Chronic Musculoskeletal Pain

Chronic pain symptoms reported by children which do not fit known physiological patterns are called "inappropriate symptoms." They often are the clue to psychosomatic causes of pain.

The authors present an Inappropriate Symptom Checklist useful in distinguishing between children with chronic pain from organic disease and those without identifiable disease.
Items on the checklist include:
Tenderness

• Superficial: skin tender to light pinch over a wide area
  
• Non-anatomic: deep tenderness over a wide area, not localized to an anatomic structure Simulation of Motion
  
• Hip/Knee/Ankle (or other joint) pain with motion of the whole extremity which imitates motion of that specific joint (e.g. elevating the leg without moving knee or ankle joints).

Distraction

• A usual examination method is done; if pain is present, patientıs position is changed and the exam repeated in a way that patient will not recognize. The best example is straight leg raising lying down, then sitting (as if to look at the bottom of the foot).

Regional Findings

• Non-anatomic sensory findings such as "sock or glove" anesthesia
  
• Weakness of unusual nature such as giving way of several muscle groups that cannot be explained on a localized neurological basis

Over-reaction

• Verbalization
  
• Tremor
  
• Facial expressions
  
• Collapsing/weakness
  
• Unusual muscle tension

Other Inappropriate Symptoms

• Pain at the tip of the coccyx
  
• Whole leg or arm painful or numb
  
• Whole leg giving way
  
• In the past year have you had periods with very little pain? ("No" is a positive response for inappropriateness.)

(Song K et al . Chronic musculoskeletal pain in childhood. J Pediat Orthopaed 1998; 18:576-581)

Comment: This check list should be very useful to the school nurse in triaging students with chronic pain. Protracted cases will require a mental health professional to sort through what is malingering vs somatization vs conversion reaction and to develop an effective treatment plan.