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Les douleurs neuropathiques (DN) restent très difficiles à soulager. Plusieurs recommandations ont été proposées au cours de ces dernières années, mais aucune n’a pris en compte à ce jour l’ensemble des approches thérapeutiques disponibles. Nous avons réalisé une revue systématique portant sur toutes les études concernant le traitement des DN périphériques et centrales de l’adulte et de l’enfant, publiées jusqu’en janvier 2018 et avons évalué la qualité des études et le niveau de preuve des traitements au moyen du système GRADE. Les principaux critères d’inclusion étaient l’existence d’une DN chronique (≥ 3 mois), une méthodologie contrôlée et randomisée, un suivi supérieur ou égal à trois semaines, un nombre de patients supérieur ou égal à dix par groupe et une évaluation en double insu pour les traitements pharmacologiques. Sur la base du GRADE, nous recommandons en première intention les antidépresseurs inhibiteurs mixtes de recapture des monoamines (duloxétine et venlafaxine), les antidépresseurs tricycliques, la gabapentine pour toute DN, et les emplâtres de lidocaïne 5 % et la stimulation électrique transcutanée pour les DN périphériques localisées. Nous recommandons en deuxième intention la prégabaline, le tramadol (avec les précautions d’emploi afférentes aux opioïdes) et certaines associations pharmacologiques (antidépresseurs et gabapentine ou prégabaline) pour toute DN, et les patchs de haute concentration de capsaïcine (8 %) et la toxine botulique de type A (en milieu spécialisé) pour les DN périphériques localisées. Nous recommandons en troisième intention la stimulation magnétique transcrânienne répétitive à haute fréquence du cortex moteur (en milieu spécialisé) et les opioïdes forts (en l’absence d’alternative et en respectant les précautions d’emploi afférentes aux opioïdes) pour toute douleur neuropathique, et la stimulation médullaire pour les douleurs radiculaires chroniques postchirurgicales et la polyneuropathie diabétique douloureuse. La psychothérapie (thérapie cognitivocomportementale et thérapie de pleine conscience) peut être recommandée en deuxième intention en association avec les traitements précédents.

Neuropathic pain remains a significant unmet medical need. Several recommendations have recently been proposed concerning pharmacotherapy, neurostimulation techniques and interventional management, but no comprehensive guideline encompassing all these treatments has yet been issued. We performed a systematic review of pharmacotherapy, neurostimulation, surgery, psychotherapies and other types of therapy for peripheral or central neuropathic pain, based on studies published in peer-reviewed journals before January 2018. The main inclusion criteria were chronic neuropathic pain for at least three months, a randomized controlled methodology, at least three weeks of follow-up, at least 10 patients per group, and a double-blind design for drug therapy. Based on the GRADE system, we provide weak-to-strong recommendations for use and proposal as a first-line treatment for SNRIs (duloxetine and venlafaxine), gabapentin and tricyclic antidepressants and, for topical lidocaine and transcutaneous electrical nerve stimulation specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a second-line treatment for pregabalin, tramadol, combination therapy (antidepressant combined with gabapentinoids), and for high-concentration capsaicin patches and botulinum toxin A specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a third-line treatment for high-frequency rTMS of the motor cortex, spinal cord stimulation (failed back surgery syndrome and painful diabetic polyneuropathy) and strong opioids (in the absence of an alternative). Psychotherapy (cognitive behavioral therapy and mindfulness) is recommended as a second-line therapy, as an add-on to other therapies. An algorithm encompassing all the recommended treatments is proposed.

Management of pain is one of the major expectations of children with neurological impairment and their families. The medical literature is poor on this topic accounting for approximately 0.15 % of the publications on pain in general. The objective of the French Pediatric Neurology Society was to review the current knowledge on this topic. Bibliographic research was conducted with PubMed and RefDoc for publications between 1994 and 2014 in French or English. A total of 925 articles were retrieved and 92 were selected for review. Pain is common in this population: a 2-week survey indicated that pain occurs in 50-75 % of children. Pain negatively impacts the quality of life of children and their parents. Children with neurological impairment express their pain with pain expression patterns and specific patterns common to children (change of tone, abnormal movements, spasticity, paradoxical reactions, such as laughter, self-injury or vasomotor dysfunction). Some children with neurological impairment are able to use self-report pain scales. If not, observational measures should be used. Behavioral rating scales specifically designed for this population are more sensitive than others. Scales must be selected according to children's communication skills, type of pain, and the context. Sometimes behavioral changes are the only expression of pain: any change in sleep, tone, feeding, or mood must suggest pain in this population. Management of pain remains difficult. There are no specific guidelines. Procedural pain management guidelines and the usual analgesic drugs can be used in children with neurological impairment with specific concerns regarding tolerance and side effects. These children are particularly at risk for neuropathic pain. A multidisciplinary approach is helpful, involving physicians, nurses, physiotherapists, psychologists and parents.

The Analgesia Nociception Index (ANI), based on heart rate (HR) variability analysis, is known to decrease after a painful stimulus during surgery under general anesthesia in adults. It is measured continuously and noninvasively. We studied ANI response to procedural pain in a pediatric population and ANI measurement's feasibility in this context, across age. A prospective, noninterventional pilot study was performed. All children (between 6 mo and under 18 y) undergoing muscle biopsy conducted under analgesia and light sedation were included. Medical staff was blind to the ANI monitor. HR and ANI were recorded and analyzed during 2 periods: T1 before incision and T2 after incision. Pain was assessed by the FLACC scale at T2. We observed ANI and HR variations after incision. ANI, HR, and FLACC were compared between children younger or older than 6 years. Enrollment or technical issues were reported. A total of 26 children were included (median age, 6 y; ranging from 6 mo to 16 y; 16 male). ANI decreased from T1 to T2. HR, ANI, or FLACC values were not different in children younger or older than 6 years. No parents or children refused to take part in the study. No technical issues was reported. In this pilot study, ANI measurement seems relevant in pediatric procedural pain, across age. Further studies are needed to confirm these results.

Resume Contexte La douleur chronique peut engendrer chez l’enfant un handicap majeur. Pour prendre en compte toutes les dimensions de son modele bio-psychosocial, le concept d’un traitement multidisciplinaire semble optimal. De tels programmes existent a l’etranger ou des etudes ont montre leur efficacite. Nous avons realise une etude retrospective dans un centre de reeducation fonctionnelle (CRF) francais pour decrire la prise en charge multidisciplinaire qui y etait realisee et ses resultats. Methodes Il s’agit d’une analyse retrospective des dossiers des patients consecutivement hospitalises pour des douleurs chroniques inexpliquees, majoritairement musculo-squelettetiques, a partir de 2010. Le critere principal composite etait la douleur et son retentissement fonctionnel et scolaire. Resultats Vingt-neuf patients de 9,4 a 17,8 ans avaient ete hospitalises pour douleur chronique entre 2010 et aout 2014, dont 65,5 % en hospitalisation de semaine et 34,5 % en hospitalisation de jour, pour des durees de 1 a 68 semaines. La prise en charge avait associe un suivi medical, une kinesitherapie, une ergotherapie, une prise en charge psychologique, une pharmacotherapie et la scolarite. La douleur avait ete amelioree de maniere significative chez 89,7 % des patients (IC95 % [0,73–0,98]). Il n’y avait pas de difference significative selon que les enfants avaient ete pris en charge en hospitalisation de jour ou de semaine. Conclusion Le traitement multidisciplinaire de la douleur chronique de l’enfant dans ce CRF francais a eu une efficacite comparable a celle des programmes decrits dans les etudes etrangeres. Cette prise en charge gagne a etre encadree par des evaluations standardisees comme des echelles de mesure du retentissement de la douleur.

Management of pain is one of the major expectations of children with neurological impairment and their families. The medical literature is poor on this topic accounting for approximately 0.15 % of the publications on pain in general. The objective of the French Pediatric Neurology Society was to review the current knowledge on this topic. Bibliographic research was conducted with PubMed and RefDoc for publications between 1994 and 2014 in French or English. A total of 925 articles were retrieved and 92 were selected for review. Pain is common in this population: a 2-week survey indicated that pain occurs in 50-75 % of children. Pain negatively impacts the quality of life of children and their parents. Children with neurological impairment express their pain with pain expression patterns and specific patterns common to children (change of tone, abnormal movements, spasticity, paradoxical reactions, such as laughter, self-injury or vasomotor dysfunction). Some children with neurological impairment are able to use self-report pain scales. If not, observational measures should be used. Behavioral rating scales specifically designed for this population are more sensitive than others. Scales must be selected according to children's communication skills, type of pain, and the context. Sometimes behavioral changes are the only expression of pain: any change in sleep, tone, feeding, or mood must suggest pain in this population. Management of pain remains difficult. There are no specific guidelines. Procedural pain management guidelines and the usual analgesic drugs can be used in children with neurological impairment with specific concerns regarding tolerance and side effects. These children are particularly at risk for neuropathic pain. A multidisciplinary approach is helpful, involving physicians, nurses, physiotherapists, psychologists and parents.

Gastrointestinal symptoms are very frequent in myotonic dystrophy but largely unrecognized. They can be the revealing factors of the disease. We report 2 cases of 10 and 17-year-old children with persistent encopresis starting at the age of 3 and 5 years in spite of laxative treatment. Neurological examination and anorectal manometry provided the diagnosis of myotonic dystrophy. Procainamide treatment was introduced and the digestive symptoms improved. Any child with encopresis should have complete evaluation to rule out the diagnosis of myotonic dystrophy and physicians should look for upper and/or lower gastrointestinal symptoms in every patient with myotonic dystrophy.

Chronic pain in children and adolescents has a major impact on their life in terms of school, sleep as well as family and social life. Teenagers aged 13-15 and girls are at the highest risk. Zeltzer et al. established a bio-psychosocial model of chronic pain in 1998 to account for all its dimensions and advocated a multidisciplinary management plan. Programs based on their principles target specific symptoms such as anxiety and loss of function, while treating underlying factors and teaching coping skills to patients and their families. They aim for patients to regain autonomy rather than focusing on pain resolution. Such programs, with varied protocols, have existed outside of France for approximately 15 years. The efficacy of these multidisciplinary programs has been shown in studies in Germany, the United Kingdom, the United States, Canada, and Australia. To our knowledge, there are no French studies on this topic; therefore, our aim was to describe a French program. We hypothesized that the program would be effective in reducing chronic pain and its impact.The aim of this study was to describe the multidisciplinary management of chronic pain in a French pediatric functional rehabilitation center. It is a public health establishment located in the suburbs of Lille, offering care for children aged 0-18 with various conditions. It has 52 hospital beds, can accommodate up to 22 day-hospital visits per day and has comprehensive technical facilities. This prospective study consisted in a chart review of all consecutive patients who were hospitalized in the functional rehabilitation center for chronic pain with significant disability since 2010. We reviewed the treatment protocol for each patient as well as the treatment results for the composite primary endpoint, comprising pain characteristics and the impact of pain on function and schooling after discharge.Twenty-nine patients, aged 9.4-17.8 years, 62.1% of whom were girls, were hospitalized for chronic pain with a significant impact on their daily life between 2010 and August 2014. The most common diagnosis was complex regional pain syndrome type 1 (CRPS1) (37.9%). Pain had major consequences, with total disability in 69% of cases and 100% of children taking pain medications. In 65.5% of cases, patients were hospitalized in an inpatient setting, and 34.5% attended an outpatient program. Treatment lasted from 1 to 68 weeks (mean, 24.3; standard deviation [SD], 21.6). Patients received a combination of medical care, physical therapy (100%), occupational therapy (37.9%), psychological counseling (100%), pain medications (96.6%), and schooling (96.6%). Pain improved significantly in 89.7% of patients (95% confidence interval [95% CI] [0.73-0.98]) and pain medication consumption decreased significantly in 72.4% of children (95% CI [0.53-0.87]). Patients who had stopped walking could ambulate again in 91.7% of cases (95% CI [0.73-0.99]) and 86.4% of patients who had been missing school were back at school full time (95% CI [0.65-0.97]). There were no significant differences for these results between inpatient and outpatient management programs. Improvements were maintained at 3-6 months after discharge in 83.3% of cases.The multidisciplinary pain management program in this French pediatric functional rehabilitation center shows results comparable to the programs described in other countries. Chronic pain should be evaluated with standardized and validated tools, such as the measurement of the pain-related disability with the Functional Disability Index.

Gastrointestinal symptoms are very frequent in myotonic dystrophy but largely unrecognized. They can be the revealing factors of the disease. We report 2 cases of 10 and 17-year-old children with persistent encopresis starting at the age of 3 and 5 years in spite of laxative treatment. Neurological examination and anorectal manometry provided the diagnosis of myotonic dystrophy. Procainamide treatment was introduced and the digestive symptoms improved. Any child with encopresis should have complete evaluation to rule out the diagnosis of myotonic dystrophy and physicians should look for upper and/or lower gastrointestinal symptoms in every patient with myotonic dystrophy.