Pain amplification, juvenile fibromyalgia and complex regional pain syndrome: Case

Framing the case

This thirteen-year-old girl with the widespread pain, the fatigue, the unrefreshing sleep and the school absence, whose investigations are normal and whose Widespread Pain Index is nine, has the classic juvenile fibromyalgia by the 2010 American College of Rheumatology criteria. The framework that organises the case is the central sensitization, the amplified processing of the nociceptive signals in the nervous system, and the management is the multidisciplinary rehabilitation that addresses the pain, the function, the sleep, the mood and the family. ^[3][7]

The diagnosis and the classification

The diagnosis is made by the 2010 American College of Rheumatology preliminary diagnostic criteria, validated in the adolescents by Ting and colleagues in 2016. The criteria require the symptoms for at least three months and no other disorder explaining the pain, plus a Widespread Pain Index of seven or more with a Symptom Severity Scale of five or more, or a Widespread Pain Index of three to six with a Symptom Severity Scale of nine or more. This girl meets the first alternative with the Widespread Pain Index of nine and the Symptom Severity Scale of seven. The fatigue, the unrefreshing sleep, the headaches and the abdominal pain are the central features, and the normal blood tests confirm that no other disorder explains the pain. ^[1][3]

The exclusion of the red flags

The inflammatory and the malignant disease are excluded before the amplified pain label is applied. The juvenile idiopathic arthritis is excluded by the absence of the morning stiffness and the objective synovitis and the normal inflammatory markers. The leukaemia is excluded by the normal full blood count and the absence of the cytopenias and the systemic features. The thyroid disease, the vitamin D deficiency and the anaemia are excluded by the first-line panel. The absence of the objective synovitis, the persistent fever, the weight loss, the night pain and the neurological deficit confirms that the primary amplified pain diagnosis is appropriate. ^[3][7]