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Somatosensory Test Responses in Children with Growing Pains

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Somatosensory Test Responses in Children with Growing Pains Journal of Pain Research Dovepress open access to scientific and medical research Open Access Full Text Article ORIGINAL RESEARCH Somatosensory test responses in children with growing pains Shanthi Pathirana1 Purpose: To further the understanding of growing pains (GP), in particular, the nature of this David Champion1,2 pain disorder. Tiina Jaaniste1 Methods: This study included 33 children aged 5–12 years who met criteria for GP (cases) Anthony Yee2 and 29 children without GP of similar age and sex (controls). Nineteen controls were siblings Cindy Chapman1 of cases. GP was diagnosed by standard consensus questionnaires. A questionnaire addressed characteristics of the pain and family history of GP. Evidence for peripheral neuropathic disorder 1Department of Anesthesia and was tested by somatosensory testing and provocation tests of peripheral nerves. Somatosensory Pain Medicine, 2Department of Rheumatology, Sydney Children’s testing by a blinded researcher involved threshold determination and/or response magnitude to Hospital, Randwick, New South nonpainful stimuli including touch, dynamic brush, cold, vibration, and deep pressure applied Wales, Australia to limb and abdominal sites. Results: Distributional, temporal, and quality characteristics of the pain were in accordance with published descriptions. There was no indication of primary musculoskeletal disorder. No evidence was found that GP is a peripheral neuropathic pain syndrome. There were minor but statistically significantly increased responses to cutaneous cold, vibration, and to deep pressure stimuli in cases compared to controls, evident in a wider distribution than the symptomatic lower limbs. Conclusion: GP is a regional pain syndrome with evidence in this study of mild widespread disorder of somatosensory processing. Keywords: growing pains, somatosensory testing, case-control study Introduction From the time of the earliest descriptions of growing pains (GP) to the most recent reviews,1–3 the nature of the prevalent disorder of childhood, GP (benign nocturnal limb pains of childhood), has remained enigmatic. Early etiological theories of GP addressed growth,4 relative hyperactivity and fatigue,5–8 anatomical/biomechanical factors,9,10 and psychogenic factors.4,11 However, none of these factors have been shown to be more than potential contributors. The current study was designed to shed light on the question put forward by Naish and Apley, “What is this malady called GP?”4 Evidence that GP may be arising from somatic tissues, particularly musculoskeletal structures, in the limbs has not been convincing.1,3 The possibility that GP is mediated Correspondence: David Champion by peripheral nerve dysfunction has not been definitively tested. Evidence of disordered Department of Anesthesia and Pain somatosensory processing in the form of widespread deep pressure allodynia (pain Medicine, Sydney Children’s Hospital, High St, Randwick, NSW 2031 Australia due to a stimulus which does not normally provoke pain)/hyperalgesia (an increased Tel +61 2 9382 1585 response to a stimulus which is normally painful) has been demonstrated by pain Fax +61 2 9904 4900 Email [email protected] threshold testing by Hashkes et al.12 This is the only published study of somatosensory submit your manuscript | www.dovepress.com Journal of Pain Research 2011:4 393–400 393 Dovepress © 2011 Pathirana et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article http://dx.doi.org/10.2147/JPR.S24875 which permits unrestricted noncommercial use, provided the original work is properly cited. Pathirana et al Dovepress testing in GP and did not include responses to cutaneous dizygotic). The high number of twins was the result of adver- stimuli which are less sensitively elicited in clinical condi- tisements that, for purposes external to the current study, tions characterized by a widespread deep hyperalgesic state. indicated a particular interest in twins. The hypothesis of this paper is based on Haschkes et al’s A set of clinical somatosensory test procedures was evidence for deep hyperalgesia, with the aim of confirming developed based on the standard neurological clinical this hypothesis and extending the evidence to cutaneous examination and selected somatosensory tests applicable somatosensory responses. to children in an office practice to obtain evidence about Arising from this background, the hypothesis that GP is peripheral neuropathic disorders and/or abnormal central characterized by widespread disorder of somatosensory pro- sensory processing. These methods were derived from pub- cessing was tested. Alternatively, it is a peripheral neuropathic lished protocols.16–20 The selection of multimodal-stimulus pain syndrome (pain initiated or caused by a primary lesion response measures has been further supported recently by or dysfunction in the (peripheral) nervous system).43 Neziri et al,21 who showed that responses to different modali- ties represent different specific dimensions and should be Materials and methods assessed in combination. The current study however did Thirty-three children (14 males, 19 females) aged 5–12 not use any noxious stimuli (pain provocation in children years were recruited by advertisement (newspaper, radio, with a normally functioning nervous system) on request school newsletter, hospital notice board), conscious that the from the South Eastern Sydney Area Health Service Ethics peak age of point prevalence for GP is 4–6 years.8 However, Committee, who approved the final protocol. Thus, there symptoms may develop later and continue into adolescence,35 were no pain threshold determinations. The procedures were and somatosensory test responses are less reliable under demonstrated by the researcher (SP), who was blinded as 5 years.23 The written advertisements were headlined: to case or control status. The process was organized by the “Volunteers, children aged 5–12 years, are required for an participating pediatrician so that the blinding was strictly ethically approved study into the nature of nocturnal limb applied. pain syndrome (GP).” The content included: “This study Taking into consideration the avoidance of quantitative will be conducted by personnel from the Sydney Children’s sensory testing apparatus requiring a laboratory base, the Hospital (Pain Medicine Unit) and the University of New related portability and time availability for office/bedside South Wales. If your child has aches and pains in the limbs, application, and the avoidance of pain thresholds for heat, especially legs and particularly at night, participation in this cold, and mechanical stimuli, the following test stimuli study would be greatly appreciated. This study is in no way (and responses) were selected and applied to specified sites. harmful and should not cause distress. We shall also be asking Additionally, the cases and controls were assessed for abnor- for a volunteer, such as a friend, of similar age and same sex mal responses in peripheral nerve or dermatomal distribution. as your child to come along and participate in what will be The procedures are summarized in Table 2.22–25 an interesting study.” Those who responded were mailed a package con- Test stimuli taining further information about the study including the With focus on the distribution of quantitative or qualitative planned sensory testing, consent forms, and a GP screening abnormalities, static light touch was assessed by nonstroking questionnaire,13 based on Petersen’s GP criteria (Table 1).14 touch of obliquely applied soft brush fibers to lower legs, With there being no gold standard for the diagnosis of GP, forearms, and abdomen. This was the first assessment of the Petersen criteria have been widely applied in published A-beta peripheral sensory channel, central lemniscal pathway, studies to a point of reasonable consensus.15 A case selection and a large array of cortical regions. flowchart is presented as Figure 1. Each participant (cases Calibrated von Frey monofilament stimuli (VF1 and controls) was also reviewed by a pediatrician (AY) to Optihair-2 [set of 12 optical glass filaments with force range consider differential diagnoses of lower limb pain. 0.25–512 mN]; Marstock, Marburg, Germany) enabled fixed The control group comprised 29 children (12 males, 17 graded stimuli to assess static light touch. This procedure also females) who did not have limb pain. In view of the dif- assessed A-beta peripheral sensory channels and lemniscal ficulties in recruiting volunteers to undergo somatosensory central pathway. Applied to lower legs, forearms, and abdo- testing, 19 controls were siblings of cases without GP, eight men, it provided mechanical detection threshold for touch, of whom were unaffected twins (three monozygotic; five pain threshold in states of cutaneous hyperalgesia. For touch 394 submit your manuscript | www.dovepress.com Journal of Pain Research 2011:4 Dovepress Dovepress Somatosensory test response in children with GP Table 1 Definition of Petersen’s ‘‘growing pains,’’12 modified by Evans and Scutter13 Pain factors Inclusion criteria Exclusion criteria Nature of pain Intermittent Persistent Some pain free days and nights Increasing intensity Unilateral or bilateral Bilateral Unilateral Location of pain Anterior thigh, calf, Joint pain posterior knee – in muscles Onset of pain Late afternoon or evening Pain still present next morning Physical examination Normal Swelling, erythema, tenderness Local trauma or infection. Reduced joint range or motion Limping Laboratory
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