The aim of treatment is to enable the young person to return to age appropriate activities and lifestyle. Ideally this would be pain free but, in many cases, this is initially with the pain. Physiotherapists, occupational therapists and psychologists (67-69) are key players in the team. They will be the primary professionals supporting the young person and the family. The physician is there to provide support if needed, occasional analgesic advice and very rarely, direct intervention. In some conditions, such as CRPS, intensive physiotherapy may be given for a set period of time (15).
The aim of this is accelerated mobilization (70). Many cases of diffuse pain will require a gentle, paced approach. In all cases the increase of activity should be consistent despite the pain. With musculoskeletal pains the more active the musculoskeletal system becomes, the more likely the muscle spasms and tightening are to reduce. Proprioception improves and auto-nomic changes subside. Where possible adolescents should work to devise their own "fitness plan." Fun games can be included with an aim to return gradually to activities the young person used to enjoy. Using a local gym rather than a hospital physiotherapy gym allows them to start to return to a more normal environment (71).
Working in this consistent, paced manner is extremely hard for the young person and their parents. The pain invariably continues at the beginning (if not throughout) and motivation is poor. Parental anxiety is high (72) and there is a fear that damage will be done. Psychological support during this time is key. The young person will need help setting goals, learning how to communicate pain to peers and family, keeping up motivation on "bad days," managing low mood, dealing with anger and frustration and overcoming fears. Often they have not been at school for a long period of time and need help in preparing again for this difficult environment. In some cases there may be other mental health needs that can be identified and appropriately treated. Relaxation, advice on sleep and eating and advice on how to pace other areas of life can all be given by members of the team.
In our experience it is essential that parents are included in this rehabilitation. We have shown that parental stress and anxiety can reduce the impact of any treatment plan. Parents often perceive their child as very disabled; there is a fear that any physical activity or intervention will lead to further pain and damage (72). It is important that they are able to see their child become functionally less disabled. They will need a great deal of emotional support but, as the rehabilitation plan continues, they will actually start to facilitate further improvement. An aim of treatment is to reduce the impact of pain on the whole family's life, not just that of the child.
Ideally most of the ongoing rehabilitation can be carried out by the young person and family and the input from the health care professionals gradually reduce.
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