Management of chronic pain in children and young people: summary

5. Physical therapies for children and young people

5.1 Exercise Therapy

For the purpose of this guideline, studies were included if they encompassed an intervention that could be described as exercise therapy or an exercise programme.

One systematic review appraised studies, including RCTs and case series, of a variety of combinations of graded exercise therapy including weight-bearing, aerobic, resistance activities, hydrotherapy and facilitated movement, in children with CRPS Type 1. It concluded that the combination of exercise therapies or exercise and other psychological and medical interventions result in short-term improvement in signs and symptoms, and functional ability in children with CRPS type 1 [64].
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A Cochrane systematic review found very low quality but consistent evidence that exercise therapy for chronic Patella Femoral Pain Syndrome ( PFPS) results in a clinically significant reduction in pain. This may also result in an improvement of functional ability, as well as enhancing long-term recovery. Hip plus knee exercises may be more effective in reducing pain in children with long term PFPS than knee exercise alone [65].
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A cost-utility study was performed in conjunction with a randomised clinical trial showing that exercise therapy in adolescents and young adults suffering from PFPS was cost effective when compared with a conservative strategy of background knowledge of the condition and its favourable prognosis [66].

In a small RCT of children with CRPS, Lee et al. (2002) reported that pain reduced and function significantly improved after physical therapy (low or high intensity), combined with CBT, when compared to pre- intervention levels (p<0.01). It was not possible to separate the benefits of exercise and its intensity from this study [67].

5.2 Manual Therapy

Manual therapy is an umbrella term that has increasingly been adopted to encompass various forms of hands-on treatment, including both manipulation and mobilisation. It is practised by a variety of healthcare professionals including physiotherapists, osteopaths and chiropractors. No evidence was identified for the use of manual therapy in children and young people with chronic pain.

5.3 Other Physiotherapy Modalities

A systematic review of CRPS in children and young people examined exercise, motor imagery and mirror feedback, relaxation, acupuncture, and electro-acupuncture, Transcutaneous Electrical Nerve Stimulation ( TENS) and combined treatment programmes. Although there was some evidence of benefit with these treatments, overall the evidence was of low quality with many methodological weaknesses. Based on the quality of the available evidence, it is not possible therefore to recommend any of these specific interventions either alone, or in combination [68].
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Expert opinion suggests that due to the individual response and low risk of adverse side effects mirror therapy, relaxation and TENS may be of use in children and young people with chronic pain.
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5.4 Orthotic Interventions

A systematic review of children with long term PFPS appraised the addition of orthotics to exercise therapy. There was no additional effect of knee braces over exercise therapy alone on pain and functional outcomes. Conflicting evidence for the additional effect of tape and foot orthotics to exercise therapy on pain and function was found [69].
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Expert opinion suggest that the use of early immobilisation (i.e. plaster/moon boots) is not helpful in the treatment of CRPS.
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Recommendations

• Exercise should be considered as a key component of chronic pain management in children and young people.

• There should be consideration of early interventions to increase movement, physical activity and restore of function.

• Exercise should be used with the aim of producing functional improvement in children and young people with CRPS. Mirror therapy should be considered.

• Exercise therapy should be considered for children and young people with PFPS to enhance long term recovery and reduce pain.

• Relaxation and TENS are low risk interventions that should be considered for the treatment of children and young people with chronic pain.