Yes stomach problems can be directly related to amplified pain and we frequently see children with abdominal pain and dysfunction. Other possible causes of abdominal pain do need to be ruled out before a diagnosis of amplified pain of the abdomen can be made. It is important to make sure that children with stomach issues do not develop an eating disorder. It is imperative for these children to have a stable weight in order to participate in the intense physical and occupational therapy program.
Gastroparesis is a condition where there is delayed emptying of the stomach. The stomach and intestines are controlled by the autonomic, or automatic (fight or flight), nerves so it is not unusual for this to be part of amplified pain since it is through these nerves that the stomach symptoms become amplified. Along with these symptoms, stomach motility may be decreased. We treat it the same way as amplified pain, that is, with aerobic conditioning and desensitization. In children with gastroparesis we desensitize the stomach by putting food in the stomach frequently (breakfast, morning snack, lunch, afternoon snack, supper, evening snack, bedtime snack). The amount does not need to be large at first but it is important that they keep eating. We have had children who had zero motility on the repeated stomach emptying studies and, once they exercise and eat, their stomach motility has been documented to be above average. Medications for gastroparesis are fraught with side effects including causing stomach pain.
Irritable bowel syndrome can take on many different manifestations such as abdominal pain, gas, bloating, constipation mixed with diarrhea, and there may be motility issues such as gastroparesis (see above). The automatic, or autonomic nerves control the intestines, thus children who are prone to amplified pain, which is also controlled through the autonomic nerves, may also develop irritable bowel syndrome. In these children we emphasize continuing to be normally functioning regardless of symptoms. This means going to school, participating in aerobic training, and if there is pain with eating, to eat frequently, as we recommend for gastroparesis. If constipation is a significant problem then that needs to be treated specifically, just as any other medical condition needs to be treated. When these children are having frequent stools they still need to fully participate in life (school, shopping, visiting with friends) although they may need to have allowances for frequent trips to the bathroom. Once the diagnosis of irritable bowel syndrome has been made there should be no further testing done since there is the great temptation that just “one more test” well reveal a different diagnosis. Medications are generally not helpful for this. There has been a very good study of amitriptyline and children with irritable bowel syndrome that showed that it had no benefit over placebo.
Amplified Abdominal Pain in Children
By Lori Brake, PTA; Jennifer Sherker, PsyD; David Sherry, MD; Kathy Fash, PT, DPT, CSCS, CBIS
Most commonly, children we see in our clinic will have Amplified Musculoskeletal Pain (AMP), also known as Complex Regional Pain Syndrome (CRPS), Reflex Sympathetic Dystrophy (RSD), Reflex Neurovascular Dystrophy (RND), or widespread pain such as in fibromyalgia. These conditions have historically been a challenging disorder for medical professionals to recognize and treat, and for patient and families who deal with prolonged pain and disability. Additionally patients and families may spend a prolonged time in the medical system before a correct diagnosis is arrived at and may undergo multiple therapeutic trials without success. Patients with autonomic features such as temperature changes, swelling, cyanosis, abnormal sweating, slow capillary refilling, atrophic skin changes, and allodynia (increased sensitivity to normal stimuli on skin) are more likely to be recognized earlier than those without such findings. Even so, many of the children we see have had months to even years of symptoms before diagnoses. In children with AMP, common treatment approaches include physical therapy, medications, nerve blocks, and surgical procedures; however, many medical interventions have various and limited outcomes often leading to only temporary resolution for children and adolescents who have been treated by those techniques. For examples, there is only a limited role for regional or sympathetic nerve blocks or narcotic analgesia in the management of Amplified Musculoskeletal Pain in children (Maillard, S., 2004).
The AMP program at The Children’s Hospital of Philadelphia uses a multidisciplinary exercise approach to treating AMP. This is a non-medication, function-based approach that concentrates on return to full function through an intensive exercise program and psychosocial support. Research shows that this approach helps children return to a full functional and, in most cases, a pain-free way of life (Sherry et al, 1991, 1992, 1999). Ultimately, it is the children who work through the pain and thus cure themselves.
While virtually any part of the body can be affected by pain, the focus of this article is on abdominal AMP. When amplified pain affects the patient’s abdomen and digestive tract, it often becomes even more challenging to obtain a correct diagnosis and treatment. For those who suffer from AMP of their abdomen, the symptoms can present themselves in a variety of ways including pain, nausea, difficulty eating or swallowing, and/or particular difficulties with specific food types. Although treatment approaches vary depending on what symptoms are present, the overall treatment approach is no different than treating amplified pain elsewhere in the body. It is important to focus on restoring function and strength through challenging those areas that are causing the most difficulty.
If abdominal AMP is suspected, it is important for the entire medical team to be on board together in making and understanding the diagnosis. Guidelines for identification of abdominal AMP type of pain have been published and can be used to guide the diagnostic process (Drossman, 2004). Once the diagnosis is made, it is important to discontinue further medical testing, pain medications (often, this is much harder on the doctors than on the patients) and make sure the patient, family and other medical providers understand AMP.
Our Treatment of Abdominal AMP
The overriding principle of our program is to have the children exercise and desensitize through the pain to establish normal function and eating. The amount of physical and occupational therapy varies tremendously between patients. Once children know that doing things that cause pain are not going to damage their body but actually help it heal, some will be able to establish normal function and resolve their pain on their own. However, for most children this hurts too much and they will need to work with a therapist. The amount of therapy can be as little as outpatient therapy several times a week to being hospitalized to receive up to 7 hours of physical and occupational therapy daily for many weeks. At The Children’s Hospital of Philadelphia children are treated as either Day Hospital patients (5 days a week from 8 AM to 4 PM) or as inpatients 7 days a week. Those with abdominal pain, especially because there are nutrition and eating issues, are generally best treated as inpatients at first so that appropriate monitoring can be done. Outlined below are some of the specific goals of our program.
Musculature: Core strengthening is an important part of any treatment program, but especially so when the pain is in the abdomen. Being creative with exercises is key to targeting those painful areas, thereby attacking the pain and leading to a more functional and hopefully less painful daily life. When first beginning to work on these exercises, many children are not accustomed to working those painful muscles and their body is often good at unconsciously or unwittingly compensating to avoid pain. Because of this, careful monitoring of position is important when exercising either by working out with someone who can help provide feedback or working in front of a mirror to self monitor position.
Examples of exercises that target abdominal pain: Push-ups, and holding push up position (planking) are very important exercise activities in treating abdominal pain. There are many ways in which this position can be incorporated into exercises, whether it is just holding the position, walking hands side to side while in this position, or even completing a puzzle or sorting shapes while holding a plank position. It is important for the body to be straight in order to ensure the abdominal muscles are fully engaged. If the patients’ hips are too bent, then the abdominal muscles do not have to work as hard, decreasing the effectiveness of the exercises. Walking up a steep hill out in the community or on a treadmill without holding onto the railings can be a great overall body workout and helps strengthen your abdominals and increase rotation. When doing exercises for the lower body, holding a ball out in front or overhead is an effective way to assist the abdominals in becoming engaged and this can be incorporated during squats, lunges, walking on knees, or moving from kneeling to standing repeatedly.
Pain to touch (allodynia): Incorporate desensitization into abdominal exercises whenever possible to help combat allodynia. With abdominal pain, the allodynia is often not just surface pain, but pressure pain when areas of the abdomen or ribs are pushed or massaged. What is used to desensitize varies from patient to patient and depends on what is most difficult and painful for each patient. For those who are sensitive to light touch, wearing fitted clothing may provide enough desensitization. For others, desensitization needs to be more rigorous. Plastic grass doormats from the local hardware store can be used to lie on or strapped to the stomach during exercises, tight shirts, tube tops with things like tennis balls, or Velcro tucked inside can also provide desensitization. The tennis balls are particularly helpful if the area is only sensitive to deep pressure. If touch is not an issue, but pressure is, then lying over a ball (playground, soccer, or basketball) while completing things such as a puzzle, or even while drawing, writing or coloring can be effective for desensitizing the area. Just like with the exercises, it is important to be creative with desensitization, and not always repeat the same strategies in order to keep motivation up and ensure the pain does not accommodate to just that one desensitization technique, but to all types of sensations.
Eating: Often when faced with AMP of the abdomen patients’ eating habits are affected. When eating is involved, it is always important to consider and evaluate the possibility of an underlying eating disorder; however eating disorders are not always present in patients with abdominal pain. The approach to this aspect of therapy is done under the guidance of the physician and where appropriate, nutritional specialist. If an eating disorder is suspected, it is important to refer the patient to the appropriate specialists. However, once an eating disorder has been ruled out and difficulties are primarily pain-related, snack time is typically incorporated during therapy sessions. Depending on how much else they are eating throughout the day, snack time may be as simple as eating a few crackers or may involve the intake of something more hearty and packed with calories and nutrients, such as nutritional shakes. The goals of this include both nutrition and desensitization. Additionally, eating at a normal speed is an issue for so many so eating may need to be timed and repeated if not at an age appropriate rate.
Stress: Stress can both cause and arise from abdominal pain. It is a classic symptom of children who first go to school and are suffering from the newness of a school situation and separation from their family. As mentioned above, children with amplified abdominal pain frequently have multiple diagnoses, procedures, medication without effect, suffer from isolation from peers, and many times professionals, teachers and friends do not believe they have as much pain as they have. This is very stressful and needs to be a part of a complete therapeutic program. We have a psychologist and music therapist help with coping strategies (sometimes co-treating in the gym), and allowing them to explore the meaning of the pain. School can be a major stress and our educator works with the child’s school to get them back into school with appropriate academic accommodation so that re-entry is as smooth as possible.
While research needs to be done to examine the effectiveness on this type of treatment for abdominal AMP, especially the physical and occupational therapy aspect, we do know that this approach has been very successful in resolving pain in the vast majority of patients treated for other types of amplified pain (Sherry, 1991, 1992, 1999) and we have had marked success in most of the children we see with abdominal pain. We, however, tend to see children who are significantly impaired due to their pain. Despite the pain, it does not have to interfere with function and is very treatable. Although the diagnostic and treatment process can be challenging, recognizing the symptoms, obtaining the appropriate diagnosis and engaging in treatment is key. It is important to be persistent and to educate patients, families, doctors, physical and occupational therapists and mental health professional that may be affected by this condition or treating someone who is. Treatment using a combination of exercise, desensitization, and eating, as well as psychosocial support can help patients increase and restore their function leading to decreased or resolved pain.
What can I do if I think I may be suffering from Abdominal AMP?
Talk with your medical professionals about your concerns and share information with them about AMP. Make sure you do not let the pain interfere with your life. Attend school and social events, and incorporate exercise into your daily routine, making sure to use those areas that are painful, including not only your abdominal muscles, but also your stomach itself. Additionally, carefully evaluate the role that stress in your life plays in your pain and the degree that the pain has caused you stress and have it evaluated by someone who has good insight into childhood psychological problems.
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