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FEATURE | SHERRY
Children with diffuse pain or fibromyalgia may have more
long-term pain, depending on the treatment and study (17,
19). However, 11 of 15 school children identified on screening
to have fibromyalgia resolved their fibromyalgia after 30
months (20). It is important to realize that these children were
not seeking medical help when diagnosed. Cognitive-behavior
therapy alone was employed in five girls with fibromyalgia, and
four reported no pain 10 months later (21).
Children with amplified musculoskeletal pain may develop
other bodily pains such as headache and abdominal pain (8). In
the children we have followed, unresolved psychological issues
contributed to nonpainful poor outcomes such as conversion
reactions, eating disorders, school avoidance, suicide attempts,
and acting out behaviors.
Summary
AMPLIFIED MUSCULOSKELETAL PAIN IN CHILDREN may vary
from localized CRPS to widespread, total body pain. Children
with amplified musculoskeletal pain all suffer significant pain
and disability and need compassionate care that should include
a timely and accurate diagnosis, explanation of the possible
causes of pain, and an effective therapeutic approach (see Table
2). The diagnosis involves excluding conditions that can cause
pain and by the typical pattern manifest in most with amplified
musculoskeletal pain. The psychological aspects involved should
be formally assessed in all children. Intense exercise therapy
along with desensitization is the treatment of choice and of
great benefit to most. Normal function, at a minimum, should
be restored, and reflected in school attendance and social and
sports activities. In those in whom the pain continues, cognitive-behavior
therapy or more formal psychotherapy should be
pursued. Pharmacological agents should be limited to specific
indications, not pain. Children with amplified musculoskeletal
pain and their families challenge one’s diagnostic and therapeutic
skills, but the outcome is rewarding. Rarely can we so significantly
alter the course of a condition that renders children
completely debilitated as we can in those who suffer with
amplified musculoskeletal pain.
6. Malleson, P.N., M.Y. Fung, and A.M. Rosenberg, The incidence of pediatric
rheumatic diseases: results from the Canadian Pediatric Rheumatology Association
Disease Registry. Journal of Rheumatology, 1996. 23(11): p. 1981-7.
7. Manners, P.J., Epidemiology of the rheumatic diseases of childhood. Current
Rheumatology Reports, 2003. 5(6): p. 453-7.
8. Sherry, D.D., Pain Syndromes, in Adolescent Rheumatology, D.A. Isenberg
and J.J.I. Miller, Editors. 1998, Martin Dunitz Ltd: London. p. 197-227.
9. Okifuji, A., et al., A standardized manual tender point survey. I. Development
and determination of a threshold point for the identification of positive
tender points in fibromyalgia syndrome. Journal of Rheumatology,
1997. 24(2): p. 377-83.
10. Rusy, L.M., S.A. Harvey, and D.J. Beste, Pediatric fibromyalgia and dizziness:
evaluation of vestibular function. Journal of Developmental &
Behavioral Pediatrics, 1999. 20(4): p. 211-5.
11. Laxer, R.M., et al., Technetium 99m-methylene diphosphonate bone scans
in children with reflex neurovascular dystrophy. Journal of Pediatrics,
1985. 106(3): p. 437-40.
12. Sherry, D.D., An overview of amplified musculoskeletal pain syndromes.
Journal of Rheumatology Supplement, 2000. 58: p. 44-8.
13. Sherry, D.D., et al., Psychosomatic musculoskeletal pain in childhood: clinical
and psychological analyses of 100 children. Pediatrics, 1991. 88(6):
p. 1093-9.
14. Sherry, D.D., et al., Short- and long-term outcomes of children with complex
regional pain syndrome type I treated with exercise therapy. Clinical
Journal of Pain, 1999. 15(3): p. 218-23.
15. Sherry DD, executive producer. Amplified Musculoskeletal Pain in Childhood.
Diagnosis and Treatment. A Guide for Physical and Occupational
Therapists. (Videotape, DVD) MMII, www.childhoodrnd.org
16. Sherry, D.D. and R. Weisman, Psychologic aspects of childhood reflex neurovascular
dystrophy. Pediatrics, 1988. 81(4): p. 572-8.
17. Sherry, D.D. and P.N. Malleson, The idiopathic musculoskeletal pain syndromes
in childhood. Rheumatic Diseases Clinics of North America, 2002.
28(3): p. 669-85.
18. Wilder, R.T., et al., Reflex sympathetic dystrophy in children. Clinical characteristics
and follow-up of seventy patients. Journal of Bone & Joint Surgery
American, 1992. 74(6): p. 910-9.
19. Siegel, D.M., D. Janeway, and J. Baum, Fibromyalgia syndrome in children
and adolescents: clinical features at presentation and status at follow-up.
Pediatrics, 1998. 101(3 Pt 1): p. 377-82.
20. Buskila, D., et al., Fibromyalgia syndrome in children—an outcome study.
Journal of Rheumatology, 1995. 22(3): p. 525-8.
21. Walco, G.A. and N.T. Ilowite, Cognitive-behavioral intervention for juvenile
primary fibromyalgia syndrome. Journal of Rheumatology, 1992.
19(10): p. 1617-9.
REFERENCES
1. Malleson, P.N., M. al-Matar, and R.E. Petty, Idiopathic musculoskeletal
pain syndromes in children. Journal of Rheumatology, 1992. 19(11): p.
1786-9.
2. Merskey, D.M. and N. Bogduk, Classification of Chronic Pain. Descriptions
of Chronic Pain Syndromes and Definitions of Pain Terms. 1994, Seattle:
IASP Press.
3. Wolfe, F., et al., The American College of Rheumatology 1990 Criteria for
the Classification of Fibromyalgia. Report of the Multicenter Criteria
Committee. Arthritis & Rheumatism, 1990. 33(2): p. 160-72.
4. Yunus, M.B. and A.T. Masi, Juvenile primary fibromyalgia syndrome. A
clinical study of thirty-three patients and matched normal controls.
Arthritis & Rheumatism, 1985. 28(2): p. 138-45.
5. Bowyer, S. and P. Roettcher, Pediatric rheumatology clinic populations in
the United States: results of a 3-year survey. Pediatric Rheumatology Database
Research Group. Journal of Rheumatology, 1996. 23(11): p. 1968-74.
DAVID D. SHERRY, MD
Director, Clinical Rheumatology,
Attending, Pain Management,
Professor of
Pediatrics at The Children's
Hospital of Philadelphia
University of Pennsylvania
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