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FEATURE | SHERRY
TABLE 1 | The Yunus & Masi Criteria
for Fibromyalgia in Children (4)
Major:
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❥ 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:
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❥ 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:
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❥ 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.
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