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Moretti A, Snichelotto F, Liguori S, Paoletta M, Toro G, Gimigliano F, Iolascon G. The challenge of pharmacotherapy for musculoskeletal pain: an overview of unmet needs. Ther Adv Musculoskelet Dis 2024; 16:1759720X241253656. [PMID: 38799611 PMCID: PMC11119417 DOI: 10.1177/1759720x241253656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 04/10/2024] [Indexed: 05/29/2024] Open
Abstract
Musculoskeletal disorders are characterized by several impairments, including pain, affecting muscles, bones, joints and adjacent connective tissue, resulting in temporary or permanent functional limitations and disability. Musculoskeletal pain is particularly prevalent worldwide and greatly impacts the quality of life, social participation and economic burden. To date, several issues persist about the classification of musculoskeletal pain and its management strategies and resources. The treatment of musculoskeletal pain conditions is complex and often requires a multimodal approach, including pharmacological and non-pharmacological therapy that might be ineffective in many cases, resulting in poor patient satisfaction and controversial expectations about the potential benefits of available interventions. This manuscript provides an overview of unmet needs in managing musculoskeletal pain, particularly focusing on pharmacotherapeutic pitfalls in this context.
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Affiliation(s)
- Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples 80138, Italy
| | - Francesco Snichelotto
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Sara Liguori
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Francesca Gimigliano
- Department of Physical and Mental Health and Preventive Medicine, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
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Lee RR, Mountain D, Connelly M, Palermo TM, Peters S, Cordingley L, McDonagh JE. 'That's what makes me better': Investigating children and adolescents' experiences of pain communication with healthcare professionals in paediatric rheumatology. Eur J Pain 2023; 27:111-128. [PMID: 36200660 PMCID: PMC10092465 DOI: 10.1002/ejp.2043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 09/29/2022] [Accepted: 10/02/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pain communication should be an integral part of clinical consultations, particularly in paediatric rheumatology where children and adolescents frequently present with chronic musculoskeletal pain. To date, literature exploring the nature of and extent to which pain communication occurs has focused on healthcare professionals as respondents, yielding inconsistent and incomplete findings. The aim of this study was to explore children and adolescents' experiences of pain communication in the context of paediatric rheumatology consultations. METHODS Data were collected using semi-structured telephone interviews with children and adolescents recruited from three tertiary paediatric rheumatology centres in the United Kingdom. A framework analysis approach was used to explore the similarities and divergences in participant accounts. RESULTS Twenty-six children and adolescents (aged 6-18 years, median = 14, 58% female) participated. Diagnoses included: juvenile idiopathic arthritis, Chronic Idiopathic Pain Syndromes, Ehlers Danlos Syndrome/Hypermobility. Four themes were identified: (1) Co-ordination of pain communication; (2) Barriers to pain communication; (3) Facilitators of pain communication; (4) Dissatisfaction with pain communication. These themes particularly encompassed the process of communication, disclosure of effective and ineffective approaches and the impact of communication. Participants expected questions about pain, felt cared about and found talking about pain natural. Challenges included augmenting the feeling of being different to peers and concerns about management plans changing as a result of pain conversations. CONCLUSIONS Children and adolescents recalled a range of effective and ineffective pain communication approaches. Our study informs recommendations which highlight how healthcare professionals can improve their communication about pain with children and adolescents in the future. SIGNIFICANCE Our findings demonstrate that children and adolescents attending paediatric rheumatology expect to be and value being asked about their pain during consultations with healthcare professionals. Children and adolescents remember many of the processes involved, experiences of and the outcomes of pain communication. The current study reveals insights which can improve healthcare professional pain communication with children and adolescents. Our study introduces key recommendations for healthcare professionals to have more effective pain conversations in future.
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Affiliation(s)
- Rebecca Rachael Lee
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Institute for Health Research Biomedical Research Centre, Manchester University Hospital NHS Trust, Manchester, UK
| | - Danielle Mountain
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Institute for Health Research Biomedical Research Centre, Manchester University Hospital NHS Trust, Manchester, UK
| | - Mark Connelly
- Division of Developmental and Behavioral Health, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Tonya M Palermo
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Sarah Peters
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Lis Cordingley
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Institute for Health Research Biomedical Research Centre, Manchester University Hospital NHS Trust, Manchester, UK
| | - Janet E McDonagh
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,National Institute for Health Research Biomedical Research Centre, Manchester University Hospital NHS Trust, Manchester, UK.,Royal Manchester Children's Hospital, Manchester University Hospitals Trust, Manchester, UK
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van Straalen JW, van Stigt Thans M, Wulffraat NM, de Roock S, Swart JF. A Diagnostic Prediction Model for Separating Juvenile Idiopathic Arthritis and Chronic Musculoskeletal Pain Syndrome. J Pediatr 2022; 251:164-171.e6. [PMID: 35460700 DOI: 10.1016/j.jpeds.2022.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/08/2022] [Accepted: 04/15/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To develop and validate a diagnostic prediction model that can distinguish between juvenile idiopathic arthritis (JIA) and chronic musculoskeletal pain syndrome (CMPS) based on patient-reported outcomes. STUDY DESIGN This retrospective cohort study evaluated whether the Juvenile Arthritis Multidimensional Assessment Report (JAMAR) performs well in distinguishing JIA from CMPS. We analyzed JAMARs completed by 287 patients at their first visit to the pediatric rheumatology department of Wilhelmina Children's Hospital in Utrecht, The Netherlands. Relevant JAMAR items for predicting a diagnosis of JIA were selected in a penalized multivariable model suitable for clinical application. The model was subsequently validated with new data from the same center. RESULTS A total of 196 JAMARs (97 JIA, 99 CMPS) were collected in the model development data, and 91 JAMARs (48 JIA, 43 CMPS) were collected in the validation data. Variables in the prediction model that were strongest associated with a diagnosis of JIA instead of CMPS were asymmetric pain/swelling in the shoulder (OR, 2.34), difficulty with self-care (OR, 2.41), skin rash (OR, 2.07), and asymmetric/pain swelling in the knee (OR, 2.29). Calibration and discrimination (area under the receiver operating characteristic curve, 0.83; 95% CI, 0.74-0.92) of the model in the validation data were good. CONCLUSIONS Several items from the JAMAR questionnaire can potentially distinguish JIA from CMPS in patients with corresponding symptoms. We present an easy-to-use, adjusted, and validated model to separate these 2 diagnoses early at presentation based on patient-reported outcomes to facilitate proper referral and treatment.
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Affiliation(s)
- Joeri W van Straalen
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands; Faculty of Medicine, Utrecht University, Utrecht, The Netherlands.
| | - Martine van Stigt Thans
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands; Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Nico M Wulffraat
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands; Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Sytze de Roock
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands; Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Joost F Swart
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands; Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
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Bodily expression of psychological distress in adolescents: a qualitative study. Child Adolesc Psychiatry Ment Health 2022; 16:40. [PMID: 35659270 PMCID: PMC9166518 DOI: 10.1186/s13034-022-00476-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/13/2022] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION The bodily expression of psychological disorders is one of the leading motives for consultations in adolescent medicine. The diagnostic entity corresponding to DSM-5 "Somatic symptom and related disorders" is sparsely used in the English-language literature, especially for adolescents. Qualitative studies on this topic mostly concern the experiences of healthcare professionals. This study seeks to explore the experience of adolescents expressing psychological distress through their body. METHODS This exploratory research took place in a Paris hospital department of adolescent medicine. Our sampling method was purposive. For inclusion, patients had to be aged 11-24 years, with a "somatic symptom disorder" meeting the DSM-5 criteria. Semi-directive interviews were proposed with visual narration inspired by photoelicitation. Thematic analysis allowed us to explore the data with an inductive approach. RESULTS Thirty adolescents were interviewed; they were 14-22 years old and mostly had somatic symptom or functional neurological disorders. Three principal themes emerged from our analysis of the interview contents: the personal, including bodily, experience of the disorder, the experience of relationships, and the question of what is visible through the body. CONCLUSION This research allowed us to discuss the reversal of generations, the function of the DSM-5 diagnosis, illuminated by sociology, and finally, cultural pathways. It shows the importance of recognizing the reality of the adolescents' bodily feelings, reassuring them by ruling out serious causes, and supporting their search for meaning. It is important to think about a specific framework of family therapy that can make effective use of this experience of the reversal of generations.
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Ibrahim N, Rietsch J, Harf A, Lefèvre H, Moro MR, Ludot M. [Multidisciplinary care of an adolescent with somatic disorders]. SOINS. PEDIATRIE, PUERICULTURE 2021; 42:45-48. [PMID: 34763845 DOI: 10.1016/j.spp.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Theo's clinical observation illustrates the management of a 14-year-old adolescent with unexplained somatic symptoms. His symptoms can be integrated into what the classification of mental illnesses calls a somatic symptom disorder, with a depressive comorbidity. The description of the care pathway shows the gradual acceptance of psychological suffering by the adolescent and his parents in a service where different professionals are involved, with sufficient time for a good therapeutic alliance to be built.
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Affiliation(s)
- Nour Ibrahim
- Maison de Solenn, AP-HP, 97 boulevard de Port-Royal, 75014 Paris, France
| | - Joanne Rietsch
- Maison de Solenn, AP-HP, 97 boulevard de Port-Royal, 75014 Paris, France
| | - Aurélie Harf
- Maison de Solenn, AP-HP, 97 boulevard de Port-Royal, 75014 Paris, France
| | - Hervé Lefèvre
- Maison de Solenn, AP-HP, 97 boulevard de Port-Royal, 75014 Paris, France
| | - Marie Rose Moro
- Maison de Solenn, AP-HP, 97 boulevard de Port-Royal, 75014 Paris, France
| | - Maude Ludot
- Maison de Solenn, AP-HP, 97 boulevard de Port-Royal, 75014 Paris, France.
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Ludot M, Merlo M, Ibrahim N, Piot MA, Lefèvre H, Carles ME, Harf A, Moro MR. ["Somatic symptom disorders" in adolescence. A systematic review of the recent literature]. Encephale 2021; 47:596-604. [PMID: 34538623 DOI: 10.1016/j.encep.2021.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 04/02/2021] [Accepted: 04/18/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Body expression of mental disorders is common in adolescence. Only two literature reviews over the last five years have been identified about somatoform disorders in children., The present article provides a systematic review of articles in English, which concern "Somatic Symptom and Related Disorders" according to the DSM-5 (Diagnostic and Statistical Manual - 5th Edition) among adolescents. METHODS The article search was made on Medline, Psychinfo, Google Scholar, BiomedCentral, Central and tripdatabase (for grey literature) according to PRISMA criteria and with the items "somatoform disorders" or "somatic symptom disorders". An age filter was applied for "adolescents", and a selection was done from the last five years. All articles concerning adolescents (often associated with children) were initially included, except for articles concerning eating disorders, dysmorphic disorders or adult population. Comments, editorials, opinion or descriptive articles were also excluded. The authors then carried out an analysis of the main topics, themes and questions covered in the selected publications and presented a descriptive synthesis. RESULTS A total of seventy-seven publications were included in the analysis, from three hundred and seventy-two publications. First, the terms used to refer to these "somatic symptom disorders" were varied, such as "somatization", "somatic complaints/symptoms", "functional disorder", "unexplained symptoms" and "somatoform disorders". Then, studies related just to adolescents were limited: most of studies included children and adolescents in their methodologies; and some of them questioned somatic symptoms from a developmental perspective. Case reports were the most represented articles among all medical specialties, with clinical descriptions about "functional neurological symptom disorder", "factitious disorder" and "somatic symptom disorder" with a medical disease, among children and adolescents. We sometimes observed a controversial borderline between psychological and somatic disorders. Various explanatory models appeared, especially the trauma path; familial and social environment was also pointed out, with a possible peer group effect; neurocognitive theories were finally described. The literature highlights the effectiveness of psychosocial therapies (especially the cognitive-behavioral therapy) and the importance of multidisciplinary management. Finally, a few studies with a qualitative methodology are represented. CONCLUSIONS Only nine articles included "somatic symptom disorder" in their titles, despite a terminology valued by many authors (compared to "somatoform disorders" from the DSM-IV). The heterogeneity of terminologies, case reports and explanatory models witness a lack of connexions between medical specialties. This could explain in part the wandering of adolescents and their families in the health care system. It could also contribute to the delay before diagnosis, especially when neurological symptoms exist, and a late referral for psychiatric consultation. Further studies are needed to understand difficulties to use a clinical pathway among medical specialties, when the benefit of amultidisciplinary approach seems to be unanimous.
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Affiliation(s)
- M Ludot
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France.
| | - M Merlo
- Maison de Solenn, hôpital Cochin, 75014 Paris, France
| | - N Ibrahim
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France; Groupe français de recherche en médecine et santé de l'adolescent, maison de Solenn, hôpital Cochin, 75014 Paris, France
| | - M-A Piot
- Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France; Faculté de santé, UFR de médecine, université de Paris, 75006 Paris, France; Service de psychiatrie de l'enfant, de l'adolescent et du jeune adulte, institut mutualiste Montsouris, 75014 Paris, France
| | - H Lefèvre
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France; Groupe français de recherche en médecine et santé de l'adolescent, maison de Solenn, hôpital Cochin, 75014 Paris, France
| | - M-E Carles
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France
| | - A Harf
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France
| | - M R Moro
- Maison de Solenn, hôpital Cochin, 75014 Paris, France; PCPP, université de Paris, 92100 Boulogne-Billancourt, France; Inserm, CESP, Team DevPsy, UVSQ, université Paris-Saclay, 94807 Villejuif, France
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Lefèvre H, Loisel A, Meunier BB, Lemoine N, Moro MR, Quartier P, Lachal J. [Professional representation of chronic idiopathic musculoskeletal pain in adolescents]. SOINS. PÉDIATRIE, PUÉRICULTURE 2021; 42:27-30. [PMID: 34099234 DOI: 10.1016/j.spp.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chronic idiopathic musculoskeletal pain is common in adolescence, and its impact is sometimes severe. The diagnostic process, which consists of eliminating other etiologies, can be long, complex, and at risk of medical nomadism. Specialists rely on many clinical elements to orient themselves. The care pathway and the subjective feeling of the professional are valuable diagnostic elements.
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Affiliation(s)
- Hervé Lefèvre
- Maison de Solenn - Maison des adolescents de l'hôpital Cochin, AP-HP, 97 boulevard de Port-Royal, 75014 Paris, France; Université Paris-Saclay, UVSQ, Inserm, Centre de recherche en épidémiologie et santé des populations, Team DevPsy, 16 avenue Paul-Vaillant-Couturier, 94807 Villejuif, France; Groupe français de recherche clinique en médecine et santé de l'adolescent, 97 boulevard de Port-Royal, 75014 Paris, France.
| | - Alexandra Loisel
- Maison de Solenn - Maison des adolescents de l'hôpital Cochin, AP-HP, 97 boulevard de Port-Royal, 75014 Paris, France
| | - Brigitte Bader Meunier
- Centre de référence national pour les rhumatismes inflammatoires et les maladies auto-immunes systémiques rares de l'enfant, unité d'immunologie, hématologie et rhumatologie pédiatrique, Hôpital Necker-Enfants malades, 149 rue de Sèvres, 75015 Paris, France
| | - Noémie Lemoine
- Maison de Solenn - Maison des adolescents de l'hôpital Cochin, AP-HP, 97 boulevard de Port-Royal, 75014 Paris, France
| | - Marie Rose Moro
- Maison de Solenn - Maison des adolescents de l'hôpital Cochin, AP-HP, 97 boulevard de Port-Royal, 75014 Paris, France; Université Paris-Saclay, UVSQ, Inserm, Centre de recherche en épidémiologie et santé des populations, Team DevPsy, 16 avenue Paul-Vaillant-Couturier, 94807 Villejuif, France
| | - Pierre Quartier
- Centre de référence national pour les rhumatismes inflammatoires et les maladies auto-immunes systémiques rares de l'enfant, unité d'immunologie, hématologie et rhumatologie pédiatrique, Hôpital Necker-Enfants malades, 149 rue de Sèvres, 75015 Paris, France
| | - Jonathan Lachal
- Maison de Solenn - Maison des adolescents de l'hôpital Cochin, AP-HP, 97 boulevard de Port-Royal, 75014 Paris, France; Université Paris-Saclay, UVSQ, Inserm, Centre de recherche en épidémiologie et santé des populations, Team DevPsy, 16 avenue Paul-Vaillant-Couturier, 94807 Villejuif, France
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Coles ML, Weissmann R, Uziel Y. Juvenile primary Fibromyalgia Syndrome: epidemiology, etiology, pathogenesis, clinical manifestations and diagnosis. Pediatr Rheumatol Online J 2021; 19:22. [PMID: 33648522 PMCID: PMC7923821 DOI: 10.1186/s12969-021-00493-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 01/11/2021] [Indexed: 12/12/2022] Open
Abstract
Juvenile primary fibromyalgia syndrome (JPFS) is a chronic, musculoskeletal pain syndrome affecting children and adolescents, most commonly adolescent girls. The syndrome has a multifactorial etiology, with altered central pain processing playing an important role. The hallmark symptom is severe, widespread musculoskeletal pain. Other symptoms include sleep and mood disturbances, headaches, stiffness, and subjective joint swelling. Physical examination can reveal multiple tender points. The diagnosis is clinical, with defined criteria. Early diagnosis and intervention are important. In this part of the review, we discuss the epidemiology, etiology, pathogenesis, clinical manifestations and diagnosis of JPFS. Part two will focus on treatment and prognosis.
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Affiliation(s)
- Maya Levy Coles
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, 49 Tshernichovsky St., 44281, Kfar Saba, Israel
| | - Rotem Weissmann
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, 49 Tshernichovsky St., 44281, Kfar Saba, Israel
| | - Yosef Uziel
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, 49 Tshernichovsky St., 44281, Kfar Saba, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.
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