A review of biobehavioral research in juvenile primary fibromyalgia syndrome

Expanding the notion of mechanism to further understanding of biopsychosocial disorders? Depression and medically-unexplained pain as cases in point

Evidence-Based Medicine has little consideration for mechanisms and philosophers of science and medicine have recently made pleas to increase the place of mechanisms in the medical evidence hierarchy. However, in this debate the notions of mechanisms seem to be limited to 'mechanistic processes' and 'complex-systems mechanisms,' understood as 'componential causal systems'. I believe that this will not do full justice to how mechanisms are used in biological, psychological and social sciences and, consequently, in a more biopsychosocial approach to medicine. Here, I propose, following (Kuorikoski, 2009), to pay more attention to 'abstract forms of interaction' mechanisms. The present work scrutinized review articles on depression and medically unexplained pain, which are considered to be of multifactorial pathogenesis, for their use of mechanisms. In review articles on these disorders there seemed to be a range of uses between more 'abstract forms of interaction' and 'componential causal system' mechanisms. I therefore propose to expand the notions of mechanisms considered in medicine to include that of more 'abstract forms of interaction' to better explain and manage biopsychosocial disorders.

Alexithymia, fibromyalgia, and psychological distress among adolescents: literature review

The purpose of this article is to review the literature regarding the relationships between alexithymia, fibromyalgia (FM), and psychological distress among adolescents. Google Scholar and databases were searched using alexithymia, fibromyalgia, psychological distress, and adolescent keywords. Studies that examine the relationship between alexithymia and fibromyalgia and the contribution of psychological distress on this relationship among adolescents are lacking. However, based on previous studies on adult samples and theoretical background, there are possible relationship between alexithymia and fibromyalgia as well as possible mediating effect of psychological distress on this relationship in adolescents. Further studies are recommended to examine the relationships between alexithymia, fibromyalgia, and psychological distress among adolescents.

Fibroline: A mobile app for improving the quality of life of young people with fibromyalgia

Fibroline is a mobile application with a self-administered cognitive behavioral treatment for young people with fibromyalgia or chronic widespread pain, designed to reduce pain and other common negative symptoms and improve quality of life. Our aims are to report on the usability and feasibility protocols used to assess the app. Two usability cycles were implemented. A group of patients followed the cognitive behavioral treatment intervention to test its feasibility. Qualitative data were collected and content analyses were conducted. The results demonstrated that the app is error-free, easy to use, liked by the users, and acceptable.

Psychological aspects of juvenile fibromyalgia syndrome: a literature review

Juvenile fibromyalgia syndrome (JFMS) is a non-inflammatory chronic pain condition that occurs mainly in girls aged 9-15 years. JFMS is characterized by constant widespread pain in different parts of the body, poor sleep quality, daytime sleepiness and an altered mood. Concomitant psychological and organic factors result in a diminished capacity to cope with pain. The quality of life of individuals with chronic pain and their caregivers is severely restricted and the occurrence of symptoms of anxiety and depression is common in this population. The aim of the present study was to perform a systematic review of the literature on psychosocial factors related to JFMS. The findings reveal differences in opinion between patients and family members regarding the effect of the condition, as mothers tend to classify JFMS as more severe than the patients themselves. Individuals with JFMS seem to share the same personality traits and there seems to be a type of family environment that is favorable to the occurrence of this condition. Psychological and functional aspects should be treated with methods that can help patients and family members alter their coping strategies regarding day-to-day problems, attenuate the dysfunctional consequences of pain and fatigue and diminish the risk of catastrophizing that individuals submitted to constant pain develop in relation to their surrounding environment.

Juvenile fibromyalgia: current status of research and future developments

Juvenile-onset fibromyalgia (JFM) is a poorly understood chronic pain condition most commonly affecting adolescent girls. The condition is characterized by widespread musculoskeletal pain and other associated symptoms, including fatigue, nonrestorative sleep, headaches, irritable bowel symptoms, dysautonomia and mood disorders such as anxiety and/or depression. In the past few years, there has been a greater focus on understanding JFM in adolescents. Research studies have provided insight into the clinical characteristics of this condition and its effect on both short-term and long-term psychosocial and physical functioning. The importance of early and effective intervention is being recognized, as research has shown that symptoms of JFM tend to persist and do not resolve over time as was previously believed. Efforts to improve treatments for JFM are underway, and new evidence strongly points to the potential benefits of cognitive-behavioural therapy on improving mood and daily functioning. Research into pharmacotherapy and other nonpharmacological options is in progress. Advancements in the understanding of adult fibromyalgia have paved the way for future studies on diagnosis, assessment and management of JFM. This Review focuses on our current knowledge of the condition, provides an update of the latest research advances, and highlights areas for further study.

Relationship between sleep and pain in adolescents with juvenile primary fibromyalgia syndrome

STUDY OBJECTIVES

To investigate sleep quality in adolescents with juvenile primary fibromyalgia syndrome (JPFS) and determine whether sleep abnormalities, including alpha-delta sleep (ADS), correlate with pain intensity. We hypothesized that successful treatment for pain with exercise therapy would reduce ADS and improve sleep quality.

DESIGN

Single-center preintervention and postintervention (mean = 5.7 ± 1.0 weeks; range = 4.0-7.3 weeks) observational study.

PATIENTS

Ten female adolescents (mean age = 16.2 ± 0.65 SD yr) who met criteria for JPFS and completed treatment.

INTERVENTIONS

Multidisciplinary pain treatment, including intensive exercise therapy.

MEASUREMENTS AND RESULTS

Pain and disability were measured by a pain visual analog scale (VAS) and the functional disability inventory. Subjective sleep measures included a sleep VAS, an energy VAS, and the School Sleep Habits Survey. Objective sleep measures included actigraphy, polysomnography (PSG), and the Multiple Sleep Latency Test. Baseline PSG was compared with that of healthy age- and sex-matched control patients. At baseline, patients had poorer sleep efficiency, more arousals/awakenings, and more ADS (70.3% of total slow wave sleep [SWS] versus 21.9% SWS, P = 0.002) than controls. ADS was unrelated to pain, disability, or subjective sleep difficulty. After treatment, pain decreased (P = 0.000) and subjective sleep quality improved (P = 0.008). Objective sleep quality, including the amount of ADS, did not change.

CONCLUSIONS

Although perceived sleep quality improved in adolescents with JPFS after treatment, objective measures did not. Our findings do not suggest exercise therapy for pain improves sleep by reducing ADS, nor do they support causal relationships between ADS and chronic pain or subjective sleep quality.

Exposure and acceptance in the rehabilitation of adolescents with idiopathic chronic pain - A pilot study

For chronic pain of unclear origin (idiopathic), pharmacological therapy is often insufficient. Psychological treatment strategies have been developed and evaluated for adults with chronic pain. However, few such studies are seen with youths, and to date there is limited empirical evidence regarding the effectiveness of psychological treatment for generalized musculoskeletal pain syndromes in adolescents. Acceptance and commitment therapy (ACT) is a development of cognitive behaviour therapy emphasizing exposure and acceptance. In this pilot study, 14 adolescents referred to the pain treatment service due to chronic debilitating pain were treated using an ACT-based approach. It was hypothesized that avoidance of pain and related stimuli was central to the disability seen among these patients, and that exposure and acceptance strategies could increase functioning and decrease pain. In contrast to emphasizing reductions in pain and distress, the treatment objective was to improve functioning by increasing the patient's ability to act in line with personal values in the presence of negative thoughts, emotions or bodily sensations. Following treatment, and retained at 3- and 6-month follow-up, improvements in functional ability, school attendance, catastrophizing and pain (i.e., intensity and interference) were seen. The outcome of this pilot study indicates that exposure and acceptance can been useful in the rehabilitation of adolescents with chronic debilitating pain. Randomized controlled studies are needed to empirically evaluate the effectiveness of this approach.

Mediators of change in acceptance and commitment therapy for pediatric chronic pain

Even though psychological interventions are well established in the treatment of pediatric chronic pain, there is a clear need for further development, especially with severely disabled patients. However, optimizing effectiveness in psychological treatments for pain requires clarification of the mechanisms of action. Studies addressing change processes are scarce, however, particularly in relation to pediatric chronic pain. Acceptance and Commitment Therapy (ACT), as an extension of traditional cognitive behavior therapy, is essentially aimed at improving functioning by increasing the ability to act effectively in the presence of pain and distress, that is, psychological flexibility. ACT has shown promising results for both adult and pediatric chronic pain. In the present study, the mediators of change in an ACT-oriented treatment for pediatric chronic pain were examined using a bootstrapped cross product of coefficients approach. Pain interference and depression were used as outcome variables. Six different variables relevant to theories underlying ACT and cognitive behavior therapy were included in the analyses as possible mediators of change: pain impairment beliefs, pain reactivity, self-efficacy, kinesiophobia, catastrophizing, and pain intensity. Results illustrated that pain impairment beliefs and pain reactivity were the only variables that significantly mediated the differential effects of treatment on outcomes at follow-up. Also, these 2 mediators were shown to independently predict effects in outcome variables at follow-up while controlling for earlier effects in outcome, but only for the ACT condition. Although tentative, the pattern of results suggests that variables consistent with psychological flexibility mediate the effects of ACT-based interventions to improve functioning in patients with chronic debilitating pain.

Preliminary evaluation of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain

PURPOSE

To describe the outcome of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain.

METHODS

STUDY DESIGN

exploratory retrospective cohort study. The study sample consisted of a cohort of 70 children and adolescents (age: 8-21 years) with chronic musculoskeletal pain who completed a 3-month inpatient multidisciplinary pain management program. The program consisted of graded physical exercises, graded activities and counseling of the children and their parents. Assessed were motor and social activities, pain intensity, global assessment of physical functioning and psychosocial well-being (by patient and physician), understanding of the pain process and reduction of medical consumption. Assessments were performed at pre-admission, day of admission, day of discharge and at three months after discharge. Data collection took place over a 10-year period.

RESULTS

Compared to admission, at discharge there were significant improvements in motor performances, school attendance, reduction of pain scores, understanding of the chronic pain process and reduction of medical consumption. Results remained stable at follow-up after three months.

CONCLUSION

The results of this study indicate that a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain may be effective.

Fibromyalgia symptoms are reduced by low-dose naltrexone: a pilot study

OBJECTIVE

Fibromyalgia is a chronic pain disorder that is characterized by diffuse musculoskeletal pain and sensitivity to mechanical stimulation. In this pilot clinical trial, we tested the effectiveness of low-dose naltrexone in treating the symptoms of fibromyalgia.

DESIGN

Participants completed a single-blind, crossover trial with the following time line: baseline (2 weeks), placebo (2 weeks), drug (8 weeks), and washout (2 weeks).

PATIENTS

Ten women meeting criteria for fibromyalgia and not taking an opioid medication.

INTERVENTIONS

Naltrexone, in addition to antagonizing opioid receptors on neurons, also inhibits microglia activity in the central nervous system. At low doses (4.5 mg), naltrexone may inhibit the activity of microglia and reverse central and peripheral inflammation.

OUTCOME MEASURES

Participants completed reports of symptom severity everyday, using a handheld computer. In addition, participants visited the lab every 2 weeks for tests of mechanical, heat, and cold pain sensitivity.

RESULTS

Low-dose naltrexone reduced fibromyalgia symptoms in the entire cohort, with a greater than 30% reduction of symptoms over placebo. In addition, laboratory visits showed that mechanical and heat pain thresholds were improved by the drug. Side effects (including insomnia and vivid dreams) were rare, and described as minor and transient. Baseline erythrocyte sedimentation rate predicted over 80% of the variance in drug response. Individuals with higher sedimentation rates (indicating general inflammatory processes) had the greatest reduction of symptoms in response to low-dose naltrexone.

CONCLUSIONS

We conclude that low-dose naltrexone may be an effective, highly tolerable, and inexpensive treatment for fibromyalgia.

Feasibility and effectiveness of an aerobic exercise program in children with fibromyalgia: results of a randomized controlled pilot trial

OBJECTIVE

To determine the feasibility of conducting a randomized controlled trial of a 12-week exercise intervention in children with fibromyalgia (FM) and to explore the effectiveness of aerobic exercise on physical fitness, function, pain, FM symptoms, and quality of life (QOL).

METHODS

FM patients ages 8-18 years were randomized to a 12-week exercise intervention of either aerobics or qigong. Both groups participated in 3 weekly training sessions. Program adherence and safety were monitored at each session. Data were collected at 3 testing sessions, 2 prior to and 1 after the intervention, and included FM symptoms, function, pain, QOL, and fitness measures.

RESULTS

Thirty patients participated in the trial. Twenty-four patients completed the program; 4 patients dropped out prior to training and 2 dropped out of the aerobics program. Better adherence was reported in the aerobics group than in the qigong group (67% versus 61%). Significant improvements in physical function, functional capacity, QOL, and fatigue were observed in the aerobics group. Anaerobic function, tender point count, pain, and symptom severity improved similarly in both groups.

CONCLUSION

It is feasible to conduct an exercise intervention trial in children with FM. Children with FM tolerate moderate-intensity exercise without exacerbation of their disease. Significant improvements in physical function, FM symptoms, QOL, and pain were demonstrated in both exercise groups; the aerobics group performed better in several measures compared with the qigong group. Future studies may need larger sample sizes to confirm clinical improvement and to detect differences in fitness in childhood FM.

Fibromyalgie: Eine körperliche Krankheit oder unspezifische psychische Störung?

Zusammenfassung. Die Fibromyalgie (FM) ist eine multilokale, nichtentzündliche Schmerzstörung an bestimmten druckschmerzhaften Punkten des Bewegungsapparates. Hinzu treten multiple funktionelle Symptome wie Schlafstörungen, Magen- und Darmbeschwerden, Konzentrationsstörungen und nicht zuletzt psychische Beeinträchtigungen und Störungen (Depression, Angst, eingeschränkte Lebensqualität). Bei Kindern und Jugendlichen stellt die FM eine eher seltene Extremform weitverbreiteter funktioneller Schmerzstörungen des Bewegungsapparates dar. Die medizinische Diagnostik ergibt keinen pathologischen Befund. Entsprechend kontrovers wird die Ätiopathogenese diskutiert. Drei Störungsmodelle werden vorgestellt: (1) FM als organische Erkrankung auf der Basis einer genetischen Prädisposition, mit Regulationsstörungen der Hormonachse, des Vegetativums und der Neurotransmittersysteme, (2) FM als chronisch-funktionelle Schmerzstörung infolge einer Schmerzsensitivierung und -verstärkung (Wind-up-Phänomen), (3) FM als psychische Störung mit hoher Komorbidität im Bereich der Depression und Angststörungen im Sinne einer somatoformen Schmerzstörung mit katastrophisierender Symptomverarbeitung und exzessiv gesteigertem Krankheits- und Inanspruchnahmeverhalten. Zur Integration dieser Störungsmodelle stellt der Beitrag ein entwicklungspsychopathologisches Modell vor. Es unterscheidet vier Störungsetappen, denen jeweils spezifische medizinische wie psychologische Interventionsmethoden zugeordnet werden können; ausführlich werden verhaltensmedizinische Strategien vorgestellt.

Assessment and management of pain syndromes and arthritis pain in children and adolescents

Chronic musculoskeletal pain, whether it is idiopathic or disease-related, is common in childhood. Pediatric rheumatologists and other pediatric health care providers must understand the epidemiology of musculoskeletal pain as part of childhood, diagnose pain syndromes in children and rule out rheumatic disease, and be willing to initiate treatment of pain in children and adolescents. Practitioners' ability to carry out these tasks is enhanced by an awareness of the biopsychosocial model of pain, which integrates biologic, environmental, and cognitive behavioral mechanisms in describing the causes and maintenance of children's pain. A growing body of research in rheumatic diseases, such as JIA, and idiopathic musculoskeletal pain syndromes, such as JPFS, highlights the importance of environmental and cognitive behavioral influences in the pain experience of children in addition to the contribution of disease activity. These influences include factors innate in the child, such as emotional distress, daily stress, coping, and mood, and familial factors, such as parental psychologic health, parental pain history, and the nature of family interactions. Addressing these issues, while providing aggressive traditional medical management, optimizes pain treatment and improves overall quality of life for children who have musculoskeletal pain.

Fibromyalgia: diagnosis, pathogenesis, and treatment

Fibromyalgia is characterized by chronic widespread pain and the presence of tender points, often accompanied by several non-specific symptoms, such as fatigue, depressive mood, and sleep disturbances. The apparent overlap between fibromyalgia and other syndromes, such as chronic fatigue and irritable bowel, is not sufficient cause to consider all these syndromes as manifestations of a single syndrome. Fibromyalgia is a multifaceted problem. Central afferent pain amplification and perhaps also impaired descending pain inhibition are supposed to underlie widespread pain. Neuroendocrine perturbations, sleep disturbances, health beliefs, mood disorder, and physical deconditioning play a role in the modulation and perseverance of pain and other symptoms. It is extremely difficult to mitigate chronic generalized pain and to deal with other symptoms in fibromyalgia. A uniform intervention strategy is missing. Essential in the tailored management of fibromyalgia are an enhancement of functional capacities and quality of life, and the symptomatic treatment of individual symptoms such as pain, distress, and sleep disturbances. Rather than analysing monotherapy per se, the objective in future evaluations should be to try to find the combined pharmacological or non-pharmacological treatment of choice for specific subgroups of patients.

The PedsQL as a patient-reported outcome in children and adolescents with fibromyalgia: an analysis of OMERACT domains

BACKGROUND

Fibromyalgia is a chronic health condition characterized by widespread musculoskeletal pain, multiple tender points on physical examination, generalized muscular aching, stiffness, fatigue, nonrestorative sleep pattern, cognitive dysfunction, and mood disturbance. Recently, the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) Fibromyalgia Syndrome Workshop ranked and prioritized the domains that should be consistently measured in fibromyalgia clinical trials, specifically, pain, generic health-related quality of life, fatigue, sleep quality, and physical function. The focus of these deliberations was exclusively on adult patients, and to our knowledge, these domains have not been previously tested within a multidimensional framework in children and adolescents with fibromyalgia.

METHODS

An analysis to determine the feasibility, reliability, and validity of the PedsQL 4.0 (Pediatric Quality of Life Inventory) Generic Core Scales, PedsQL Multidimensional Fatigue Scale, and PedsQL Rheumatology Module Pain and Hurt Scale as patient-reported outcome (PRO) measures for pediatric patients with fibromyalgia. The PedsQL Scales were completed by 59 families in a pediatric rheumatology clinic in a large children's hospital.

RESULTS

The PedsQL evidenced minimal missing responses (0.53% patient self-report, 0.70% parent proxy-report), achieved excellent reliability for the Generic Core Scales Total Scale Score (alpha = 0.88 patient self-report, 0.87 parent proxy-report), the Multidimensional Fatigue Scale Total Scale Score (alpha = 0.94 patient self-report, 0.94 parent proxy-report), and acceptable reliability for the 4-item Rheumatology Module Pain and Hurt Scale (alpha = 0.68 patient self-report, 0.75 parent proxy-report). The PedsQL Generic Core Scales and Multidimensional Fatigue Scale significantly distinguished between pediatric patients with fibromyalgia and healthy children. Pediatric patients with fibromyalgia self-reported severely impaired physical and psychosocial functioning, significantly lower on most dimensions when compared to pediatric cancer patients receiving cancer treatment, and significantly lower on all dimensions than pediatric patients with other rheumatologic diseases. Patients with fibromyalgia self-reported significantly greater pain and fatigue than pediatric patients with other rheumatologic conditions, and generally more fatigue than pediatric patients receiving treatment for cancer.

CONCLUSION

The results demonstrate the excellent measurement properties of the PedsQL Scales in fibromyalgia. These PedsQL Scales measure constructs consistent with the recommended OMERACT Fibromyalgia Syndrome Workshop domains. The findings highlight the severely impaired HRQOL of pediatric patients with fibromyalgia. Regular monitoring of pediatric patients with fibromyalgia will help identify children and adolescents at risk for severely impaired HRQOL. These PedsQL Scales are appropriate outcome measures for clinical trials and health services research for pediatric patients with fibromyalgia.

Adolescent self-perception: associations with chronic musculoskeletal pain and functional disability

Associations among pain, functional disability, and self-perceived competence were examined in a retrospective record review of the initial clinical evaluations of 115 adolescents (ages 13 to 18 years) with chronic musculoskeletal pain not associated with a specific organic cause. Adolescents self-reported on pain intensity, functional disability, and 9 developmentally relevant domains of self-perceived competence, using the Self-Perception Profile for Adolescents (Harter, 1988). Results confirmed a relation between usual pain intensity and functional disability (r = 0.47, P < .001). A series of multiple regression analyses revealed that adolescents' perceptions of global self-worth significantly moderated the relation between pain and disability. These findings extend our understanding of the relations among self-perception, chronic pain, and disability to include adolescents with chronic musculoskeletal pain syndromes and have future research and therapeutic implications.

PERSPECTIVE

Adolescents with chronic pain syndromes can face significant challenges in accomplishing developmental goals with respect to the pain and disability they experience. Perceptions of self-worth appear to play an important role in understanding the relation between pain and functional disability among adolescents with chronic pain.

What are the costs of childhood-onset rheumatic disease?

Juvenile rheumatic diseases have important impacts on health, i.e. on patients' body functions and structures, activities, and social participation. The identification and treatment of these disorders is costly. Treatment involves periods of hospitalization, the use of physicians and other professional services, drugs and other treatments. Frequent outpatient visits are needed, as may be surgery. This all imposes a large financial burden on health-care systems and on families of children who suffer from rheumatic illnesses. Costs borne by families are both out-of-pocket as well as related to time spent in providing care, which may involve loss of income. Of course, the burdens are not only monetary, and they sometimes continue for life. The measurement of the different types of cost is essential to get a full picture of the burden of childhood-onset rheumatic illnesses. This chapter presents data on the costs of these illnesses, and introduces methodologies and their limitations for cost evaluation within paediatric rheumatology.

Development and evaluation of a cognitive-behavioral intervention for juvenile fibromyalgia

OBJECTIVE

To describe the development and test the efficacy of a cognitive-behavioral intervention (CBT) for juvenile fibromyalgia.

METHOD

Sixty-seven children with fibromyalgia and their parents were recruited to participate in an 8-week intervention that included modules of pain management, psychoeducation, sleep hygiene, and activities of daily living. Children were taught techniques of cognitive restructuring, thought stopping, distraction, relaxation, and self-reward. Additionally, they kept daily pain and sleep diaries. Children completed questionnaires of pre- and post-treatment measuring physical status and psychological functioning.

RESULTS

Following CBT, children reported significant reductions (p < .006) in pain, somatic symptoms, anxiety, and fatigue, as well as improvements in sleep quality. Additionally, children reported improved functional ability and had fewer school absences.

CONCLUSION

Children with fibromyalgia can be taught CBT strategies that help them effectively manage this chronic and disabling musculoskeletal pain disorder.

Pediatric pain syndromes and management of pain in children and adolescents with rheumatic disease

This article introduces important issues related to pain in children with musculoskeletal pain syndromes and rheumatic disease, using juvenile primary fibromyalgia syndrome (JPFS) and juvenile idiopathic arthritis (JIA) as models. A brief summary of the prevalence of pain in healthy children is followed by a summary of existing pain-assessment techniques. The remainder of the article describes the pain experience of children with JPFS and JIA and discusses issues related to pain management.

Person-centered approach to care, teaching, and research in fibromyalgia syndrome: justification from biopsychosocial perspectives in populations

OBJECTIVES

To describe complex interactions of multiple factors believed to contribute to fibromyalgia syndrome (FMS) at a person-centered level to enhance approaches to care, teaching, and research. The main factors addressed were central nervous system sensory sensitization, autonomic nervous system (ANS) activation, neurohumoral perturbations, and psychosocial and environmental stressors. A person-centered approach is defined as attention to major biopsychosocial issues of affected individuals.

METHODS

Literature on classification, mechanistic pathways, course and outcomes, and management of FMS was reviewed to assess applications of person-centered approaches to care, teaching, and research. Various biopsychosocial influences were considered in relation to the heterogeneous subjective manifestations of this illness, including central hyperalgesia, ANS and other neurohumoral perturbations, functional hyperexcitability, nonrestorative sleep, and psychologic distress.

RESULTS

A person-centered approach to FMS can expand on and strengthen traditional biomedical concepts. Adding such a focus can help to untangle current controversies in the course, outcomes, and treatment of FMS. A person-centered approach can also help in the subgrouping of affected patients for greater specificity in care programs and in improved clinical investigations. In the biomedical model, diverse symptoms of FMS are often addressed separately and apart from their interconnectedness and linkages to the patient's individualized biopsychosocial factors. However, the causes of FMS symptomatology are not likely to be caused by uniform biologic abnormalities across populations. Rather, the syndrome likely results from personal reactivities to varied multifactorial biopsychosocial influences. Common denominators among individuals may include varying degrees of ANS activation (or personal susceptibility to ANS activation), nonrestorative sleep, negative affectivity, and other central pain sensitization mechanisms, among the pathways reviewed.

CONCLUSIONS

Innovative analytical methodologies will need to be developed to more effectively investigate complex interacting biopsychosocial dynamics at a person-centered level, including qualitative research, and multifactorial and multilevel techniques. Adding person-centered approaches to biopsychosocial concepts of FMS promises to show new physiopathogenetic insights and more effective treatment than current biomedical models alone. Person-centered approaches enhance patient-physician relationships and help prioritize patients' goals in mutually derived treatment plans.

Depression, coping, and functional disability in juvenile primary fibromyalgia syndrome

This study describes pain characteristics, coping, depression, and functional disability in children with juvenile primary fibromyalgia syndrome (JPFS) and compares them with a group of children with nonmalignant chronic back pain (CBP). Subjects were 18 female subjects (9 to 19 years of age) diagnosed with JPFS and 18 matched control subjects with CBP. Visual Analog Pain Rating Scales, the Pain Coping Questionnaire, the Children's Depression Inventory, and Functional Disability Inventory were administered. Results indicated that both JPFS and CBP groups reported significant disruption in functional abilities and school attendance as a result of chronic pain. Both groups reported mildly elevated symptoms of depression overall, but there was a subgroup of JPFS subjects who reported severe levels of depression. The JPFS group had suffered from pain for significantly longer than the CBP group before being referred for specialty care. However, pain duration was not significantly related to depression, functional disability, or pain coping efficacy. The levels of functional disability were similar in both groups, but the JPFS group reported somewhat more school absences. The longer time to receive specialty care and identification of a subgroup of depressed subjects at risk for long-term psychosocial consequences are of particular concern in JPFS.

Psychosocial aspects of pediatric rheumatic diseases

Pediatric rheumatic diseases present psychosocial challenges for patients and their families. These include (1) adjusting and coping with disease symptoms and limitations; (2) adhering to complex and demanding medical regimens; and (3) coping with chronic pain. This article reviews recent studies on these psychosocial issues for children with pediatric rheumatic diseases. There is a paucity of empirical studies addressing these issues and a clear need for multisite collaborative studies to address the psychosocial needs of patients and families.