Although children and adults with fibromyalgia syndrome (FMS) experience similar symptoms, children seem to experience more sleep disturbances and fewer TPs than adults. Yunis and Masi first described similarities and differences of juvenile FMS as compared to presentation in adults. Diagnosis is made by history, physical examination, lab studies, and exclusion of other causes of findings. The 1990 American College of Rheumatology (ACR) diagnostic criteria for FMS include diffuse pain and 11 or more TPs. The goal of treatment is to control the symptoms using multiple therapies of medication, physical therapy, exercise regime, support groups, and psychological therapy. Incidence of FMS in children may be as high as 6.2% of the general pediatric population. The prognosis of children with FMS is more favorable than in adults.

The ACR defined 2 major diagnostic criteria for classifying FMS in adults. The first is a history of widespread pain for at least 3 months involving both sides of the body above and below the waist. Specific areas include the cervical skeleton (eg, spine, anterior chest), the shoulders or buttocks (considered for each involved side), and the lower back (considered below the waist). The second criterion requires pain on palpation of 11 of 18 defined TPs when digitally palpated with approximately 4 kg per unit area of force. The patient must indicate that palpation is painful for a positive result.

History: FMS is characterized by musculoskeletal pain, stiffness, and aching. The severity of pain at the TPs rates 8 on a scale of 10. Complaints of fatigue, anxiety, and depression are reported. Adolescents with FMS often describe abnormal sleep patterns that interfere with school and family activities. Descriptions of difficulty falling asleep, frequent awakenings due to discomfort, and feeling unrested in the morning are common.

• Questions for patient and family should explore presence of the following:

• Widespread pain or aching
• Headaches
• Morning stiffness and fatigue
• Subjective joint swelling
• Abdominal pain
• Symptoms of depression
• Quality and amount of sleep

• Assess quality of pain (eg, when, what, where, how long)

• When did the pain start?
• What makes it better?
• What makes it worse?
• How long does it last?
• Does it vary throughout the day?
• Does it wake you up at night?
• Where is the pain?
• What is it like (eg, sharp, dull, aching, deep)?
• What is the appearance of the affected area (eg, swelling, edema)?

• Other associated symptom questions

• Do you have fever?
• Do you have any change in appetite?
• Do you have any weight loss?
• Describe your sleep pattern.
• Are you disturbed easily during sleep?
• Do you have frequent awakenings?
• Do you feel rested in the morning?
• Do you have any bowel or GI symptoms?
• Do you feel anxious, down, depressed?
• Are your muscles weak?

• Psychosocial aspect questions

• Are you experiencing any stressors or problems at school?
• Are you experiencing any stressors or problems in your family?
• Are you tired in school?
• Are you able to keep up with the other children at school and outside activities?
• What has been the impact of the pain on routine activities?
• How has your family responded to the pain?
• Is there any one else at home with similar problems?

• Common aggravating factors of FMS

• Anxiety/stress
• Cold weather
• Humid weather
• Inactivity
• Physical overactivity
• Poor sleep

• Common alleviating factors of FMS

• Hot shower/bath
• Moderate activity
• Stretching/exercising
• Warm weather
• Massage

• Perform thumb palpitation of 18 specific TP sites with a force of 4 kg per unit area. This force is approximately the pressure necessary to blanch the examiner's nail. It is important to note that this criteria is suggested but not agreed upon among practitioners. Neumann, Smythe, and Buskilia suggest using a 3-kg criterion rather than 4 kg in children because their threshold is different from adults. In the child, palpation elicits tenderness in 5 of 11 TPs at the following locations:

• Occiput - Bilateral, at the suboccipital muscle insertions

• Low cervical - Bilateral, at the anterior aspects of the intertransverse spaces at C5-C7

• Trapezius - Bilateral, at the mid point of the upper border

• Supraspinatus - Bilateral, at origins, above the scapula spine near the medial border

• Second rib - Bilateral, at the second costochondral junctions just lateral to the junctions on upper surfaces

• Lateral epicondyle of humerus - Bilateral, 2 cm distal to the epicondyles

• Gluteal - Bilateral, in upper outer quadrants of buttocks in anterior fold of muscle

• Greater trochanter - Bilateral, posterior to the trochanteric prominence

• Knee - Bilateral, at the medial fat pad proximal to the joint line

• In general, Calabro describes examination of joints in juvenile FMS to reveal normal findings despite tenderness and spasms in soft tissue on palpation. Physical findings that should be explored are the presence of hypermobility in the joints using the criteria developed by Carter and Wilkerson and modified by Bird, presence of swelling or joint edema, abdominal tenderness, and range of motion to determine joint stiffness.

Lab Studies:

• The history and physical examination guide the laboratory workup for FMS. Because the presentation and diagnosis by exclusion of other physical problems often are confusing, children with FMS may be evaluated by a number of physicians who perform various batteries of tests. Most laboratory tests performed are expected to be within normal limits when making the diagnosis of FMS.

  Studies to consider in a child presenting with a clinical picture consistent with FMS include the following:

• CBC - Normal

• Erythrocyte sedimentation rate (ESR) - Mean ESR is 15 mm/h

• Rheumatoid factor (RF) - Negative

• C-reactive protein and antinuclear antibody (ANA) titer - May be positive. However, given the high incidence of ANA in the general population, ANA testing should be avoided unless the history and physical exam point to features and abnormalities not found in fibromyalgia.

• Prolactin serum levels - Negative

• Electrolytes - Normal

• Liver function tests - Normal

• Muscle enzymes - Normal

• Purified protein derivative (PPD) - Negative

• Blood and urine cultures - Negative

• Thyroid Function Tests - Normal

Imaging Studies:

• Plain radiographs including chest, ribs, back - Normal

• Ultrasounds of abdomen, pelvis, paravertebrae - Findings normal

• Bone scan - Normal

• CT scan/MRI studies - Normal

• Polysomnography, including PLMS assessment, to evaluate possible sleep disorders - Normal

• The goal of an exercise regime is to improve cardiovascular health and musculoskeletal fitness through nonimpact aerobic activity.

• Returning to normal activity is imperative for the child who has stopped sport and social activities due to pain because this helps to modulate the pain. A physical therapist may be extremely helpful in establishing a reasonable exercise and activity regime.

• Other modalities found to be helpful in modulating pain include hypnotherapy, cognitive-behavioral intervention, physical therapy, and transcutaneous electrical nerve stimulation (TENS). Using palliative measures to treat symptoms and minimizing physical disability is an important treatment mainstay.

Typical medication regimens for pediatric FMS primarily include skeletal muscle relaxants and low-dose tricyclic antidepressants. Some evidence reports that pain and symptom management with nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with antidepressants and nonaddictive analgesics is effective. The most well-described medications used in the treatment of pediatric FMS are low-dose antidepressants, skeletal muscle relaxants, and NSAIDs. Low-dose antidepressants, such as amitriptyline (Elavil), and skeletal muscle relaxants, such as cyclobenzaprine (Flexeril), help decrease the hyperarousal mechanisms in FMS and, in turn, help the child and adolescent sleep better. Both medications are administered at bedtime or 1-2 hours before bedtime. Some debate exists in the literature as to which medication is used initially. Some authorities, such as Gedalia et al, suggest use of cyclobenzaprine first in treatment, while others begin medication therapy with low-dose tricyclic antidepressants.

Depending on which medication is started first, either skeletal muscle relaxants or low-dose tricyclic antidepressants have been used when the child or adolescent fails to respond to the initial medication. An NSAID or acetaminophen is used in conjunction with the muscle relaxants or antidepressants in some cases that are unresponsive to the mainstay therapies alone. Active investigation is underway looking at the potential role for S-adenosylmethionine (SAMe) and the selective serotonin reuptake inhibitors (SSRIs) in the adult population.
 

Drug Category: Tricyclic antidepressants -- Help decrease pain intensity and improve sleep quality. They counteract the hyperarousal mechanism in FMS and promote deeper sleep in children and adolescents. Both medications are administered at bedtime or 1-2 hours before bedtime. SSRIs have been found useful for treating chronic pain states.

Drug Category: Skeletal muscle relaxants -- May act centrally by a selective action on the CNS and are principally used for relieving painful muscle spasms or spasticity occurring in musculoskeletal and neuromuscular disorders. Their mechanism of action may be due, in part, to their CNS-depressant activity.

Drug Category: Nonsteroidal anti-inflammatory drugs -- Used for their anti-inflammatory effects, analgesic, and antipyretic effects. They are useful for the relief of mild to moderate pain.

Prognosis:

• Improvement in signs and symptoms of FMS is likely in children and adolescents. Gedalia and colleagues observed children in a rheumatology clinic collecting data on 50 children with an average follow-up period of 18 months. They found that 60% of the children had improved, 36% stayed the same, and 4% worsened compared to their initial presentation. Nearly all of the children needed to continue medications for up to 4 years after initial presentation.

• Buskila and colleagues studied FMS among children aged 9-15 years. Data on 15 of the children showed that 73% (ie, 11 of the 15) no longer met criteria for FMS at 30-months follow-up. The mean number of TPs and the amount of force necessary to elicit pain at each point showed significant improvement. Complaints among the 4 children who still met criteria for FMS included abdominal pain, headache, paresthesias, morning stiffness, and sleep disturbance. Additionally, 7 children were observed who did not progress to the point of meeting the full criteria over the 30 months, and all 7 children had improved.

• Siegel and colleagues observed 33 patients with a mean follow-up of 2.6 years. Improvement was observed in the majority of patients during that follow-up time, with all patients showing some positive response to treatment. Given prognostic findings, children with FMS as a whole are more likely to have a favorable outcome than adults diagnosed with FMS.

Patient Education:

• Health care providers are responsible to educate children and families about every aspect of FMS in an effort to improve basic knowledge and coping mechanisms to deal with the long-term aspects of the disease. It is imperative for all involved to have full understanding of the goals of treatment, including exercise regimes, expectations of medication therapy, and overriding aspects of living with chronic pain. Successful treatment and improved outcomes are enhanced when the patient has a multifaceted approach to treatment, including medical care, psychological interventions, and physical therapy. Education concerning every aspect of care and intervention is a key to successful treatment of FMS.

• Summary: The understanding of FMS in children still is in its infancy stage; however, strides in both diagnosis and treatment modalities have progressed in the past 10 years. Because prevalence of FMS in children is increasing, diagnosing the disorder early in its course and then recommending a multidisciplinary approach to the child's disorder is important. An approach that involves support for the family and specific recommendations for treatment may help decrease the symptomatology and increase the child's functioning.