Center for Amplified Musculoskeletal Pain Syndrome

Treating Amplified Musculoskeletal Pain Syndrome

CHOP’s approach to treating AMPS

The Center for Amplified Musculoskeletal Pain Syndrome at CHOP treats children with AMPS using a series of therapeutic exercises.

It is very important for children with AMPS to begin using their bodies in a normal way. Some children with AMPS are able to follow an intense physical and occupational therapy (PT/OT) program on their own by exercising at home. Although it hurts to do the therapy, it does not cause damage, and some children are able to work through the pain. Our experienced clinical and therapeutic team will work with you and your child to construct a home exercise program.

However, many children will need to participate in an intense PT/OT treatment program at the Hospital. It just hurts too much for them to do it on their own.

At The Children’s Hospital of Philadelphia, intense PT/OT is usually an outpatient program, where children come to our Day Hospital every weekday for treatment.

We also offer inpatient hospitalization for children who are severely incapacitated, have a chronic medical condition that requires closer monitoring during treatment, need to wean off certain medications, have marked pain behaviors such as night time screaming or need a behavior modification program.

Our intense program provides each child six hours of daily PT and OT, along with psychological evaluation and support through psychotherapy and creative art therapy.

Prior to, or as part of the initial clinic evaluation, we perform an evaluation to help determine if stress plays a role in your child’s AMPS. This involves filling out questionnaires and often talking to a psychologist. Our social worker may request your child’s academic record, and we may administer academic testing.

After this evaluation, we can give you more specific advice about how stress may be contributing to your child’s AMPS and whether counseling is advisable. A few children need a behavior modification program. If we think your child may benefit from such a program, we will discuss it with you in depth.

Phases of the AMPS intensive treatment program

Phase I

The intense PT/OT Hospital treatment program is just the first phase of our program. Although most children with AMPS will be fully functional at the end of this phase, many will still experience some pain. For most children, the pain starts to decrease by the time of their discharge from the Hospital.

Phase II

The second phase of our AMPS intensive treatment program is to maintain normal function (school, sports, chores, socializing) and continue to do a home exercise program. Depending on the results of our evaluation, this phase may include psychotherapeutic counseling. It is during this phase of the program that most children with AMPS resolve their pain.

Phase III

The third phase of our program is to help children with AMPS graduate from a formal home exercise program and to have normal function without pain.

How long does the intensive treatment program take?

The average length of treatment is three weeks for the first phase. Occasionally, a child will respond quickly and only need one or two weeks. Likewise, a few will require many weeks. The duration of treatment needed is impossible to predict until we see the rate of your child’s progress once in the program.

It is important to realize that function comes back first; normally the pain will take longer to decrease. While some children will resolve their pain during the first phase of treatment, most will do so during the second phase; that is, once they are back in school, maintaining normal function and, perhaps, receiving counseling.

The pain usually diminishes gradually over the ensuing month or two, but rarely will take many months. There are a few children who will have pain for years, but almost all patients who have gone through our program remain functional. It is not uncommon for the pain to increase at first or move or spread to different locations. 

What will my child do during the first phase of treatment?

Our team will design an individualized PT/OT program specifically for your child. It focuses on strengthening your child’s total body, specifically the areas of the body that are painful or do not function properly. If there are body areas that are painful to touch, these areas are desensitized with rubbing and massage.

Physical and occupational therapists who are experts in in treating children with AMPS direct our program therapy. A home exercise program is part of the treatment, especially during weekends. There will also be scheduled appointments with the psychologist for you and your child, a patient support group, a parent support group, art therapy and music therapy.

What if the pain spreads or goes to a new site while my child is in the intense PT/OT program?

It is not uncommon for the pain to spread or to go to a new site while undergoing the intense PT/OT program. It is frequently a good sign when the pain moves, since it means we have connected to the autonomic nervous system. For example, one child with elbow pain developed knee pain as the elbow pain resolved, then ankle pain as the knees got better, then no pain.

Our therapists will adjust the program to include the new areas of pain. Itching also occurs in many children as they get better. This itching is normal and temporary and does not need to be specifically treated.

Does the exercise program have to be done at CHOP?

The intense first phase of the program has to be done at CHOP’s Main Campus (or a similar center with therapists experienced in treating AMPS).

Children who need an intense PT/OT program are best served by therapists who understand AMPS. The type of therapy needed is different from what most physical and occupational therapists are taught. Most local therapists are not able to deliver the amount of therapy required.

However, there are situations where we can work with a local therapist and not all children need the full six-hour-a-day program. We are very supportive of having other therapists develop expertise in treating children with AMPS. We can supply your physician and therapist with written descriptions of our exercise program. Resource material is available at http://www.childhoodrnd.org.

Do children come back to the intense PT/OT program for second treatments?

Yes. Unfortunately, some children will have relapses that require second treatments. It just hurts too much for them to work through the pain without the support of an experienced team. Additionally, there are children who need to become more emotionally ready to get better before they can fully benefit from our program.

What are the long-term outcomes for children diagnosed with AMPS?

There are few studies of long-term outcomes for children diagnosed with AMPS. In one study where 103 children were treated with an intense PT/OT program, 88 percent were pain-free and fully functioning after an average of five years.

We find that children who have more difficulty becoming pain-free after treatment tend to minimize the role of stress in their lives and are reluctant to engage in the psychological components of treatment. Overall, the more fully children engage in all aspects of treatment, the better their prognosis.

Children who have psychological stress as a primary cause of AMPS often develop a wide variety of other psychologically-driven disorders after treatment for AMPS, such as:

If your child experiences any prolonged, unexplained pain or other symptoms, you may suspect an amplified pain syndrome, amplified symptom or conversion. We encourage you to consult your child's healthcare provider for a careful evaluation and diagnosis.

Frequently asked questions about AMPS treatment

Are parents allowed in the exercise sessions?

No, we have found it is best that parents not be present. Children often respond differently in a parent’s presence. We find it important to help children gain confidence in their abilities to cope independently, as we emphasize their independence throughout their treatment.

While your child is being treated, we encourage family members to go about their usual activities as much as possible.

Can parents eat lunch with their children?

Parents are allowed to have lunch with their children on the first day of admission only. After day one we want to closely simulate a school day; therefore, your child will have lunch daily with the other children in our Hospital treatment program. Lunchtime also provides opportunities for patients to socialize with and provide support to each other.

What about school?

School attendance is put on hold during the program. Some children can benefit from homebound instruction during the evenings. Before beginning the intensive therapy program, we will contact your child’s school to obtain your child’s academic records and other pertinent information. If indicated, we will perform academic testing or a psychoeducational evaluation to ensure your child’s educational goals are appropriate.

It is our treatment expectation that all children will return to school full-time without physical accommodations for pain or conversion at the end of the intense Phase I of the program.

As treatment is ending, we will again contact the school to help your child re-enter with appropriate educational accommodations so he or she will not be overly stressed and overworked.

Children who benefit from academic accommodations due to a learning disability, attention deficit or other learning need will keep such services. We do not typically encourage cyber-school after your child is discharged.

What is music therapy?

Music therapy helps your child gain coping skills to work through and decrease pain. It may also help with sleeping. Methods include music-assisted relaxation techniques to promote positive mind-body connection through deep breathing, progressive muscle relaxation, imagery or mindfulness-based techniques.

Music therapy promotes self-expression through music production, song-writing or lyric discussion. Your child will typically work individually, once a week and sometimes in lieu of free time, with a music therapist who has extensive experience working with children with amplified pain syndrome. There is a weekly music therapy group session and music-assisted relaxation during one pool group.

What is art therapy?

Art therapy is another way to help your child express his or her feelings by using various art techniques with the guidance of a trained art therapist who has extensive experience with children with AMPS.

Your child will typically participate in one individual art therapy session and one group art therapy session a week. The process of creating art focuses on self-expression as a support while in the program, and helps teach healthy coping and wellness awareness your child can use in everyday life.

What happens if my child gets sick or injured?

If your child gets sick or injured during the intensive AMPS therapy, we will fully assess the nature of the illness or injury and treat it appropriately. We want to see your child even if he or she is thought to be too ill to participate in the program. Most of the time, we can continue the program with modifications.

It is not uncommon for a child to have a minor injury and develop AMPS in the injured area during the program. Very rarely a child is sick or injured to the point that he or she needs to leave the program until the illness or injury resolves.

Occasionally other issues (unable to cooperate, death in the family, severe depression or suicidal thoughts) arise that require the child to leave the program early to seek other therapies. Children who leave the program early can be readmitted once the CHOP team and family are convinced it will be successful.

What do I tell others?

In simple terms, you can explain that AMPS is a medical problem involving the nerves going to the blood vessels. These nerves are overactive and cause pain. The treatment is a special series of therapeutic exercises to retrain the nerves.

Are medicines used for the pain?

No. Most patients take no medication to treat AMPS because it seems to hinder the retraining of the nerves. This includes herbs, vitamins and other complementary treatments taken for pain. Also, medication frequently causes side effects in these children and has minimal, if any, benefit. Other pain, such as menstrual cramps, is treated as indicated, but this type of pain can also become amplified.

What about sleep?

Many children with AMPS have difficulty falling asleep, staying asleep or both. Many people think that if we can improve their sleep, their pain will decrease, but that is not the case. Therefore, we do not treat sleep with medications since they usually do not help and can cause significant drowsiness and other side effects.

We encourage good sleep hygiene, especially while children are in the intense PT/OT program. It is uncomfortable to be awake all night, and most children start sleeping better once they start the intense PT/OT program.

To promote good sleep hygiene, children should follow these guidelines:

 

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