Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Treatment of chronic pain in pediatric rheumatic disease

Nature Clinical Practice Rheumatology volume 3, pages 210–218 (2007)Cite this article

Abstract

Pain in children with rheumatic disease is common, and is most often caused by arthritis. Despite the widespread use of effective new biologic agents, pain continues to be a problem in these patients, and it greatly impairs their daily functioning and quality of life. The pathogenesis of pain in children with rheumatic diseases is multifactorial, and disease treatment alone is often not enough to alleviate it. No standard of care or detailed algorithm for managing pain in these patients exists. Specific pain treatments often include acetaminophen, NSAIDs and medications that treat arthritis, such as methotrexate and etanercept. Other approaches should include nonpharmacologic interventions, for example exercise and cognitive-behavioral therapy, as well as the use of analgesics such as opioids in patients whose pain is refractory to standard therapies. The use of systemic corticosteroids to treat pain in children with arthritis should be avoided.

Key Points

  • Pain continues to be common in children with rheumatic diseases, despite advances in arthritis treatment

  • The pathogenesis of pain in children with rheumatic diseases is multifactorial

  • Pain management should be interdisciplinary and consist of nonpharmacologic as well as pharmacologic interventions

  • There are no current detailed treatment guidelines for treatment of pain in children with rheumatic diseases

  • More agressive pain treatments should be considered in those patients who continue to have significant residual pain

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

References

  1. Lovell D and Walco GA (1989) Pain associated with juvenile rheumatoid arthritis. Pediatr Clin North Am 36: 1015–1027

    Article  CAS  Google Scholar 

  2. Petty RE et al. (2004) International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. J Rheumatol 31: 390–392

    Google Scholar 

  3. Sherry D et al. (1990) Painless juvenile rheumatoid arthritis. J Pediatr 116: 921–923

    Article  CAS  Google Scholar 

  4. Schanberg L et al. (1997) Pain coping and the pain experience in children with juvenile chronic arthritis. Pain 73: 181–189

    Article  CAS  Google Scholar 

  5. Hagglund K et al. (1995) Predicting pain among children with juvenile rheumatoid arthritis. Arthritis Care Res 8: 36–42

    Article  CAS  Google Scholar 

  6. Schanberg L et al. (2003) Daily pain and symptoms in children with polyarticular arthritis. Arthritis Rheum 48: 1390–1397

    Article  Google Scholar 

  7. Dhanani S et al. (2002) Minimal difference in pain associated with change in quality of life in children with rheumatic disease. Arthritis Rheum 47: 501–505

    Article  Google Scholar 

  8. Gruver D (2004) Living with rheumatoid arthritis: unmet needs [http://www.arthritis.org/conditions/diseasecenter/RA/RASurvey/ WhitePaperFinal.pdf] (accessed 9 February 2007)

  9. Merkel S et al. (1997) The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatr Nursing 23: 293–297

    CAS  Google Scholar 

  10. Kidd BL and Urban LA (2001) Mechanisms of inflammatory pain. Br J Anaesth 87: 3–11

    Article  CAS  Google Scholar 

  11. Giordano J (2006) The neuroscience of pain and analgesia. In Weiner's Pain Management: A Practical Guide for Clinicians (Eds Boswell MV and Cole BE) Boca Raton: Taylor & Francis

    Google Scholar 

  12. Zeltzer L et al. (1997) Pain responsiveness and chronic pain: a psychobiological perspective. J Develop Behav Pediatr 18: 13–22

    Article  Google Scholar 

  13. Woolf CJ and Salter MW (2000) Neuronal plasticity: increasing the gain in pain. Science 288: 1965–1969

    Article  Google Scholar 

  14. Pediatric chronic pain: a position statement from the American Pain Society [http://www.ampainsoc.org/advocacy/pediatric.htm] (accessed 9 February 2007)

  15. Thompson K et al. (1987) Comprehensive assessment of pain in juvenile rheumatoid arthritis: an empirical model. J Pediatr Psychol 12: 241–255

    Article  CAS  Google Scholar 

  16. Ilowite N et al. (1992) Assessment of pain in patients with juvenile rheumatoid arthritis: relation between pain intensity and degree of joint inflammation. Ann Rheum Dis 51: 343–346

    Article  CAS  Google Scholar 

  17. Malleson P et al. (2004) Predictors of pain in children with established juvenile rheumatoid arthritis. Arthritis Rheum 51: 222–227

    Article  Google Scholar 

  18. Rapoff MA and Lindsley CB (2000) The pain puzzle: a visual and conceptual metaphor for understanding and treating pain in pediatric rheumatic disease. J Rheumatol Suppl 58: 29–33

    CAS  PubMed  Google Scholar 

  19. Zeltzer L et al. (1997) A psychobiologic approach to pediatric pain: Part II. Prevention and treatment. Curr Prob Pediatr 27: 264–284

    CAS  Google Scholar 

  20. Anonymous (2002) Guideline for the management of pain in osteoarthritis, rheumatoid arthritis and juvenile chronic arthritis. Glenview: American Pain Society

  21. Kimura Y et al. (2006) Treatment of pain in juvenile idiopathic arthritis: a survey of pediatric rheumatologists. Arthritis Rheum 55: 81–85

    Article  Google Scholar 

  22. Hashkes PJ and Laxer RM (2005) Medical treatment of juvenile idiopathic arthritis. JAMA 294: 1671–1684

    Article  CAS  Google Scholar 

  23. Weiss J and Ilowite NT (2005) Juvenile idiopathic arthritis. Pediatr Clin North Am 52: 413–442

    Article  Google Scholar 

  24. Lang B and Finlayson LA (1994) Naproxen-induced pseudoporphyria in patients with juvenile rheumatoid arthritis. J Pediatr 124: 639–642

    Article  CAS  Google Scholar 

  25. Dominick K et al. (2004) Patterns of opioid analgesic prescription among patients with osteoarthritis. J Pain Palliat Care Pharmacother 18: 31–46

    Article  Google Scholar 

  26. Kalso E et al. (2004) Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain 112: 372–380

    Article  CAS  Google Scholar 

  27. Cowan D et al. (2005) A randomized, double-blind, placebo-controlled, cross-over pilot study to assess the effects of long-term opioid drug consumption and subsequent abstinence in chronic noncancer pain patients receiving controlled-release morphine. Pain Med 6: 113–121

    Article  Google Scholar 

  28. Caldwell J et al. (1999) Treatment of osteoarthritis pain with controlled release oxycodone or fixed combination oxycodone plus acetaminophen added to nonsteroidal antiinflammatory drugs: a double blind, randomized, multicenter, placebo controlled trial. J Rheumatol 26: 862–869

    CAS  PubMed  Google Scholar 

  29. Furlan AD et al. (2006) Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ 174: 1589–1594

    Article  Google Scholar 

  30. Malonne H et al. (2004) Efficacy and tolerability of sustained-release tramadol in the treatment of symptomatic osteoarthritis of the hip or knee: a multicenter, randomized, double-blind, placebo-controlled study. Clin Ther 26: 1774–1782

    Article  CAS  Google Scholar 

  31. Walker JS (2003) Anti-inflammatory effects of opioids. Adv Exp Med Biol 521: 148–160

    CAS  PubMed  Google Scholar 

  32. Varni JW et al. (1990) Cognitive-behavioral assessment and treatment of pediatric pain. In Handbook of Clinical Behavioral Pediatrics, 83–97 (eds Gross AM and Drabman RS) New York: Plenum Press

    Chapter  Google Scholar 

  33. Eccelston C et al. (2002) Systematic review of randomised controlled trials of psychological therapy for chronic pain in children and adolescents, with a subset meta-analysis of pain relief. Pain 99: 157–165

    Article  Google Scholar 

  34. Walco G et al. (1999) Empirically supported treatments in pediatric psychology: disease related pain. J Pediatr Psychol 24: 155–167

    Article  CAS  Google Scholar 

  35. Lavigne J et al. (1992) Evaluation of a psychological treatment package for treating pain in juvenile rheumatoid arthritis. Arthritis Care Res 5: 101–110

    Article  CAS  Google Scholar 

  36. Walco G et al. (1992) Cognitive-behavioral pain management in children with juvenile rheumatoid arthritis. Pediatrics 89: 1075–1079

    CAS  PubMed  Google Scholar 

  37. Takken T et al. (2003) Relationship between functional ability and physical fitness in juvenile idiopathic arthritis patients. Scand J Rheumatol 32: 174–178

    Article  CAS  Google Scholar 

  38. Takken T et al. (2002) Aerobic fitness in children with juvenile idiopathic arthritis: a systematic review. J Rheumatol 29: 2643–2637

    PubMed  Google Scholar 

  39. Klepper S (1999) Effects of an eight-week physical conditioning program on disease signs and symptoms in children with chronic arthritis. Arthritis Care Res 12: 52–60

    Article  CAS  Google Scholar 

  40. Singh-Grewal D et al. (2006) Pilot study of fitness training and exercise testing in polyarticular childhood arthritis. Arthritis Rheum 55: 364–372

    Article  CAS  Google Scholar 

  41. Maenpaa H et al. (2003) Elbow synovectomy on patients with juvenile rheumatoid arthritis. Clin Orthop Rel Res 412: 65–70

    Article  Google Scholar 

  42. Iesaka K et al. (2006) Orthopedic surgical management of hip and knee involvement in patients with juvenile rheumatoid arthritis. Am J Orthop 35: 67–73

    PubMed  Google Scholar 

  43. Kitsoulis P et al. (2006) Total hip arthroplasty in children with juvenile chronic arthritis: long-term results. J Pediatr Orthop 26: 8–12

    Article  Google Scholar 

  44. Palmer D et al. (2005) Total knee arthroplasty in juvenile rheumatoid arthritis. J Bone Joint Surg Am 87: 1510–1514

    PubMed  Google Scholar 

  45. van der Heijde D et al. (2006) Comparison of etanercept and methotrexate, alone and combined, in the treatment of rheumatoid arthritis: two-year clinical and radiographic results from the TEMPO study: a double-blind, randomized trial. Arthritis Rheum 54: 1063–1074

    Article  CAS  Google Scholar 

  46. Field T et al. (1997) Juvenile rheumatoid arthritis: benefits from massage therapy. J Pediatr Psych 22: 607–617

    Article  CAS  Google Scholar 

  47. Powell M et al. (2005) Efficacy of custom foot orthotics in improving pain and functional status in children with juvenile idiopathic arthritis: a randomized trial. J Rheumatol 32: 943–950

    PubMed  Google Scholar 

  48. Gossec L et al. (2006) Nonpharmacological treatments in early rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion. Joint Bone Spine 73: 396–402

    Article  Google Scholar 

  49. Weiss JE et al. (2006) Analgesia for intra-articular corticosteroid injections in juvenile idiopathic arthritis (JIA): a survey of pediatric rheumatologists [abstract]. Arthritis Rheum 54 (Suppl): S171

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Y Kimura is the founder and Chief of the Section of Pediatric Rheumatology at the Joseph M Sanzari Children's Hospital of Hackensack University Medical Center, Hackensack, and Associate Professor of Pediatrics at the University of Medicine and Dentistry, New Jersey.,

    Yukiko Kimura

  2. GA Walco is Professor of Pediatrics at the University of Medicine and Dentistry, New Jersey, and Director of the David Center for Children's Pain and Palliative Care at Hackensack University Medical Center, Hackensack, NJ, USA.,

    Gary A Walco

Authors
  1. Yukiko Kimura
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gary A Walco
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yukiko Kimura.

Ethics declarations

Competing interests

Dr. Walco is a consultant to Cephalon and Endo Pharmaceuticals, as well as an investigator in a clinical trial sponsored by Cephalon.

Dr. Kimura is an investigator in clinical trials sponsored by NIH, Amgen and Regeneron.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kimura, Y., Walco, G. Treatment of chronic pain in pediatric rheumatic disease. Nat Rev Rheumatol 3, 210–218 (2007). https://doi.org/10.1038/ncprheum0458

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncprheum0458

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing