Juvenile Fibromyalgia & Chronic Fatigue Syndrome  

Ten adolescents, mean age, 15.7 years with fibromyalgia underwent psychiatric interviews, testing, and family assessments. They were compared with a comparison group of patients with juvenile chronic arthritis. The pain scores for the fibromyalgia group was significantly higher than the patients with JCA. Six of the fibromyalgia patients had a psychiatric diagnosis of either depression or anxiety disorders.

In 8 families, high parental expectations for their children's achievement was evident. Seven of the mothers and 3 of the fathers had themselves a chronic disease. Three of the fibromyalgia patients were found to have JCA.

Comments: Fibromyalgia in teenagers is being increasingly recognized. The message of this paper is an analysis of  family psychodynamics, and early assessment and counseling is needed for many of these young patients.

I. H. Vandvick, and K. O. Forseth. Actor Paediatr 83:766-771, 1994.

We studied 73 children with chronic or recurrent musculoskeletal pain of > or = 6 weeks' duration. Thirty-six children had no identifiable organic etiology for their pain, with a minimum follow-up of 2 years for ongoing symptoms. Thirty-seven children had an organic etiology for their pain. Use of an Inappropriate Symptom Checklist was helpful in distinguishing between children with chronic pain who were found to have an organic disease and those without an identifiable organic disease. Seventy-seven percent of children with no inappropriate symptoms had an organic diagnosis ultimately made. Conversely, 79% of children with two or more inappropriate symptoms ultimately had no organic diagnosis to explain their pain. Behavioral self-report measures testing could not differentiate between children with chronic pain with or without organic disease. Intervention by a psychologist skilled in pain management was helpful.

Song KM, Morton AA, Koch KD, Herring JA, Browne RH, Hanway JP
Department of Orthopedic Surgery, Children's Hospital and Medical Center of Seattle, Washington 98105-0371, USA.
J Pediatr Orthop 1998 Sep-Oct;18(5):576-81

[Epidemiological study of a primary fibromyalgia in pediatric age].

BACKGROUND: The aim of the present epidemiological research was to select paediatric subjects who were suspicious of Primary Fibromyalgia (PF) and estimate its incidence in the students of the schools of Castiglione delle Stiviere (Mantova).

METHODS: The students had to answer Campbell's questionnaire which was varied and simplified in order to make it comprehensive to everybody even if the key answers were unchanged. The questionnaire was distributed in primary schools (3dr up to 5th class), secondary schools and high schools and its compilation was carried out with a doctor's help. The authors collected and examined 2408 forms.

After this evaluation 66 subjects, corresponding to 2.74%, had been considered suspected of PF and had been called to our Paediatric Department to continue the study. In the second phase of the research these 66 students have been submitted to a deep anamnesis, a careful clinical evaluation, a test of tender-points with a digital pressure algometer and some laboratory tests to exclude other rheumatic diseases. The map of the American College of Rheumatology adapted by Wolfe et al. (1990) was used to evaluate tender-points.

RESULTS: After this phase 29 students (1.20%) proved to be affected by primary fibromyalgia.

Sardini S, Ghirardini M, Betelemme L, Arpino C, Fatti F, Zanini F
Divisione di Pediatria, Ospedale Civile, Castiglione delle Stiviere, Mantova.
Minerva Pediatr 1996 Dec;48(12):543-550     [Article in Italian]

Fibromyalgia in children; diagnosis and treatment.

Fifteen children (16 years and younger, 10 females, 5 males, mean age 13 years) with juvenile primary fibromyalgia syndrome (JPFS) were seen in a private rheumatology practice over two years. This represented 45 percent of the total number of pediatric rheumatology patients.

Symptoms included polymyalgias, polyarthralgias, nonrestorative sleep, difficulty concentrating in school and fatigue. Examination revealed typical tender points, absence of joint swelling, synovitis or nodules and absence of neurological findings. Dolorimetry was abnormal and standard laboratory tests were normal.

Most of these patients (67 percent) had seen three or more doctors prior to their rheumatological evaluation and not (60 percent) were told they had juvenile chronic arthritis. Other diagnoses offered were "growing pains" (20 percent), hysteria (7 percent) and psychological problems (7 percent).

None of the JPFS patients responded to salicylate or other anti-inflammatory medication. Most (73 percent) responded to cyclobenzaprine, mean dose 12.75 mg. (range 5-25 mg. qhs). JPFS is a very common pediatric rheumatologic problem and is confused with other disorders. Reassurance is very important in the therapy since many parents are fearful that their children may have a potentially crippling disorder. Medication, especially with tricyclics, moderate exercise and proper sleep are also mainstays of therapy.

Romano TJ
W V Med J 1991 Mar;87(3):112-114

Fibromyalgia syndrome in children and adolescents: clinical features at presentation and status at follow-up.

OBJECTIVES: To 1) describe the characteristic features of fibromyalgia syndrome (FS) in a pediatric population, 2) note similarities and differences with FS in adults, and 3) determine outcome after treatment.

SETTING AND DESIGN: The Pediatric Rheumatology Clinic at the University of Rochester Medical Center is staffed by two pediatric rheumatologists and serves as a regional subspecialty referral service with approximately 450 annual patient visits, of which approximately 120 are initial evaluations. A retrospective medical record review from 1989 to 1995 was used to identify and describe the study population, and a structured telephone interview served to determine current status and response to treatment.

RESULTS: A total of 45 subjects were identified (41 female; 42 white; mean age, 13.3 years), of whom 33 were available for telephone interview at a mean of 2.6 years from initial diagnosis (0.1 to 7.6 years). Of a possible 15 symptoms associated with FS, subjects reported a mean of 8, with >90% experiencing diffuse pain and sleep disturbance. Less frequent were headaches (71%), general fatigue (62%), and morning stiffness (53%). The mean cumulative number of tender points summed over all visits was 9.7 (of 18). Telephone interviews showed improvement in most patients, with a mean positive change of 4.8 on a self-rating scale of 1 to 10 comparing current status to worst-ever condition.

CONCLUSIONS: FS in patients referred to a pediatric rheumatology clinic is characterized by diffuse pain and sleep disturbance, the latter being more common than that in adults. The mean number of tender points summed over all visits is fewer than the criterion of 11 established for adults at a single visit. The majority of patients improved over 2 to 3 years of follow-up.

Siegel DM, Janeway D, Baum J
Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, Strong Children's Research Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.  Pediatrics 1998 Mar;101(3 Pt 1):377-382

OBJECTIVE: To identify the child-mother diagnostic correlation in fibromyalgia (FM), to study sleep disturbance in juvenile FM, and to compare clinical aspects and sleep disorders between these groups.

METHODS: We studied 34 children with confirmed FM aged 11 +/- 1 years, 10 children with diffuse pain, and 17 age and sex matched asymptomatic controls. The respective 61 mothers were included: 34 asymptomatic and 27 with FM. All participants were subjected to clinical evaluation, a sleep questionnaire, and nocturnal polysomnography, preceded by a night of adaptation. Sleep scoring was done visually and a computerized analysis was performed for alpha, theta, and delta waves in slow wave sleep (SWS).

RESULTS: A significant predominance of mothers with FM was observed in the group of children with FM (71%) compared to children with diffuse pain (30%) and asymptomatic children (0%). According to the sleep questionnaire, the complaints of superficial sleep and nonrestorative sleep were more prominent in mothers with FM than in children with FM, whereas motor agitation during sleep was more frequent in the children with FM.

Polysomnographic anomalies were also more prominent in mothers with FM than in children with FM in terms of decrease in sleep efficiency, increase of number of arousals during sleep, and alpha intrusion in SWS. Both FM groups presented an increased alpha + theta time/delta time index during SWS compared to respective controls, and mothers with FM also showed an increase in alpha time/delta time index during SWS, compared to asymptomatic mothers. A correlation was found between alpha + theta time/delta time index during SWS and intensity of clinical manifestations of pain and sleep anomalies in children and their mothers.

CONCLUSION: Significant concordance was observed regarding FM diagnosis in children and their mothers. Sleep complaints and polysomnography findings were less prominent in affected children compared to mothers with FM. In addition, we observed a significant correlation between polysomnographic indexes, sleep anomalies, and pain manifestations in children and their mothers.

Roizenblatt S •Tufik S •Goldenberg J •Pinto LR •Hilario MO •Feldman D   Department of Rheumatology, Universidade Federal de Sao Paulo, Brazil. J Rheumatol 1997;24(3):579-85

Non-specific musculoskeletal pain in preadolescents. Prevalence and 1-year persistence.

A 1-year follow-up study of 1756 third- and fifth-grade schoolchildren was conducted with a structured pain questionnaire to assess the prevalence and persistence of self-reported musculoskeletal pain symptoms and disability caused by pain. At follow-up, 1626 (92.7%) children participated in the study.

Pain at least once a week persisted in 270 (52.4%) of the 564 children who reported musculoskeletal pain at least once a week in at least one part of the body at baseline. Of the regional pain symptoms, neck pain had highest persistence and, in girls, significantly more than in boys. Persistence of pain was not related to school grade.

Widespread pain, determined as in the criteria for fibromyalgia, was found in 132 children (7.5%) and persisted in 35 children (29.7%, 95% CI 21.9-38.4) at follow-up. Disability was more severe in children with pain symptoms in more than one area.

This study showed that about half of the preadolescents complaining of musculoskeletal pain at least once a week at baseline had persistent pain symptoms at follow-up. The prognosis of widespread pain in preadolescents was almost the same as the previous findings in adults.

Mikkelsson M, Salminen JJ, Kautiainen H
Rehabilitation Center, Rheumatism Foundation Hospital, Heinola, Finland.
Pain 1997 Oct;73(1):29-35

OBJECTIVES: The purpose of this study was twofold: 1) to describe the coping strategies used by children with juvenile primary fibromyalgia syndrome (JPFS), and 2) to examine how pain coping relates to measures of pain, disability/function, psychological distress, and pain behavior.

METHODS: Sixteen children with JPFS completed the Child Version of the Coping Strategies Questionnaire (CSQ-C), the visual analog scale for pain, the McGill Pain Questionnaire, the Fibromyalgia Impact Questionnaire modified for children, the Arthritis Impact Measurement Scales 2, and the Symptom Checklist-90-Revised. Subjects also also underwent pain behavior observation. Pearson's product moment correlations were conducted to examine the relationship of coping to measures of pain and disability.

RESULTS: The Pain Control and Rational Thinking composite factor score on the CSQ-C correlated with measures of pain severity, functional disability, and psychological distress. Results supported the internal reliability of the CSQ-C in assessing pain coping.

CONCLUSIONS: These results suggest that the CSQ-C may provide a reliable measure for assessing variations in pain coping in JPFS patients. Behavioral interventions aimed at increasing the perception of pain control may be beneficial in treating JPFS.

Schanberg LE  •Keefe FJ  •Lefebvre JC  •Kredich DW  •Gil KM
Arthritis Care Res 1996;9(2):89-96     

Performance of Point Count and Dolorimetry in Assessing Nonarticular Tenderness in Children

Objectives: To compare two methods for assessing tenderness in children: an 18-site point count by manual palpation and dolorimetry in nine tender point sites and four control sites.

Methods: Nonarticular tenderness was measured in 338 healthy children. The extent of agreement between the two methods was evaluated by McNemar's test, and by validity measures, sensitivity and specificity. "Tenderness" was defined if 11 or more points were tender by palpation, or if dolorimetry threshold was below 4 kg.

Results: The sensitivity and specificity of the dolorimetry method was 100% and 58.7%, respectively. When a 3 kg threshold was used, the sensitivity and specificity were 89.3% and 93.5%, respectively. The improvement in accuracy was especially remarkable for girls.

Conclusions: These preliminary findings suggest that in children the dolorimetry threshold for defining tenderness should be 3 kg, and not 4 kg, as in adults.
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By Lily Neumann, Hugh A. Smythe, and Dan Buskila
Journal of Muskuloskeletal Pain, Vol. 4, No. 3, 1996, p.29-30

Lily Neumann, PhD, is Associate Professor in Biostatistics, Unit of Epidemiology and Health Services Evaluation, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.  Hugh A. Smythe, MD, FRCPC, is Professor of Medicine, Rheumatic Disease Unit, Wellesley Hospital, Toronto, Ontario.   Dan Buskila, MD, is Associate Professor in Internal Medicine, Rheumatic Disease Unit, Soroka Medical Center, Beer Sheva, Israel.   Address correspondence to: Lily Neumann, PhD, Epidemiology Unit, Faculty of Health Sciences, Ben-Ourion University of the Negev, Beer Sheva 84105, Israel.

Chronic fatigue syndrome (CFS) and primary juvenile fibromyalgia syndrome (PJFS) are illnesses with a similar pattern of symptoms of unknown etiology. Twenty-seven children for whom CFS was diagnosed were evaluated for fibromyalgia by the presence of widespread pain and multiple tender points. Eight children (29.6%) fulfilled criteria for fibromyalgia. Those children who met fibromyalgia criteria had a statistically greater degree of subjective muscle pain, sleep disturbance, and neurological symptoms than did those who did not meet the fibromyalgia criteria. There was no statistical difference between groups in degree of fatigue, headache, sore throat, abdominal pain, depression, lymph node pain, concentration difficulty, eye pain, and joint pain. CFS in children and PJFS appear to be overlapping clinical entities and may be indistinguishable by current diagnostic criteria.

Bell DS    Bell KM    Cheney PR
Department of Pediatrics, Cambridge Hospital, Massachusetts 02139.
Clin Infect Dis 1994;18(1):S21-3    

We describe five children with varied rheumatic manifestations, including fibromyalgia and arthralgias, ultimately proved to be associated with hypothyroidism. All musculoskeletal symptoms improved after thyroid replacement therapy. We conclude that rheumatic manifestations of hypothyroidism can be as varied in children as in adults.

J Pediatr 1993;123(4):586-8
Keenan GF; Ostrov BE; Goldsmith DP; Athreya BH;
Pediatric Rheumatology Center, Philadelphia, Pennsylvania.

It has been suggested that musculoskeletal symptoms develop from early age and can be regarded as a lifespan phenomenon. The study of childhood pain might provide a better understanding of the origin of chronic pain in adults.

In a study of 569 schoolchildren, aged 10-15 years, in a local community close to Oslo, 75% reported that they usually experience bodily pain. Girls reported more pain than boys. 25% of those reporting pain experience symptoms several days a week.

Knee symptoms and back pain were most frequently reported. Thirty-seven % of the girls reported headache, only 20% of the boys. Girls also reported more neck and shoulder pain than boys. The oldest respondents reported symptoms from more body parts. Symptoms from several body parts were more frequent among girls.

Thirty-eight % of the respondents reported that it sometimes is hard to concentrate because of the pain, and 26% reported that they sometimes have to use medication. The consequences of pain increased with increasing age and increasing number of body parts affected. The results are consistent with findings in the adult population.

Smedbraten BK, Natvig B, Rutle O, Bruusgaard D
The Ullensaker Study Group, Jessheim, Norway.
Scand J Rheumatol 1998;27(4):273-6