Pain amplification, juvenile fibromyalgia and complex regional pain syndrome

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Target exams

Red flags

• A child with chronic musculoskeletal pain who develops weight loss, night pain that wakes them from sleep, persistent fever, or progressive neurological signs does not have primary amplified pain and must be re-evaluated for malignancy, infection or inflammatory disease before the pain is attributed to central sensitization
• Severe allodynia where light touch or clothing causes intense pain, with marked skin colour and temperature change and swelling in a single limb, is complex regional pain syndrome until proven otherwise and requires early mobilisation rather than immobilisation to prevent contracture and permanent disability
• Prolonged school absence, social withdrawal and escalating analgesic use in the child with amplified pain predict a poor outcome and signal the need for intensive multidisciplinary rehabilitation rather than further investigation or opioid escalation
• A child who has been immobilised for complex regional pain syndrome and develops a fixed flexion contracture of the affected limb is developing the iatrogenic complication that intensive functional restoration is designed to prevent

Life stages

Care settings

Clinical exam formats

Board mappings

• Names amplified musculoskeletal pain as chronic pain driven by central sensitization rather than ongoing tissue injury, with juvenile fibromyalgia as the widespread form and complex regional pain syndrome as the regional form
• Recognises that severe allodynia with skin colour, temperature and swelling change in a single limb is complex regional pain syndrome requiring early mobilisation
• States that the diagnosis of amplified pain is clinical and made after excluding inflammatory, infectious and malignant disease, not by a positive test
• Explains central sensitization as the amplified processing of nociceptive signals in the central nervous system with reduced descending inhibition that produces allodynia and hyperalgesia
• Applies the 2010 American College of Rheumatology preliminary diagnostic criteria for juvenile fibromyalgia using the Widespread Pain Index and Symptom Severity Scale validated in adolescents
• Coordinates the multidisciplinary management of the child with amplified pain across paediatric rheumatology, physiotherapy, psychology, the school and the family
• The 2010 American College of Rheumatology criteria for juvenile fibromyalgia require 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, with symptoms for at least three months
• Complex regional pain syndrome is classified by the Budapest clinical criteria as continuing pain disproportionate to any inciting event plus symptoms in three of four categories and signs in two of four categories
• The management is education on central sensitization, graded aerobic exercise, cognitive behavioural therapy and sleep hygiene, with avoidance of opioids and surgery
• Synthesises the recognition, exclusion of red flags and stepwise multidisciplinary management of amplified pain into a single rehabilitation plan
• Counsels the family on the biopsychosocial model of amplified pain and the rationale for active rehabilitation over further investigation and analgesic escalation
• Builds the school reintegration and functional restoration plan for the child with complex regional pain syndrome or juvenile fibromyalgia
• Level 1: Recognition of the clinical features of amplified musculoskeletal pain and the warning signs that mandate re-investigation
• Level 2: Application of the juvenile fibromyalgia criteria and the Budapest criteria and the multidisciplinary treatment pathway
• Level 3: Coordination of the intensive functional restoration programme for the refractory case
• The concept of central sensitization as the mechanism of amplified musculoskeletal pain with allodynia and hyperalgesia
• The 2010 American College of Rheumatology preliminary diagnostic criteria for juvenile fibromyalgia and the Budapest clinical criteria for complex regional pain syndrome
• The evidence-based multidisciplinary management with graded exercise, cognitive behavioural therapy and sleep hygiene and the avoidance of opioids
• Structured assessment of the child with chronic musculoskeletal pain for allodynia, functional disability and the red flags of inflammatory and malignant disease
• Recognition that severe regional pain with autonomic features is complex regional pain syndrome requiring early mobilisation
• Communication of the biopsychosocial explanation of amplified pain and the rehabilitation plan to the child and family
• Amplified musculoskeletal pain as a central sensitization syndrome with juvenile fibromyalgia and complex regional pain syndrome as the main phenotypes
• The 2010 American College of Rheumatology criteria for juvenile fibromyalgia and the Budapest clinical criteria for complex regional pain syndrome
• The multidisciplinary management with exercise, cognitive behavioural therapy and sleep hygiene and the intensive functional restoration programme
• Recognition of the clinical features of amplified musculoskeletal pain and the red flags that mandate re-investigation
• Application of the multidisciplinary management with graded exercise and cognitive behavioural therapy as the first-line
• Coordination of the referral to the specialist pain or rheumatology team and the school reintegration
• Canadian approach to the recognition and multidisciplinary management of amplified musculoskeletal pain in children
• The Budapest clinical criteria for complex regional pain syndrome and the juvenile fibromyalgia criteria
• The intensive functional restoration programme for the refractory case with complex regional pain syndrome