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

This oral is built to probe the reasoning that holds the central sensitization at the centre, and to expose the candidate who has memorised the pain label without the mechanism and the red flags. The questions escalate from the classification and the exclusion to the mechanism and the management of the two main phenotypes. ^[7]

Opening question: the classification and the exclusion

The examiner opens with the presentation and asks how you classify her pain and what you exclude before applying the amplified pain label. ^[3]

A strong answer names the juvenile fibromyalgia by the 2010 American College of Rheumatology preliminary diagnostic criteria, with the Widespread Pain Index and the Symptom Severity Scale, and then the exclusion of the juvenile idiopathic arthritis, the leukaemia and the infection through the focused history, the examination and the first-line blood panel. ^[1][3]

Model answer. This girl has the juvenile fibromyalgia by the 2010 criteria, with the widespread pain for at least three months, the Widespread Pain Index of seven or more and the Symptom Severity Scale of five or more, and no other disorder explaining the pain. The juvenile idiopathic arthritis is excluded by the absence of the morning stiffness and the synovitis, and the leukaemia is excluded by the normal full blood count and the absence of the systemic features. The amplified pain label is applied only after the exclusion. ^[1][9]

Pitfall probe. What are the red flags that exclude the primary amplified pain diagnosis? The objective synovitis, the persistent fever, the weight loss, the night pain that wakes the child, the progressive neurological deficit and the cytopenias. The amplified pain label is never applied to the child with an unexplained red flag. ^[3][9]