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FEATURE | SHERRY TABLE 1 | The Yunus & Masi Criteria for Fibromyalgia in Children (4) Major: ___________________________________ ❥ Generalized musculoskeletal aching at 3 or more sites for 3 or more months ❥ Absence of underlying condition or cause ❥ Normal laboratory tests ❥ Five or more typical tender points Minor: ____________________________________________________________________ ❥ Chronic anxiety ❥ Numbness or tension ❥ Fatigue ❥ Poor sleep ❥ Chronic headaches ❥ Irritable bowel syndrome ❥ Subjective soft tissue swelling Fibromyalgia defined as present if the subject has: _______________________________________________________________________________________________________________ ❥ All 4 major criteria and 3 minor criteria OR ❥ First 3 major criteria, 4 tender points, and 5 minor criteria. by the location or presence of autonomic dysfunction. Children with amplified musculoskeletal pain fall into two broad categories: those with localized pain and those with diffuse pain (1). The most easily recognized type of localized pain is CRPS. Children with CRPS have overt autonomic dysfunction that is manifested by coolness or cyanosis of the limb and, occasionally, increased perspiration or edema. Additionally, many, if not most, of these children have localized pain amplification without autonomic signs (e.g., cold, blue). In studies of children with diffuse pain, fibromyalgia receives the most attention (although this term is not often used in conjunction with children since it may differ from adult fibromyalgia). Two sets of criteria for childhood fibromyalgia have been established. The American College of Rheumatology criteria require 11 of 18 trigger points on the body to be painful along with three months of widespread pain (3). The criteria of Yunus and Masi require either four or five painful trigger points and multiple related symptoms (see Table 1) (4). Determining whether trigger points are painful or not is highly subjective. Most children will identify these points as tender or sore, and not painful as required by the definition. Not all children with diffuse pain have painful trigger points, so some do not satisfy the criteria for fibromyalgia. Additionally, there are children with intermittent localized or diffuse pains, or overlapping features of the above, e.g., a cool, blue foot and total body pain. Children with amplified musculoskeletal pain are more disabled than those with arthritis or with mechanical joint problems, and they and their families suffer intensely. In addition to their pain, these children often experience isolation from peers and are commonly told by medical professionals that they are “faking it” or that “it shouldn’t hurt all that much.” This does a great disservice to these children and their families. Epidemiology THERE ARE NO SPECIFIC STUDIES of the incidence of childhood amplified musculoskeletal pain. Studies of normal schoolchildren have found that 1.2% to 6% fulfill criteria for fibromyalgia and up to 7.5% report widespread musculoskeletal pain. Children with amplified musculoskeletal pain comprise approximately 10% of children in pediatric rheumatic disease clinics, and it is the impression of many clinicians that the incidence is increasing (5 - 7). The average age of onset of amplified musculoskeletal pain is preteen to early teen. Amplified musculoskeletal pain is rare below the age of six years, so diagnosing it in young children needs to be done with much circumspection; however, children as young as two years old have developed it. The majority of these children are female (80% in most series), perhaps because females have lower pain thresholds and report pain more frequently than males. Most children with amplified musculo skeletal pain are Caucasian. There is a suspicion that the majority are from upper socioeconomic levels; however, no race or economic level is spared. ❥ Pain modulation by physical activities ❥ Pain modulation by weather factors ❥ Pain modulation by anxiety/stress Etiology THE ETIOLOGY OF AMPLIFIED MUSCULOSKELETAL PAIN is unknown, but it usually can be related to trauma, illness, or psychological distress. Most pediatric rheumatologists think the latter plays a significant role in most, but not all, children. Whether cause or effect, the pain and dysfunction experienced by most of these children is such that it inflicts psychological havoc on both child and family. Genetic factors have been implicated in fibromyalgia and CRPS, and a very weak association has been made between fibromyalgia and increased flexibility. It is likely that there is a combination of both intrinsic factors (such as individual pain threshold, gender, and coping strategies) and extrinsic factors (such as previous pain experiences, social stresses, modeling of chronic pain behaviors, and central and peripheral pain mechanisms) that work together to give rise to amplified musculoskeletal pain (8). Clinical Manifestations and Diagnosis ALTHOUGH EACH CHILD IS UNIQUE, there are enough significant similarities in the history and physical examination to establish the pattern for most. The typical patient is a mature and accomplished adolescent girl who suffers a minor injury or illness and then has increasing pain and dysfunction over several days to months. The pain may be localized, with or without signs of autonomic dysfunction, or it may be diffuse. 52 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
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Page 6 and 7: EDITORS’ CORNER | COMPLEX REGIONA
Page 8 and 9: EDITORS’ CORNER | COMPLEX REGIONA
Page 10 and 11: COMMENTARY | GIORDANO Comprehending
Page 16 and 17: FEATURE | BROATCH RSDSA: Expanding
Page 18 and 19: FEATURE | BROATCH We are acutely aw
Page 20 and 21: FEATURE | BROATCH information, such
Page 22 and 23: FEATURE | PATIENT PROFILE PEOPLE WI
Page 24 and 25: PEOPLE WITH CRPS | THEIR STORIES AN
Page 26 and 27: PEOPLE WITH CRPS | THEIR STORIES AN
Page 32 and 33: FEATURE | GALER 32 | T H E PA I N P
Page 34 and 35: FEATURE | GALER TABLE 1 | IASP Diag
Page 36 and 37: FEATURE | GALER Although there is s
Page 38 and 39: FEATURE | GALER 10. Gammaitoni A, G
Page 40 and 41: INTERVIEW | COVINGTON LIFEBOAT mixe
Page 42 and 43: INTERVIEW | COVINGTON Q. Have any s
Page 45 and 46: Reap the Rewards of Membership Beco
Page 47 and 48: with depression. However, they foun
Page 49 and 50: It is common for patients in pain i
Page 51: There are multiple forms of amplifi
Page 55 and 56: especially opioids. Opioids should
Page 57 and 58: Subscribe to Currents Today! The Ac
Page 59 and 60: FEATURE | COMPLEX REGIONAL PAIN SYN
Page 61 and 62: FEATURE | COMPLEX REGIONAL PAIN SYN
Page 63 and 64: ZICONOTIDE: Promising New Treatment
Page 65 and 66: UNRIVALED INDEPENDENCE COMING SOON
Page 67 and 68: D O YO U G E T I T ? Subscribe to T
Page 69 and 70: SCS as Part of the CRPS Treatment A
Page 72 and 73: OPINION | GETSON The Use of Thermog
Page 74 and 75: IN CONCLUSION | MOSKOVITZ A Theory
Page 76 and 77: IN CONCLUSION | MOSKOVITZ even thin
Page 78 and 79: IN CONCLUSION | MOSKOVITZ Comorbidi
Page 80 and 81: IN CONCLUSION | MOSKOVITZ empathy e
Page 82 and 83: AC ADEMY NEWS | AMERICAN ACADEMY OF
Page 84 and 85: CL ASSIFIED ADS & DIRECTORY | AMERI
Page 86 and 87: RESOURCES | CRPS RESOURCES FOR CRPS
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