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Introduction

  1. Top of page
  2. Introduction
  3. Musculoskeletal Pain in Healthy Children
  4. Pain in Children With JA
  5. Assessment of Pain in Children With Arthritis
  6. Treatment of Pain in JA
  7. Procedural Pain and JRA
  8. Conclusions
  9. REFERENCES

Juvenile arthritis (JA) is one of the most common chronic diseases of childhood, affecting as many as 200,000–300,000 American children (1–4). Diagnosis is based on clinical observation of persistent arthritis in 1 or more joints for a minimum of 6 weeks, with onset prior to the age of 16 years (5). Because the chronic inflammatory arthritides of childhood are actually a heterogeneous group of diseases, there are 3 different classification schemes currently in use: juvenile chronic arthritis (JCA) in Europe, juvenile rheumatoid arthritis (JRA) in North America, and most recently, juvenile idiopathic arthritis (JIA) (6). All of the schemes are based on clinical observation and include polyarticular, pauciarticular, and systemic-onset subtypes, as well as the juvenile spondylarthropathies, psoriatic arthritis, and others (Table 1) (7). The course of arthritis is unpredictable across all types but most commonly follows a fluctuating course characterized by periods of flare and quiescence. A minority of children have unremitting disease with severe disease activity. Constitutional symptoms that may be present across the subtypes of JA include joint pain, stiffness, fever, anorexia, weight loss, growth disturbance, and fatigue (8, 9). Although not well characterized in the pediatric literature, pain is generally considered to be a clinically significant symptom for many of these children, described by the children themselves as well as by parents and siblings (10–12).

Table 1. Comparison of classification systems
Juvenile Rheumatoid ArthritisJuvenile Chronic ArthritisJuvenile Idiopathic Arthritis
PauciarticularPauciarticularOligoarthritis—persistent
  Oligoarthritis—extended
PolyarticularPolyarticular RF−Polyarticular RF−
 Polyarticular RF+Polyarticular RF+
 SpondylarthritisEnthesitis-related arthritis
 Psoriatic arthritisPsoriatic arthritis
SystemicSystemicSystemic
  Other arthritis: fits no other category; fits more than 1 category

Despite the extensive literature on pain experienced by adults with rheumatoid arthritis and osteoarthritis, the systematic investigation of the pain related to JA has received relatively little attention. This is due, in part, to early research findings that suggested children with arthritis experienced less pain than their adult counterparts (13, 14). However, these findings were misleading because researchers failed to use age-appropriate measures of pain; accounting for neither children's cognitive and developmental stages nor their conceptualizations of pain and illness. More recently, several pediatric pain researchers have developed age-appropriate measures of pain that appear to be both reliable and valid in populations of children with JA (15–18). In addition, recent guidelines published by the American Pain Society include a section devoted to the treatment of pain in children with arthritis. These developments have enabled researchers to begin systematically describing the pain experience of healthy children as well as children with JA (19).

Musculoskeletal Pain in Healthy Children

  1. Top of page
  2. Introduction
  3. Musculoskeletal Pain in Healthy Children
  4. Pain in Children With JA
  5. Assessment of Pain in Children With Arthritis
  6. Treatment of Pain in JA
  7. Procedural Pain and JRA
  8. Conclusions
  9. REFERENCES

Contrary to popular belief, musculoskeletal pain is common in healthy children. Prevalence estimates of musculoskeletal pain in general pediatric populations range from 5% to 20% (20–23), with as many as 7% of school aged children reporting pain symptoms lasting longer than 3 months and causing significant functional impairment (24). Epidemiologic studies show that childhood musculoskeletal pain, whether organic or nonorganic in etiology, more commonly occurs in girls (24–30) and older children (24, 28, 31–34). In one large epidemiologic study, pain increased with age, whereas gender differences become markedly apparent at or just before puberty (35). In the highest risk group, teenage girls, the incidence of musculoskeletal pain approached 50%; a finding useful to keep in mind when considering the pain in childhood arthritis. Childhood musculoskeletal pain has also been associated with significant psychological impairment, including higher levels of depression, behavior problems, anxiety, social difficulties, and school absenteeism (36–38). Multiple factors may influence the onset and maintenance of musculoskeletal pain, including genetics (39), anatomic factors (40), psychosocial factors (41), and illness or pain behavior (42).

Pain in Children With JA

  1. Top of page
  2. Introduction
  3. Musculoskeletal Pain in Healthy Children
  4. Pain in Children With JA
  5. Assessment of Pain in Children With Arthritis
  6. Treatment of Pain in JA
  7. Procedural Pain and JRA
  8. Conclusions
  9. REFERENCES

Recent studies have also suggested that pain is more prevalent in JA than previously recognized. For example, Sherry et al (43) found that 86% of 293 children with JRA reported pain during a routine clinic visit. Data derived from the Cincinnati Juvenile Arthritis Databank, which examined 462 children with arthritis, showed that 60% of children reported joint pain at disease onset, 50% reported pain at 1-year followup, and 40% continued to report pain 5 years later (11). In both of these studies as well as others, children reported pain intensity in the mild to moderate range (9, 11, 18, 43–45). Our research has shown considerable variability in the pain ratings of children with JA. Although most children reported mild to moderate pain intensity, as many as 25% of the children in our study reported pain intensity in the higher ranges of the pain measurement scales (46). Furthermore, daily diary data revealed that children report pain on nearly 70% of days (47), suggesting that even children with mild pain from arthritis are experiencing pain almost daily. Children describe the pain associated with JA as “aching,” “sharp,” “burning,” and “uncomfortable” (18, 48–51).

Further understanding of the pain experience of children with JA comes from the results of 2 research studies suggesting that children with chronic arthritis have reduced pain tolerance when compared with healthy peers. For example, in a study using pressure algometry, Hogeweg et al (52, 53) found that children with arthritis had significantly lower pain thresholds than healthy controls. Interestingly, this discrepancy was present in children with and without clinical evidence of active inflammation and at both inflamed and noninflamed joints. Thastum et al (54) demonstrated decreased pain tolerance in children with arthritis compared with healthy children using a cold pressor pain task. In both studies, pain tolerance and pain threshold correlated with children's reported pain intensity. In other words, lower pain tolerance and pain threshold was related to increased pain report (52–54). The authors speculated that the enhanced sensitivity to noxious stimuli in children with JA may be due to a change in pain processing as a result of prolonged activation of the peripheral and central nocioceptive systems.

Pain and demographic variables in JA.

Researchers have begun to examine the role of demographic variables, particularly age and sex, in the pain experience of children with JA, but the results to date have been inconclusive. It has been suggested that subjective pain report depends in part on the child's cognitive capabilities (18, 48, 55). As children age and mature cognitively, the meaning attributed to sensations in their inflamed joints changes, thereby influencing pain perception. With cognitive maturation, they may become capable of associating internal sensations (e.g., pain in inflamed joints) with internal pathology and the potentially serious consequences. Thus, older children with arthritis may be more distressed by the sensation in their joints and more likely to interpret sensations as “painful” or unpleasant, resulting in increased reported pain intensities as the child's age increases. Alternatively, changes in pain report with age may reflect the epidemiology of musculoskeletal pain in healthy children, which also increases with age (24, 28, 31–34).

Beales et al (49) suggested that cognitive development impacts pain perception based on a qualitative study comparing the pain reports of children aged 6–11 and 12–17 years. Although children of all ages used similar words to describe the sensation in their joints (e.g., “aching”), younger children did not associate joint sensations with anything unpleasant, whereas older children were more likely to indicate that joint sensations reminded them of their arthritis-related disability. Younger children also rated the unpleasantness of the sensation lower than their older counterparts using a visual analog scale (VAS). The data were not statistically analyzed and thus the conclusions lack strong empirical support without further research. Hagglund et al (10) reported a marginally significant effect for age, with older children reporting more severe pain on a 10-cm VAS. However, several other studies have not shown age to be a statistically significant predictor of pain in children with JA when utilizing similar quantitative assessments of child pain (46, 48, 50, 51, 56, 57).

The impact of sex on the pain report of children with JA is also unclear. Several studies in which pain was assessed at a single time point found no difference between the reported pain levels of boys and girls (9, 48, 51). However, Benestad et al (50) found that school-aged girls and boys with JA differed significantly in reported present pain intensity, with girls reporting higher levels of pain than boys. More recently, we demonstrated that girls with polyarticular arthritis report more severe daily symptoms than boys, including pain, stiffness, and fatigue as reported in a nightly diary (47). In addition, girls reported poorer sleep quality and pain coping efficacy. These results suggest that future research into the sex differences in the pain and symptom report of children with JA is warranted. Moreover, girls may need to be specifically targeted for interventions in pain management and pain coping skills (47).

Pain and disease activity in JA.

Several researchers have studied the relationships between pain and measures of disease activity and functional status, in part to determine the usefulness of pain ratings as indices of health status in JA. Across studies, a relationship between increased disease activity and increased pain report in children with arthritis has been demonstrated. For example, Vandvik and Eckblad (51) found that disease severity correlated with reports of pain intensity in a sample of 57 children admitted to the hospital with suspected rheumatic disease. Similarly, Varni et al (18) reported a positive correlation between physicians' ratings of disease activity and pain intensity in children with JRA.

However, the results of these and other studies indicate that disease severity only predicts a small to medium proportion of the variance in children's pain report, suggesting that disease severity is not the only relevant predictor of child pain. Using regression analyses, Ilowite et al (58) demonstrated that joint inflammation explained only 10% of the variance in pain scores and found no significant relationship between either disease subtype or number of joints affected and pain scores. Hagglund et al (10) failed to show a statistically significant association between disease severity and pain ratings of children with JA, and Thompson et al (45) found that medical status measures (arthritis subtype and disease activity) explained only modest amounts of variance (8% and 1%, respectively) in JA subjects' reports of pain. Using hierarchical regression analyses, we demonstrated that disease activity predicted a modest amount of variance in children's reported pain within the context of a predictive model including both disease and pain coping variables (46). Specifically, we found that disease activity accounted for 28% of the variance in children's pain report using a pain thermometer, 33% of the variance on the Oucher scale, and 13% of the variance in children's pain distribution. Clearly, medical variables alone do not account for child pain report.

Pain and psychosocial variables in JA.

The lack of robustness in the relationship between disease variables and pain variance reported by children with arthritis has prompted several researchers to take a broader look at pain predictors. The impact of many psychosocial variables has been explored including emotional distress, family functioning, mood, stress, children's pain coping strategies, and family pain history variables.

Thompson et al (45) and Varni et al (59) have proposed a model in which family environmental variables, child psychological variables, and disease variables interact in the development of children's pain experience. In their first study, a regression model including the Family Relationship Index of the Family Environment Scale, behavior and social subscales of the Child Behavior Checklist, and disease variables predicted 34% of the variance in present pain intensity and 72% of variance in children's ratings of their worst pain intensity (44). In a second study, ratings of worst pain over the past week were entered into a regression equation as a predictor variable along with the psychosocial variables from the first study. Results indicated that the regression model accounted for 57% of the variance in children's ability to carry out daily living activities (59). In a sample of 56 children with arthritis, Ross et al (57) found that increased child anxiety, increased maternal distress, and, surprisingly, increased family harmony were associated with a higher average pain rating, an average taken from pain ratings collected 3 times a day for approximately 28 days. The finding that increased family harmony was related to higher pain in children was contrary to study hypotheses. The authors hypothesized that greater family harmony may create an atmosphere that is responsive to a child's pain behavior, leading to reinforcement of the expression of pain behavior and the report of pain in children.

We are currently conducting a study investigating the interrelationships of daily stress, daily mood, and disease expression. Preliminary analyses indicate that day to day fluctuations in mood and stressful events are related to daily symptoms in children with juvenile polyarticular arthritis (60, 61). Specifically, worse mood and more stressful events were significantly related to increased daily pain, fatigue, and stiffness, as well as a decreased ability to control and decrease pain. Analyses were conducted using multilevel random effects modeling in which both within- and between-person variance is taken into account and each individual serves as his own control.

Our previous research has also demonstrated the importance of pain coping as a predictor of child pain report (46). We showed that pain coping explained a significant and unique proportion of variance in several measures of child pain, including the pain thermometer, Oucher, and body map, even after controlling for demographic and medical status measures. Children who rated their ability to control and decrease pain as high and who reported less tendency to catastrophize (i.e., engage in overly negative thinking about pain) had significantly lower pain intensity ratings and reported having pain in fewer body locations (46).

Further analyses revealed that parent and family pain history variables (e.g., family history of chronic pain conditions, parent pain intensity levels, parent pain-related interference in activities) were also significantly related to child self-reported pain and physician-rated health status (62). Moreover, within the context of hierarchical regression analyses, child catastrophizing was shown to mediate these relationships. In other words, parent and family pain variables influenced the use of catastrophizing by the child, which in turn influenced child reported pain and disease activity. Other researchers have also found catastrophizing to be important in child pain report. Thastum et al (54) showed that child catastrophizing predicted the pain response of 15 children with JA undergoing experimental cold pressor pain. Children who catastrophized more experienced increased pain intensity, reduced pain tolerance, and increased pain-related discomfort.

Taken together, there is a growing body of research pointing to the importance of psychosocial variables in the pain experience of children with JA, including emotional distress, daily stress, and mood. Also important is the way in which children perceive and cope with their pain. Finally, several studies have delineated the role of parental and familial factors in child pain, specifically parental psychological health, parental pain history, and the nature of the way in which family members interact with one another. Addressing these issues while providing aggressive traditional medical management may help to reduce pain, elevate mood, and improve overall quality of life for children with arthritis.

Assessment of Pain in Children With Arthritis

  1. Top of page
  2. Introduction
  3. Musculoskeletal Pain in Healthy Children
  4. Pain in Children With JA
  5. Assessment of Pain in Children With Arthritis
  6. Treatment of Pain in JA
  7. Procedural Pain and JRA
  8. Conclusions
  9. REFERENCES

Many pain assessment tools currently exist for research and clinical use in populations of children with arthritis and musculoskeletal pain. These include self-report measures of children's pain such as the Varni/Thompson Pediatric Pain Questionnaire (PPQ), the Oucher facial scale, and 100-mm VAS, as well as more objective measures of pain including behavioral observation. The PPQ is a multidimensional instrument that involves structured interviews with both the child and parent (18). It utilizes several techniques for assessing pain including VAS, a body map, and a list of pain descriptors. Although comprehensive in scope, the PPQ in its entirety is unwieldy for use in a clinic setting because of length; however portions, such as the VAS, have been used in the clinic setting with children older than 5 years (63).

More clinically useful assessment tools with demonstrated reliability and validity in many populations of children include the Oucher facial scale and a 100-mm pain thermometer. The Oucher facial scale consists of 6 photographs of a child's face displaying varying degrees of discomfort alongside an 11-point 0–100 numeric scale (15, 16). The photographs are available in white, African-American, and Hispanic versions and serve as pictorial cues for variation in pain intensity (16, 64). Children are asked to provide a rating that corresponds with their own levels of discomfort, a rating that reflects pain affect rather than true pain intensity (65–67). There are many other facial scales validated for use with children, including those developed by Bieri et al (65), McGrath et al (66), and Wong and Baker (67). Another variation of a VAS used in multiple studies is the pain thermometer. Children are asked to rate how much pain they are currently experiencing by drawing a line on the vertical thermometer anchored by “no pain” and “pain as bad as it can be” (68–70). Both the facial scales and pain thermometer are simple to administer and understandable even by young children (63).

Body outline figures have been shown to be useful in helping children report the location of pain (17, 18). In the pain location body map of the PPQ (18), children are given a simple body outline for the front and back views of a human body. They are instructed to shade in the areas of the body in which they are experiencing pain using different colors to reflect pain intensity. In children with arthritis involving multiple joints, the report of all pain locations on a body map adds another dimension to standard visual analog self-reports of pain. The body map may be particularly useful with children aged 5–7 years because they have concrete definitions for pain and may identify pain primarily through its location (63).

Jaworski et al (71) have also described the usefulness of a behavioral observation method in assessing pain and pain behaviors in children with arthritis. Children are asked to perform a 10-minute standard protocol of activities for video recording including sitting, walking, standing, and reclining. Trained observers code children's pain behaviors during the activities. The frequency of pain behaviors was positively correlated with children's pain report as well as parent and physician ratings of children's pain intensity (71).

Treatment of Pain in JA

  1. Top of page
  2. Introduction
  3. Musculoskeletal Pain in Healthy Children
  4. Pain in Children With JA
  5. Assessment of Pain in Children With Arthritis
  6. Treatment of Pain in JA
  7. Procedural Pain and JRA
  8. Conclusions
  9. REFERENCES

Pharmacologic treatments.

Although no clinical trials directly address pain management in JA, the treatment of pain in children with JA has historically focused on controlling the underlying disease with medications and providing symptomatic relief with acetaminophen, heat or cold, splints, adaptive devices, and physical therapy. The mainstay of drug treatment for the pain of JA continues to be nonsteroidal antiinflammatory drugs with acetaminophen for acutely painful events. Remittive agents, particularly methotrexate and etanercept, are indicated in children with multiple active joints and unremitting pain. Systemic steroids are generally avoided, but may be useful to treat painful flares while other interventions are put in place. Intraarticular steroids are a safe option to manage the inflammation in monoarticular or pauciarticular arthritis, but may also be useful to treat particularly painful joints in a child with polyarticular arthritis (63).

Opioids are used to provide pain relief in acute situations and to maintain mobility. As in adults, adjuvant medications are often useful for managing chronic pain. These most commonly include tricyclic antidepressants and selective serotonin reuptake inhibitors. The tricyclic antidepressants amytriptyline and nortriptyline are used in low doses given at night (63).

Surgical interventions.

Currently, there is no general agreement about the role of surgery in the treatment of children with arthritis. Surgical interventions can include synovectomies, soft-tissue release, and arthoplasty. Some research suggests that children experience marked pain reduction after surgical intervention (72–74). These interventions are generally limited to patients with marked functional impairment, severe disabling pain, and deformity. Whenever possible, the age of the child should be considered and surgery should be delayed until the growth plate has closed (19). Finally, surgical interventions should only be performed in specialized clinics at tertiary care centers. Given the recent advances in medications for children with arthritis, the future role of surgical interventions is unclear.

Cognitive-behavioral interventions.

As in adults (75–78), cognitive-behavioral therapy (CBT) approaches to pain management may be helpful and are designed to teach patients coping skills for controlling behavioral, cognitive, and physiological responses to pain. Typically, CBT for children involves educating children and parents about how pain messages are transmitted in the body and the role that they can play in managing this transmission of signals. Children are also instructed in a variety of pain coping skills and taught how to apply them in difficult situations. Finally, they are encouraged to anticipate situations in which they are likely to experience increased pain or difficulty managing pain and to plan strategies for handling these challenges. CBT training may be carried out in individual or group sessions, and typically ranges anywhere from 6 to 14 sessions (62).

Two published studies have investigated the efficacy of CBT among JRA patients (79, 80). Both studies demonstrated improvements in children's pain ratings after treatment; however, it is difficult to interpret the results given several important study limitations. Foremost among these include small sample size, the limited scope of the CBT intervention, and the lack of any functional outcome variables. Despite these limitations, both groups demonstrated improvement in pain ratings from pre- to post-treatment as well as from post-treatment to 6-month followup, suggesting that CBT may provide long-term benefits for children with JRA (79, 80). Future studies of CBT are necessary to more fully test the efficacy of CBT in this population.

Physical conditioning programs.

Research has demonstrated that children with chronic arthritis, particularly those with polyarticular involvement, are often less physically active than their peers due to pain, fatigue, and stiffness (81). As a result, a cycle of hypoactivity and deconditioning can be produced that only further decreases flexibility, muscle strength, and exercise tolerance. Indeed, it has been shown that school aged children with chronic arthritis have decreased aerobic capacity and endurance, decreased exercise time, and a decreased peak workload as compared with healthy controls (82, 83).

Recommendations for physical therapy and activity in children with arthritis have historically been cautious, with emphasis on rest, joint positioning, passive and active range of motion exercises, and restricting physical activities when inflammation is present (81). Despite this, pediatricians have always recognized the importance of physical activity to the normal physical and psychological development of children, including those with arthritis. Thus, a small number of researchers have begun to investigate the impact of physical conditioning programs on the pain and disease symptoms of children with JA, with a particular interest in determining the safety of such activities.

A series of studies provide preliminary support for the benefit and safety of conditioning programs in children with arthritis. Moncur et al (84) reported on 7 children with arthritis who participated in a 12-week aerobic conditioning program with bicycle ergometry. After the program, children demonstrated decreased joint counts, increased exercise time, and improved cardiovascular fitness. In a sample of 25 children with arthritis, Klepper (85) found that participation in an 8-week weight-bearing physical conditioning program led to improvements in aerobic endurance without exacerbation of disease symptoms or pain. Some children also experienced decreases in joint count and disease severity. Feldman et al demonstrated the feasibility and potential efficacy of 2 different exercise programs for children with arthritis (86, 87). Following completion of a 12-week progressive exercise program, children showed increased gait efficiency and increased peak anaerobic power for the legs, while children who completed a group exercise program including swimming and bicycle exercise training demonstrated increased exercise intensity and reported feeling highly motivated to continue exercising. Finally, Fisher et al (88) showed that resistance exercise lead to decreases in pain, disability, and medication use in a sample of 6 children with JA. Future studies are necessary to further delineate the appropriateness of exercise in children with arthritis.

Sleep.

Improving sleep quality is often overlooked in the treatment of pain. Children with pain and discomfort from arthritis may not sleep well and this in turn impacts their perception of pain. Simple measures like the use of a waterbed, or sleeping in sweat clothes to keep warm, may help ease discomfort. In addition, physical therapists can help by suggesting positions of comfort depending on the combination of active joints. Relaxation techniques such as progressive muscle relaxation or guided imagery can also be useful in improving sleep hygiene (62).

Massage therapy.

There has been 1 study examining the effects of massage therapy on pain in children with arthritis (89). Twenty children with mild to moderate arthritis were randomized to either a massage therapy group or a control group. Children in the massage therapy group received daily massage by 1 of their parents over the course of 30 days, and children in the control group took part in nightly relaxation exercises with their parents. After each treatment, children in the massage group reported decreased anxiety and had lower salivary cortisol levels. They also reported decreased present pain, less pain over the past week, and fewer painful locations at the end of the treatment period than the relaxation control. Parents and physicians also rated children who received massage as having decreased pain levels at the end of treatment compared with controls. Although this study provides initial support for the effectiveness of massage therapy in reducing the pain in children with arthritis, more research is needed to determine the role of massage in the pain management of children with JA (89).

Procedural Pain and JRA

  1. Top of page
  2. Introduction
  3. Musculoskeletal Pain in Healthy Children
  4. Pain in Children With JA
  5. Assessment of Pain in Children With Arthritis
  6. Treatment of Pain in JA
  7. Procedural Pain and JRA
  8. Conclusions
  9. REFERENCES

Often overlooked, but potentially important, is the role of repeated procedures in the pain experience of children with chronic arthritis. When children with arthritis present for diagnosis they are often fearful and anxious. The initial evaluation usually includes blood work and may include arthrocentesis. These procedures are traumatic to already scared children and their families. Many children diagnosed with JA will continue to require regular blood draws and clinic visits. Research suggests that the impact of initially negative experiences surrounding even minor procedures carry over to more negative perceptions of future procedures (90). This may add to the general anxiety surrounding the illness and physician interactions. Lidocaine and prilocaine cream (EMLA) and other topical anesthetics are widely available and easy to use. Additionally, CBT interventions such as distraction and relaxation have been shown to be effective in reducing the anxiety surrounding painful routine medical procedures in children (62).

Conclusions

  1. Top of page
  2. Introduction
  3. Musculoskeletal Pain in Healthy Children
  4. Pain in Children With JA
  5. Assessment of Pain in Children With Arthritis
  6. Treatment of Pain in JA
  7. Procedural Pain and JRA
  8. Conclusions
  9. REFERENCES

Recent studies have shown that pain is a significant problem for many children with arthritis, but a problem that may be under recognized and under treated. In the past, failure to consider the developmental stage of children with JA hindered researchers' attempts to assess pain. Newly developed pain assessment tools designed specifically for children have made it possible to conduct meaningful, valid, and reliable research on JA-related pain. Such research has highlighted the importance of demographic and psychosocial variables, as well as disease severity, in the prediction of pain in children with arthritis. Clinicians and researchers should consider child age and sex, pain coping, stress, and mood when assessing the pain and functional status of children with arthritis. Furthermore, assessment of parental and familial factors may be necessary to completely understand the nature of children's pain complaints (Figure 1).

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Figure 1. Pain in children with arthritis.

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Taken together, pain in children with JA is best conceptualized as a multidimensional construct. The complexity of the problem is best managed using a multidisciplinary approach that includes aggressive traditional medical management and incorporates interventions that address psychosocial variables, such as coping strategies and perceptions of disease. Cognitive behavioral therapy can approach these issues without interfering in the medical management of JA, and may actually help reduce pain, elevate mood, and improve overall quality of life for children with arthritis. In addition, early studies of physical interventions, such as exercise and massage, show promise in reducing pain in JA. These recommendations are consistent with the guidelines presented by the American Pain Society for the treatment of arthritis pain in children (19). Future research should attempt to further delineate the scope of the pain experience of children with JA with special attention to possible physiologic changes in pain processing as a result of chronic pain stimuli. Further understanding of the interplay between psychosocial factors and pain perception will also help with the development of targeted interventions to optimize pain management.

REFERENCES

  1. Top of page
  2. Introduction
  3. Musculoskeletal Pain in Healthy Children
  4. Pain in Children With JA
  5. Assessment of Pain in Children With Arthritis
  6. Treatment of Pain in JA
  7. Procedural Pain and JRA
  8. Conclusions
  9. REFERENCES
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