Document 6444270

British Journal of Rheumatology 1996;35:1022-1028
PAEDIATRIC RHEUMATOLOGY
BACK PAIN IN CHILDREN
P. HOLLINGWORTH
Southmead Hospital, Westbury on Trym, Bristol BSW5NB
SUMMARY
Pay attention to back pain reported by children. Half will have a specific or serious cause, the presenting symptoms of serious
conditions may be misleadingly mild, and the spectrum of causes and mode of presentation differ from adults. Warning features
include onset aged < 4 yr, symptoms persisting beyond 4 weeks, interference with function, systemic features, worsening pain,
neurological features and recent onset of scoliosis. Scintigraphy is often useful where clinical features and plain radiographs fail
to identify the diagnosis. Sports activities may cause stress reactions in the immature spine, particularly at the junction between
spinal segments of differing mobility, the vascularity of the disc and vertebra predisposes to infection, spinal tumours presenting
as pain tend to be primary and benign, congenital spinal anomalies causing pain tend to present in childhood, spondylitis presents
differently from adults, and conversion hysteria, typically presenting with gross, bizarre and disabling symptoms, is not
uncommon in adolescent girls.
LARGE community studies report up to a half of
children having experienced episodes of back pain, with
the prevalence rising through the teenage years [1]. In
contrast, children uncommonly seek medical help for
back pain, but a specific or serious cause will be found
in nearly half of these [1-4]. Serious causes may present
with minor symptoms and the diagnosis is often
delayed (Table I). Accordingly, follow-up is important
in children where a specific cause cannot be found, and
a failure of conservative treatment beyond 2 months
warrants further investigation [5].
SPONDYLOLYSIS AND SPONDYLOLISTHESIS
Defects of the pars interarticularis are the
commonest identifiable cause of low back pain in
children and adolescents [10]. These defects arise from
a stress fracture or stress reaction of the isthmus of the
pars interarticularis, the weakest part of the posterior
arch [3] of the fifth lumbar vertebra. They usually
result from excessive stresses in sport and they tend to
occur during the growth spurt. Sports such as
gymnastics, dance, football and the high jump, which
demand rapid movement between hyperflexion and
hyperextension, or excess loading in hyperextension,
such as weight lifting, are believed to result in
microfractures of the isthmus. Avoidance of sport may
allow healing, often with an elongated pars interarticularis. However, in some children, a complete fracture
occurs, usually within a year, a pseudoarthrosis
develops and the attempt at healing ceases. This
process begins on one side and is then repeated
contralaterally owing to the excessive strain borne by
the pars interarticularis. The onset of symptoms is
usually insidious and presentation with an acute
fracture is rare.
The resultant forward slip of the fifth lumbar on the
first sacral vertebra leads to a spondylolisthesis.
Degeneration of the nucleus pulposus of the L5/S1 disc
has been demonstrated on MRI in a quarter of children
with a spondylolisthesis and these changes correlate
with pain, which implicates the disc as the source of the
pain in some [11-13]. Neurological symptoms are
uncommon, possibly because these children tend to
have a wide central canal [13].
Suggestions that spondylolysis results from a
congenital abnormality of the posterior arch are not
supported by post-mortem studies on infants and by
the majority presenting after the age of 6 yr [14].
Familial spondylolisthesis has been reported as a
rarity [15].
NON-SPECIFIC LOW BACK PAIN
Several studies have shown that up to half of all
children in the community give a history of low back
pain [1,5-9] and the cumulative prevalence rises
steadily with age: compared with the 5-9 yr olds, the
prevalence is 4-fold for the 13-15 yr age group and
16-fold for the 16-20 yr age group [4]. Certain
anthropomorphic variations, which may put
excess strain on the spine, have been associated with
back pain in children: decreased mobility of
the hips; decreased lumbar extension and increased
lumbar flexion; thoracic hyperkyphosis and lumbar
hyperlordosis; tight hamstring muscles; poor
abdominal muscle strength. Other associations are a
slight preponderance of girls, sporting activities and
time spent watching television [1].
TRAUMA
This must account for a large proportion of children,
seen by family practitioners, with back pain that settles
within a few weeks. Muscular or tendinous sprains are
implicated, although on no certain knowledge, and so
pain persisting after isolated or repeated trauma
warrants investigation.
Submitted and accepted 19 June 1996.
© 1996 British Society for Rheumatology
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KEY WORDS: Children, Back pain, Spondylolisthesis, Scheuermann's disease, Discitis.
HOLLINGWORTH: BACK PAIN IN CHILDREN
on Tl-weighted images which correlates with the
scintigraphic changes [21]; the advantage of MRI is
that radiation exposure is not involved.
Normal plain radiographs and scintigraphy exclude
spondylolysis. Normal plain radiographs, but positive
scintigraphy, are found usually within 1 yr of the onset
of symptoms and indicate an attempt at healing which
may be maximized by conservative treatment.
Conservative treatment may also help a lesion
identified as a fracture on plain films with positive
scintigraphy on the same side (i.e. an attempt at healing
the fracture) or on the other side (an incipient fracture
of the contralateral pars interarticularis). However, a
fracture evident on the plain films with negative
scintigraphy indicates non-union and also that the
lesion began more than a year earlier; this may have
medicolegal implications [20].
An attempt at healing, indicated by positive
scintigraphy, is more likely to be successful within
1 yr of the onset of symptoms and without a
spondylolisthesis. Conservative treatment is recommended in these individuals with exercises to
strengthen the abdominal and paraspinal muscles, and
abstinence from running, jumping, sudden changes in
movement and contact sports [16] until the pain has
gone and the scan is normal [14]. Even then, sport
demanding extra weight bearing on extension is to be
avoided. When symptoms have settled, children should
be reviewed during the growing period as a
spondylolisthesis may still develop. Implications for
surgical fusion are a slip of > 50% or persistent back
pain despite conservative measures [22].
Continuing sporting activity usually results in
progression of the lesions with a poor outlook for sport
[20, 22, 23].
TABLE I
Back pain in children: clinical features suggesting causes that are serious or require specific treatment
Age of onset: < 4 yr
Duration of symptoms: > 4 weeks
Interference with function, such as school, play or sport
More likely to be significant
Systemic features: fever, sweats, loss of weight or appetite, malaise
Pain disturbing sleep
Infection or malignancy
Pain worsening in severity
Unlikely to be acute post-traumatic pain
A history of trauma or vigorous sporting activities
May be post-traumatic
Neurological symptoms and signs
1. Gait change
2. Sphincter disturbance: episodes of incontinence or change in bowel or
bladder habit
3. Recurrent dystonic foot or leg deformities
4. Weakness: best tested functionally in the younger patient—rising from a squat,
heel and toe walking
Neurological compromise
Straight leg raising limited by tight hamstrings
Spondylolysis, spondylolisthesis, or tumour
Pain below the knee
Nerve root irritation
Scoliosis
1.
Painful
2.
Painful thoracic scoliosis to the left
Exaggerated thoracic kyphosis
Rarely 'idiopathic'
Less frequently idiopathic
Midline skin deformities: dimples, pigmented naevus, hairy patch, myelocoele
closure scar, lipoma, dermoid cyst, dysraphism
Scheuermartn's disease
Congenital anomalies
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In Western populations, the prevalence of isthmic
abnormalities radiographically in children is reported
as being 2-7% and up to 30% in elite athletes; many
of these children are symptomless [10, 16-18]. In some
sports [15], boys are affected twice as frequently as girls
and Whites are affected more than Blacks [3].
The typical sufferer is an athletic teenage boy with an
insidious onset of low back pain, usually not
incapacitating, which occurs after sporting events and
improves with rest. Neurological symptoms are rare.
The pain is localized to the low back, just below
the level of the iliac crest. There may be local
tenderness, muscle spasm and, uncommonly, a major
spondylolisthesis results in a palpable step or a
horizontal crease across the back. Tight hamstrings
are commonly found, but the cause of this is not known
[3].
The best screening test is the 'one leg extension
manoeuvre' [19]: when standing on one leg with the
other leg and knee flexed, hyperextension of the low
back evokes unilateral or symmetrical low back pain.
The principal investigations are plain radiographs
of the lumbar spine and bone scintigraphy. Anteroposterior and lateral plain radiographs usually suffice,
but oblique views at the L5/S1 level are indicated
if a spondylolysis is still suspected. Flexion and
extension views of the lumbar spine rarely show
instability, and are no longer considered necessary.
Increased density of the pars interarticularis or a
fracture with sclerosis from a pseudoarthrosis may be
seen.
Bone scintigraphy shows increased uptake by the
pars interarticularis long before changes are present on
the plain radiograph [20]. MRI at this stage may
identify a hypo-intense area of the pars interarticularis
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STRESS REACTION OF THE
SACROILIAC JOINTS
Two athletes aged 10 and 17 yr have been described
[24] who developed low back pain with tenderness over
the sacroiliac joints after starting or increasing their
exercise programme. The diagnosis was not expected
and was made on bone scintigraphy, which showed
abnormal uptake over one or both sacroiliac joints
although plain films were normal. Interpreting bone
scintigraphy of the sacroiliac joints at this age range,
when the epiphyses are unfused, is difficult, but the
authors used both anterior and posterior views,
and computer-generated images in reaching their
conclusion. Complete recovery occurred.
SPINAL NEOPLASMS
Spinal neoplasms presenting as back pain in
childhood are rare. Most are primary, benign, and arise
from a vertebral body.
The diagnostic clues include pain waking the child at
night, unremitting pain, the development of a painful
scoliosis, localized tenderness, a palpable lump,
bilateral sciatica, neurological signs and disproportionate anaemia. Initial plain radiographs may be normal,
but scintigraphy is usually positive.
Benign vertebral tumours
Osteoid osteoma and
osteoblastoma
[33-35].
These are considered to be part of the same continuum.
Osteoid osteoma does not exceed 1 cm in diameter
radiographically, is associated with more obvious
sclerosis and may have a radiolucent centre.
Osteoblastoma is histologically identical, but larger.
Both usually arise in the posterolateral elements, but
may involve the whole vertebral body and adjacent
facets and pedicles.
They present with pain in the spine, often disturbing
sleep and not always giving the typical story of a
response to salicylates. There may be localized
tenderness and, frequently, a scoliosis. Pain radiating
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SCHEUERMANN'S DISEASE OR
JUVENILE KYPHOSIS
This is evident radiographically in 20-30% of the
adult population [15], the majority of whom cannot
remember any back symptoms. The usual presentation
is an adolescent complaining of back pain (50%) or a
painless thoracic kyphosis.
Boys present twice as frequently as girls, they usually
play sports and cannot identify a specific onset, which
is typically insidious. The thoracolumbar junction is
the most common site, although the thoracic or lumbar
spine alone may be affected; lumbar lesions are said to
be more painful.
The pain is usually mild to moderate in severity,
worse towards the end of the day or after physical
activity, and is relieved by rest.
Examination may be normal or show an exaggerated
thoracic kyphosis which is fixed in attempted
hyperextension, in contrast to the 'mobile round back'
[15]. A compensatory hyperlordosis and mild scoliosis
are common.
Plain radiographs of the thoracic spine show an
increased kyphosis with anterior wedging of one or
more vertebrae, irregularity of the vertebral end plate
and herniation of the disc upwards or downwards
into the body of the adjacent vertebra (Schmorl's
node). Similar changes are seen in any condition
weakening the end plate, notably osteoporosis,
hyperparathyroidism, neoplasia and disc degeneration [15]. Anteroposterior herniation under the
ring apophysis may separate a fragment of the
apophysis (anterior Schmorl's node) which may ossify
separately—the 'limbus vertebra'. The presence of
these radiographic findings is the same in the
adolescent population without back pain, but MRI
studies show a higher prevalence of concomitant
degenerative disc changes in those with symptoms [25].
The consensus of opinion implicates trauma,
repeated or acute, of the immature spine: the
prevalence of these radiographic changes is greater in
athletes [26, 27], especially those whose sport involves
loading of the back in flexion such as gymnastics or
weight lifting; post-mortem studies of vertically loaded
spines show bulging of the vertebral end plate into the
adjacent vertebra, causing local ischaemia of the bone,
and later rupture of the disc into the body [28]. The
prevalence is increased in adolescents engaged in
physical labour—Scheuermann called it 'apprentice
kyphosis' and another author noted that it was eight
times more common in 'lads from the country' [30].
Hyperextension loads the spine anteriorly at the
thoracolumbar junction [31]; in a study of symptomatic
Scheuermann's disease, one-third of patients also had
changes of spondylolysis [29].
The evolution of these changes has been described
[27] in two gymnasts with a brief episode of pain at the
thoracolumbar junction following a hyperflexion
manoeuvre. Radiographs at the time showed normal
disc spaces in both, but separation of the anterior
fragment of the ring apophysis of T12 in one gymnast.
The pain returned after a few weeks and persisted for
a year or two. Repeat radiographs at this stage showed
separation of an anterior fragment of the superior ring
apophysis, excavation of its previous attachment to
T12, and narrowing of the adjoining disc space. MRI
showed extension of the disc material anteriorly.
These established findings are the same as the
'anterior Schmorl's node'. Possibly recognition of the
nature of the injury and abstinence from sport might
have allowed healing without extrusion of disc
material. Other suggested causes of Scheuermann's
disease are osteonecrosis of the ring apophysis and
osteochondritis.
The outlook is good. Pain decreases with restricted
activity, but immobilization in plaster is occasionally
needed. Bracing exercises may help. A brace is
indicated in a few with a severe kyphosis [3]. A rapid
and marked return of disc height after starting to wear
a brace is reported [29]. Back pain in later life is more
common than in controls, but is rarely severe [32].
HOLLINGWORTH: BACK PAIN IN CHILDREN
Malignant vertebral tumours
Ewing's sarcoma is the most common malignant
tumour and can mimic spinal infection as the back pain
may be accompanied by fever, leucocytosis, a raised
sedimentation rate and moth-eaten bony changes on
the radiographs.
Primary lymphomas may involve the spine, and nonHodgkin's and Hodgkin's lymphoma can metastasize
there.
Neuroblastoma is the most common malignancy in
young children and usually presents as an abdominal
mass. Spinal metastases may present with back pain.
The initial haemoglobin level, often < 10 g, is an
important laboratory finding suggesting malignancy
[40].
Intraspinal tumours. These are even less common.
Half are extradural, spreading from adjacent vertebrae,
a quarter are intramedullary, principally slow-growing
astrocytomas, and a quarter extramedullary—
neurofibromas, lipomas and dermoid cysts [41].
Seventy per cent are benign and slow growing with
subtle progression of symptoms and signs. Forty per
cent present with spinal pain which often radiates to
the involved dermatomes. The remainder present with
a limp or difficulty walking, changes in bladder or
bowel habit, or leg or foot deformities from
neuromuscular imbalance.
DISCITIS AND VERTEBRAL OSTEOMYELITIS
Discitis chiefly affects young children; half are aged
< 4 yr and it is rare after 10 yr. The presentation ranges
from an otherwise well child complaining of a stiff back
to a distressed, febrile child refusing to walk because of
back pain [42-44]. The pain may radiate to, or only be
felt in, the abdomen or thighs. The child often protects
the back by sitting in a hyperextended position, using
the arms as support, or by assuming an unusual
posture. They are often comfortable lying down, but
cry if they are made to sit.
Lesions are confined to one lumbar disc space and
80% are either L3/4 or L4/5. Bone scintigraphy is
positive in all by the time of presentation, but plain
radiographic changes do not appear until after 2 weeks
when there is disc space narrowing and vertebral end
plate irregularity.
Only one-quarter of disc aspirates are positive,
usually for Staphylococcus; routine aspiration is not
recommended by many authorities. The sedimentation
and white blood cell count may be normal or
moderately raised.
Recovery without antibiotics is common, but an
appropriate antimicrobial agent is advised for the ill
child. The outcome is good for most, but long-term
studies have shown fusion of the affected vertebrae
(block vertebra) [46]. The good outcome seems to
reflect either the good vascular supply of the juvenile
disc or infection with organisms of low virulence.
VERTEBRAL OSTEOMYELITIS
This affects older children and is usually caused by
Staphylococcus aureus; spinal tuberculosis is now rare.
The disc is very vascular in childhood and infection
may seed there. It presents with severe back pain and
muscle spasm with a marked systemic reaction. Bone
scintigraphy is positive long before plain radiographs,
which eventually show collapse of a vertebra or a
paravertebral abscess.
A positive aspirate confirms the diagnosis.
Treatment is with rest, antibiotics and surgery for
neurological compromise.
The condition chronic recurrent multicentric
osteomyelitis (CRMO) is a rare condition which affects
adolescent children. The natural history of the disease
is said to be self-limiting, but there is a good deal of
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to the hip or trunk from radicular involvement occurs
in half. Cervical or thoracic osteoblastomas may
eventually cause cord compression.
Bone scintigraphy is more sensitive than plain
radiographs, which are often initially normal. Sclerosis
of the posterior elements may resemble a healing
spondylolysis [36]. Excision is usually successful, but
local recurrence of osteoblastoma occasionally occurs.
The scoliosis may not correct if treatment is delayed for
>18 months [37].
Aneurysmal bone cysts. One-fifth of these rare bone
lesions may affect the spine, usually arising in the
posterior elements and sometimes affecting several
adjoining vertebrae or ribs, expanding to cause
extradural pressure and a neurological deficit [38].
They usually present during adolescence, typically with
pain, but sometimes with a painless scoliosis or
restriction of movement. Occasionally, a swelling is
palpable.
The initial radiograph may be normal. Later
radiographs show a cyst bounded by a thin cortex and
traversed by fine trabeculae, scintigraphy shows
increased isotope uptake. MRI identifies the degree of
soft tissue spread and neural compression, and
angiography demonstrates arteriovenous shunting. A
needle biopsy can cause marked bleeding and is not
advised when this diagnosis is suspected. Surgical
excision, sometimes preceded by cryosurgery or by
pre-operative embolization to reduce bleeding, is
preferred to radiotherapy, which may be ineffective
[38], can cause spinal growth defects, radiation
myelopathy and sarcomatous change [39].
Eosinophilic granuloma. The most common
presentation is with back pain, usually thoracic, of
a few weeks duration in an adolescent. Neurological
involvement is rare. Radiographs show a wellcircumscribed area of osteolysis often with marked
collapse of the vertebra-vertebra plana. Occasionally,
several adjacent vertebrae are involved, suggesting the
systemic form of histiocytosis X, of which eosinophilic
granuloma is a localized form. With isolated lesions in
young children, vertebral regrowth may be complete
even without treatment. A neurological deficit is rare;
soft tissue extension requires radiotherapy and bony
impingement surgery. Chemotherapy is required for
systemic histiocytosis X.
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morbidity associated with it. Vertebral collapses could
occur. Biopsy results are usually negative for culture.
Treatment is controversial, but the case report in this
section illustrates a successful treatment of this
condition. The plain X-ray appearance is characteristic,
and MRI and bone scintigraphy are all helpful to
identify occult lesions.
EPIDURAL ABSCESS
This may present in children acutely or chronically
with systemic features, back pain and/or neurological
changes in the legs or bladder. Staphylococcus aureus
is implicated in most. Treatment is with surgical
drainage and long-term antibiotics. Irreversible
neurological residua are not uncommon [45, 46].
DISC HERNIATION
Although rare, accounting for < 2 % of all those
coming to surgery, disc herniation should be considered in the differential diagnosis of back pain in
children as in two-thirds the only or the predominant
complaint will be back pain without sciatica, which
occurs in the remainder [48, 49].
There is a slight preponderance of boys [50, 51]. One
of the lowermost two discs is nearly always affected. A
familial predisposition is reported [50-52].
SLIPPED VERTEBRAL EPIPHYSIS
The posterior rim of the inferior epiphysis, usually
the fourth lumbar, together with the adjacent disc, is
displayed posteriorly into the spinal canal, analogous
to a slipped femoral epiphysis. Adolescents are
affected, usually boys, often after heavy lifting. The
presentation is with back pain, usually without
neurological impairment. Lateral radiographs may
show the edge of the vertebral rim as a small bony
fragment within the spinal canal and radiculography
shows the disc as a large filling defect. Surgery is
usually indicated [55, 56].
ANKYLOSING SPONDYLITIS AND OTHER
SPONDYLOARTHROPATHIES
Back pain is rarely a feature of ankylosing
spondylitis when it presents in children. The typical
picture is a teenage boy with a remittent, asymmetrical
oligoarthritis of the lower limb joints. The diagnostic
clues at this stage are enthesopathies (chiefly plantar
fasciitis, Achilles tendinitis, at the greater trochanter
and around the patella), a family history of a
spondyloarthropathy, or a personal or family history
of psoriasis, inflammatory bowel disease or acute
anterior uveitis.
The proportion of children with spondyloarthropathies who later develop back symptoms is disputed,
with up to 80% being quoted, and of those who do the
onset is usually delayed for a number of years [57, 58].
Spondylitic pain typically disturbs sleep, it is worse
in the morning when it is associated with stiffness,
and improves with movement. On examination,
there is symmetrical restriction of lumbar spinal
movements, often with residua of peripheral arthritis or
extra-articular features.
Most Caucasian patients have the HLA B27 tissue
type. Radiographic identification of sacroiliitis may be
impossible before the age of 21, because the epiphyses,
which are themselves irregular, do not fuse until about
that age. However, in some studies, it is evident in
three-quarters by 5 yr from the onset and in nearly all
by 12 yr.
CONVERSION HYSTERIA
This is a not uncommon cause for back pain in
children [59], presenting predominantly in pubescent
girls. The diagnosis is often obvious with symptoms
and signs that are bizarre, grossly exaggerated and
inappropriate to organic pathology. Trick manoeuvres,
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JUVENILE INTERVERTEBRAL DISC
CALCIFICATION
This is characterized by calcification of the nucleus
pulposus which may remain symptomless or produce
an acute onset of severe cervical or thoracic pain, often
with a fever and an acute-phase reaction, which
resolves spontaneously within weeks or months. With
the onset of pain, the disc calcification starts to resorb
and is complete within days to years, occasionally
with disc protrusion, but rarely with neurological
compromise [47].
The group of children presenting with acute pain
differs from the group where disc calcification is an
incidental radiographic finding: they are older (average
age 7 vs 4 yr), the cervical spine is predominantly
affected (thoracic spine in symptomless individuals),
boys outnumber girls 1.5:1 (girls outnumber boys 2:1
in the symptomless group) and a single disc is affected
(often multiple discs in the symptomless group). In
contrast, disc calcification in adults is usually of the
annulus fibrosis, lumbar, persistent and symptomless.
While an inflammatory response within the disc
appears to trigger the symptoms and lead to resorption
of the calcification, the mechanism is obscure. The
acute presentation suggests infection, but is unlikely as
septic discitis in children is lumbar, affects a solitary
disc, and can result in disc space narrowing and a block
vertebra.
A suggested mechanism is that calcification is related
to developmental changes of the nucleus pulposus and
an unknown trigger (trauma, infection, interference
with blood supply) incites the acute inflammatory
response.
Some physical signs appear to be more common in
children: marked postural or gait disturbance, when
shuffling; restricted straight leg raising tests; weakness
of plantar flexion. The plain radiograph is seldom
helpful. MRI study should be interpreted with caution
as a high instance of 'abnormalities' is reported
in symptomless controls [53] and 'disc degeneration'
is found no more frequently in this group than
in controls, although disc protrusion is [54]. Although
in children a large amount of nucleus pulposus tends
to be extruded, sciatica is uncommon.
HOLLINGWORTH: BACK PAIN IN CHILDREN
CONGENITAL SPINAL ANOMALIES
Congenital absence of a lumbar pedicle is rare. It
presents in teenagers with back pain, rotation of the
lumbar spine, scoliosis and, sometimes, neurological
signs. The pain appears to result from excessive
mobility of the affected segment or a spondylolysis of
the overstressed contralateral pedicle [60, 61].
Other disorders—congenital spinal fusion [42],
congenital spinal stenosis [42] and widening of the
spinal canal, sometimes as part of Marfan's syndrome—may all present as spinal pain. However, the
most common presentation of" congenital defects of the
spine is painless deformity, sometimes with a
neurological defect in the lower limbs.
TABLE II
Back pain in children: other disorders
Dysmenorrhoea
Fibromyalgia
Retroperitoneal disorders
Chronic recurrent multifocal osteomyelitis [62]
Idiopathic juvenile osteoporosis
Cystic fibrosis [63]
Fibrodysplasia ossificaru [64]
Sickle cell disease
Cushing's disease
Arachnoiditis and arachnoid diverticula
OTHER DISORDERS CAUSING BACK PAIN
These are listed in Table II.
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such as being hardly able to bend forward when
standing, yet sitting up from lying without difficulty,
may be elicited. There may be apparent marked spinal
tenderness to light touch and diffuse tenderness along
the length of the spine.
An interest in amateur dramatics should raise
suspicion. Frank depression is rare and overt
psychopathology often absent as the unconscious
purpose is to communicate stress in coded form. The
child often remains incongruously cheerful despite
severe pain and incapacity, which are typically
unresponsive to the usual measures. The degree of
closeness between the mother and the child often
appears inappropriate with the mother speaking for the
child and overt non-verbal messages passing between
them. The onset often follows a minor illness or injury
and conversion hysteria may co-exist with organic
disease, all of which can cause diagnostic confusion.
Avoid overinvestigation, which conveys to the child
that you suspect you are missing a serious diagnosis.
Take the problem seriously, acknowledge there is pain,
do not make the child feel dismissed by insinuating
there is 'nothing wrong' or it is psychosomatic. Manage
the social handicap, such as transport to school, discuss
the problem with the child and be optimistic. Look
for psychological problems, liaise with non-medical
colleagues such as a psychologist, along with the family
practitioner and teachers.
Treatment is multi-faceted, including psychological
support, avoidance of rest (which worsens the
problem), and a programme of graded physical activity
supervised by physiotherapists; this also provides a
face-saving way to recovery.
1027
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