (%) Speed (m/s)

1 0-3 10 1.7

2 3-6 12 2.5

3 6-9 14 3.4

4 9-12 16 4.2

5 12-15 18 5.0

6 15-18 20 5.5

7 18-21 22 6.0

• Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)

• 8 subtests that assessed together provides a comprehensive picture of motor development

• Assists in development of plan of care as well as goal writing

• Functional Disability Inventory (FDI)• Parent version

• Patient version

• 9 Hole Peg

• Complete Minnesota Dexterity Test (CMDT)

• Box & Blocks

• The GOAL

FUNCTIONAL DISABILITY INVENTORY

Flowers and Kashikar-Zuck, 2011

• No/Minimal0-12

• Moderate13-29

• Severe≥ 30

ACTIVITIES OF DAILY LIVING

• Can use Pedi as reference

• Go through each ADL• Any Modification?

• Avoidance present?

• Is pain impacting?

• Looking for accommodations during self help skills• May need to probe a little

INSTRUMENTAL ACTIVITIES OF DAILY LIVING

• Leisure• Participates in the following?

• Stopped participating in the following?

• Any accommodations?

• Chores• What do you do around the house?

• Does pain impact?

EVALUATION OF FINDINGS

http://bestptbilling.com/lets-start-with-some-trunk-rotation/

PLAN OF CARE DEVELOPMENT

Level of Service Needed

Consultative OutpatientIntensive program

EDUCATION

Education

Psy chology

Function

Diagnosis

Activity level

Desensitization

Parent Education

RECOMMENDATIONS

• Goals for Treatment

• Family/Patient buy-in

• Home Exercise Program

GOAL WRITING

• OT Example: • Patient will accept various types of desensitization (both light and

deep touch) x 25 consecutive minutes with min to no pain behaviors or compensations 3/4 observed occasions in preparation for showering and leisure participation.

• PT Example: • Patient will independently ambulate community distances with age

appropriate gait speed, without AD, with no-min pain behaviors and compensations in preparation for ambulation within school environment without accommodations.

HOME EXERCISE PROGRAM DEVELOPMENT

Desensitization

Endurance

Strengthening

MODIFYING EVALUATION FOR SPECIFIC CONDITIONS

http://bestptbilling.com/yup-definitely-case-frozen-shoulder/

COMPLEX REGIONAL PAIN SYNDROME (CRPS)

• What else do you need to assess?• Edema – circumferential measurements

• Skin integrity (shiny, dry, cracked, color, temperature)

• Use of mobility devices

• Willingness to use affected extremity

• Extent of allodynia with border checks

• Active movement

UPPER EXTREMITY

Start of Program 7 Days later with

exercise only

CRPS with Conversion

Admission

After exercise x 7 days

Wrapping

LOWER EXTREMITY

CRPS PROGRESSION

January 17, 2016 February 2, 2016 February 4, 2016 March 8, 2016 April 6, 2016

CONVERSION DISORDER

• Stiffness

• Paralyzed

• Shaking

• Conversion gait

• Non-epileptic (pseudo-seizure)

• Blind, Deaf, memory loss

• Lack of ROM

• Fluctuating weakness

CONCUSSION/DIZZINESS

• Observe behaviors with examination prior to questioning about sensation

• Look for inconsistencies

TAKE HOME MESSAGES

• These patients are truly experiencing pain

• It is critical to initiate treatment immediately• Physical & Psychological

• Be considerate of AMPS vs. Organic system impairments• These can co-exist

• Up next…• A clinical application to the evaluation process

• Presentations on OT & PT interventions for AMPS

REVIEW OF INITIAL EVALUATION

• Address goals • These are your guide to treatment

• Clearly understand the problem areas

• What are the patient’s strengths

• Do they know coping strategies and how to use them

• What are the motivating factors for this patient?

TREATMENT

TYPES OF INTERVENTIONS

• Desensitization

• Functional activities• ADLS

• IADLS

• Leisure activities

• Strengthening

• Endurance

• School Simulation

ALLODYNIA

• Pain due to stimulus that does not normally provoke pain

• Approximately 80% of patients who present at CHOP have allodynia

• As quickly as possible-transition to self-desensitization except for hard to reach areas

TYPES OF DESENSITIZATION

Tactile stimulation

Vibration

Temperature

TACTILE STIMULATION

• Towel rub

• Lotion massage

• Brushing

• Body Painting

• Textured mats and balls

• Audible tapping

• Tubigrip

TOWEL RUB

• Instructions:

• Briskly rub the sensitive area with a towel.

• Use firm pressure in all directions in the areas that are painful.

• Integrate into daily routine

LOTION MASSAGE

• Instructions: • Apply lotion

• Massage body part with pressure to decrease sensitivity.

• Integrate into daily routine

RETROGRADE MASSAGE

• Instructions: • Position your extremity on pillows or hold extremity in the air

resting on a table.

• Apply lotion to the hand.

• Begin at your distal end (finger tips) and use firm pressure with long, smooth strokes to rub down your fingers towards the hand and wrist.

84 Before After

BRUSHING

• Instructions:• Using brush, rub in all directions, with firm pressure.

BODY PAINTING

• Multi-faceted

• Cold paint

• Paint brush

• Cracking when it dries

• Scrubbing

• Washing it off

TEXTURED EQUIPMENT

Small Textured Disks The Stick

(The Hawley Company)

Rock Mat

TEXTURED EQUIPMENT

Happiness in a Bag

Large Textured Disc

AUDIBLE TAPPING

• Instructions: • Cup your hand.

• Tap area with enough pressure to create a loud tapping sound.

COMPRESSION

• Instructions:• Instruct patient to wear tight clothes or Tubigrip.

• Check circulation

VIBRATION

• Shaker

• Handheld massager• Size

• Intensity

• iPalm

• iHelmet

SHAKER OPTIONS

• Standing

• Single leg stance

• Squat

• Supine

• Prone

• Quadruped

• Horseback riding

• Sitting

• Sitting with feet on the shaker (car simulation)

SHAKER

HAND HELD MASSAGERS

• Instructions:• Using handheld massager, move in all directions with firm

pressure.

94Can use all with or without

lotion.

LOCATION SPECIFIC VIBRATION

Breo iPalmhand

Massager

Helmet Vibrating Mat

TEMPERATURE

IceContrast

PacksParaffin

• Instructions: Slowly rub ice cup on sensitive area. • Time: 3-10 min

https://www.amazon.com/Cryocup-Ice-Massage-Therapy-Tool/dp/B000VGFY04

CONTRAST BATH

• Instructions:• Fill up two large buckets or bowls with ice water in one and

hot/warm water in the other.

• Place painful area completely in the cold water for 30 seconds

• Quickly switch to the warm water for 30 seconds.

• Repetitions vary by patient.

https://www.google.com/search?q=contrast+bath&sou rce=lnms&tbm=isch&sa=X&ved=0ahUKEwiN4cyjkPrdAhXhdd8KHahPCKwQ_AUIDygC&biw=1008&bih=665#imgrc=DOv0k6--fwQpwM:&spf=1539114493031

WARM PACKS

• Instructions:• Apply warm packs with towels to affected extremity.

http://soa.md/blog/wp-content/uploads/2016/10/PT-hot-pack.jpg

PARAFFIN

• Instructions:• Wash/sanitize extremity.

• Two Methods:

1. Paper Towels: rip paper towel, place in paraffin bath, remove paper towels, and place on extremity.

2. Pour Method: grab an extra bucket, dip plastic cup in paraffin bath, and pour over extremity over additional bucket.

• Can cover with plastic wrap and towel to intensify heat.

• Instructions:• Position fan to have it blow on affected extremity.

DESENSITIZATION

DESENSITIZATION- HOME EXERCISE PROGRAM

• Complete 1x/day at night during week

• Complete 2x/day on weekends

• Patients completes themselves

• Best results if integrated into daily routine

• Education on progression and purpose is key to treatment

HOME DESENSITIZATION (HEP)

FUNCTIONAL ACTIVITIES

• Functional ambulation

• Chores• Washing windows

• Sweeping

• Dishes

• Making bed

• Laundry

• Gardening

• Baking/Cooking

• School simulation• Carrying books/backpack

• Changing classes

• Handwriting/typing

• Prolong sitting

• Carrying lunch tray

• Locker use

• Return to • Sports

• Dance

• Cheerleading

• Band/musical instrument

• Laying in bed • Position

• Blankets

• Dressing/tolerating types of clothing (sitting versus standing)

• Shoes – sneakers, flip-flops, high heels, dance shoes, athletic shoes

• Pants –skinny jeans, leggings, loose fitting pants

• Shirts – tight, loose, long sleeve

• Manicure/pedicure

• Hair cut

IMPORTANT REMINDER

• Exercises should be monitored in order to diminish common compensations which are often used to alleviate pressure on painful area(s) and promote safety.

STRENGTHENING

• Standard of Care• Theraband• Weights• Weight-bearing• Arm Bike• Core strengthening

• Plank bolster walks outs

• Prone on scooter board

• Overhead writing• Standing• Supine• Side-lying

STRENGTHENING (CON’T)

• Tall kneel <> stands

• Hallway drills

• Hand air hockey

• Weighted dowel rod

• Biometrics

• Heavy ropes

• Cervical strengthening- “Neck 4 ways”

• Escape from the Hospital

• Bodyblade

PLANK BOLSTER WALK OUTS

• Instructions: • Use a large bolster.

• Place horizontally on floor with a yoga mat behind it.

• Have patient tall kneel on yoga mat and lay over bolster so they are perpendicular to the bolster.

• Have them walk them selves out forward into a plank position. The bolster will roll from their chest to thighs.

• Then walk hands backward to starting position.

PLANK BOLSTER WALK OUTS

SCOOTER BOARD

Instructions:• Have patient lay prone on scooter board.

• Have their knees flexed so they do not try to use their feet.

• Have them move forward, by self propelling with palms of hands on floor.

• Depending on strength can do unilateral or bilateral forward motion.

• Can use disks under hands to increase resistance.

OVER HEAD WRITING

• Standing• Instructions: Patient stands (feet, SLS) in front of flat surface.

Place patient at or above shoulder level and have them sustain this position while completing writing/coloring task against wall.

• Can increase/decrease time• Stand on textured surface• Or change positions (tall kneel/ ½ kneel)

• Supine• Instructions: Patient lays supine under table. Patient holds arms

at 90 degrees shoulder flexion to stabilize the paper under the surface. Complete coloring tasks in this position.

• Can add textured surface for desensitization • Can elevate legs to add pressure to back

OVERHEAD WRITING

Both Feet Single leg stance Standing on textured disc

TALL KNEEL <> STANDS

• Instructions:• Use padded surface, i.e yoga mat

• Have patient step over yoga mat and lower self in half kneeling position.

• Bring opposite knee down onto mat for tall kneel position.

• Patient then brings opposite leg into half kneel position.

• Push up to return to standing position.

• With/without weighted ball

• On static vs dynamic surface

• Add desensitization (textured mats/surfaces)

TALL KNEEL TO STANDS

HALLWAY DRILLS

• Instructions: • Distance can vary.

• With/without weighted ball

• Watch for speed/form

Activities

Butt kickers

High knees

Grapevines

Galloping

Skipping

Lateral squats

HAND AIR HOCKEY

• Instructions:

WEIGHTED DOWEL ROD

• Instructions:• Take a dowel rod at least 2-3 feet long and attach a rope.

• Knot rope onto dowel.

• Add any size weight to rope at the bottom.

• Have patient activate wrist flexion and extension to bring the weight from the floor to the rod.

“ESCAPE FROM THE HOSPITAL”

• Instructions:• Open a sheet and tie diagonally opposite corners to another sheet

tightly

• Tie one end to another surface

• If on tile floor, have patient sit on folded sheets

• Have them pull on sheet hand over hand so they travel to where sheet is tethered

• Then push on floor with hands to return to start

• When exercise is finished, have patient take knots out of sheet for hand strengthening

DESENSITIZATION WITH EXERCISE

• Tennis balls,

• Vibrating mat

• Textured disk/mat

• Feathers

• Fan

• Rug surface

• Grass doormat

• Roller stickhttp://soa.md/blog/wp-content/uploads/2017/01/foam-roller.jpg

ENDURANCE

• Arm bike

• Zoom ball

• Jump rope

• Hula hoop

• Rebounder

• Virtual reality

• Skip-it

REBOUNDER

TREATMENT BASED ON PAIN AREA

• Total body

• Abdomen

• Back

• Head/neck

• CRPS

TREATMENT TOTAL BODY

• Desensitization• Shaker- Standing, single leg stance, sitting

• Vibration- Brookstone to most painful area

• What activities?• Core Strengthening via plank program

• Arm bike

• Functional ambulation with weighted back pack

TREATMENT OF ABDOMEN

• Desensitization• Vibration • Ice cup• Laying on textured surface

• Eating• Snack breaks• Non- preferred foods

• Exercise • Trunk rotation• Supine -> sits• Plank program• Prolong sitting for simulated school• Hula hoop targets both

TREATMENT-BACK

• Desensitization:• Vibration via Brookstone

• Supine on shaker

• Laying on textured mat

• What Activities?• Supine overhead writing

• Prone extension

• Prolong sitting

TREATMENT HEAD/NECK

• Desensitization:• Breo helmet

• Scalp massager tool

• Brushing hair

• Braiding hair

• What Activities?• Neck 4 ways

• Prone extension

• Carrying back pack

DOCUMENTATION

HOW DO WE MEASURE PAIN?

• Therapist never ask about pain or pain score (except evaluation/Re-evaluation if warranted)

• Documenting pain: NA out of NA; write in pain behaviors.

• Pain behaviors classified as:• Zero to maximum pain behaviors

• Use description – facial grimacing, crying, moaning, moving from stimulus

LOOKING BACK AT COMPLEX REGIONAL PAIN SYNDROME (CRPS)

TREATMENT FOR CRPS

• Remove mobility aids as quickly as possible

• Start weight-bearing

• Start everyday functional activities

• Start with just doing the activity then move towards quality

• Retrograde massage or wrapping for edema

• Desensitization

UE CRPS

Initial Presentation 7 days later

UE CRPS

Initial Presentation 7 days later

TREATMENT

• Wrapping

• Retrograde massage

• Active movement- proximal and distal

• Open container/lids

CRPS OF HAND WITH CONVERSION

TREATMENT

REFERENCES

• Black WR, Kashikar-Zuck S. Exercise intervensions for juvenile fibromyalgia: current state and recent advancements. Pain Manag. 2017 May;7(3):143-148. doi: 10.2217/pmt-20160066. Epub 2017 Feb 3.

• Gmuca S, Sherry DD. Fibromyalgia: Treating Pain in the Juvenile Patient. Paediatr Drugs. 2017 Aug;19(4):325-338. doi: 10.1007/s40272-017-0233-5. Review.

• Hoffart CM, Wallace DP. Amplified pain syndromes in children: treatment and new insights into disease pathogenesis. Current opinion in rheumatology. 2014;26(5):592-603.

• Kashikar-Zuck S. et al. Long-term outcomes of adolescents with juvenile-onset fibromyalgia in early adulthood. Pediatrics. 2014 Mar;133(3):e592-600. doi: 10.1542/peds.2013-2220. Epub 2014 Feb 24.

• Kaufman EL, Tress J, Sherry DD. Trends in Medicalization of Children with Amplified Musculoskeletal Pain Syndrome. Pain Med. 2017 May 1;18(5):825-831. doi: 10.1093/pm/pnw188.

• Sherry DD et al. The Treatment of Juvenile Fibromyalgia with an Intensive Physical and Psychosocial Program. J Pediatr. 2015 Sep;167(3):731-7. doi: 10.1016/j.jpeds.2015.06.036. Epub 2015 Jul 21.

• Weissmann R, Uziel Y. Pediatric complex regional pain syndrome: a review. Pediatric rheumatology online journal. 2016;14(1):29.

REFERENCES

• Black WR, Kashikar-Zuck S. Exercise interventions for juvenile fibromyalgia: current state and recent advancements. Pain Manag. 2017 May;7(3):143-148. doi: 10.2217/pmt-20160066. Epub 2017 Feb 3.

• Coverly, D. (2016, Fevurary). Gingerbread [Photo]. Retrieved from http://www.cartoonistgroup.com/subject/The-Knee-Comics-and-Cartoons-by-Speed+Bump.php

• Dharamcomics. Where does it hurt [Photo]. Retrieved from https://dharmacomics.com/dharma-comics/tell-me-where-it-hurts/

• Hoffart CM, Wallace DP. Amplified pain syndromes in children: treatment and new insights intodisease pathogenesis. Current opinion in rheumatology. 2014;26(5):592-603.

• Konold, G. (2014, August). Elephant [Photo]. Retrieved from http://bestptbilling.com/lets-start-with-some-trunk-rotation/

• Konold, G. (2014, December). Snowman [Photo]. Retrieved from http://bestptbilling.com/yup-definitely-case-frozen-shoulder/

• Konold, G. (2014, August). Statue of Liberty [Photo]. Retrieved from http://bestptbilling.com/funny-physical-therapy-cartoon-its-a-stretch/

• Weissmann R, Uziel Y . Pediatric complex regional pain syndrome: a review. Pediatric rheumatology online journal. 2016;14(1):29.

REFERENCES

• Black WR, Kashikar-Zuck S. Exercise intervensions for juvenile fibromyalgia: current state and recent advancements. Pain Manag. 2017 May;7(3):143-148. doi: 10.2217/pmt-20160066. Epub 2017 Feb 3.

• Hoffart CM, Wallace DP. Amplified pain syndromes in children: treatment and new insights intodisease pathogenesis. Current opinion in rheumatology. 2014;26(5):592-603.

• Weissmann R, Uziel Y. Pediatric complex regional pain syndrome: a review. Pediatric rheumatology online journal. 2016;14(1):29.

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