Juvenile Primary Fibromyalgia Syndrome Treatment & Management

Because of the multifaceted problems that develop, effective treatment of fibromyalgia syndrome (FMS) requires a multidisciplinary approach, which may include medication, physical therapy, exercise, support groups, and psychological therapy. No surgical treatment is indicated. The goals of treatment are to reduce pain and depression, to decrease sleep disturbances, and to promote physical activity. A number of cognitive-behavioral interventions may help to mitigate the disorder. ^[21] Activity is a mainstay in the treatment of FMS.

Go to Fibromyalgia and Rehabilitation and Fibromyalgia for complete information on these topics.

The medication treatment for juvenile primary fibromyalgia syndrome (JPFS) is inferred for what has been studied and used in adult fibromyalgia. Typical medication regimens for pediatric FMS primarily include skeletal muscle relaxants, low-dose tricyclic antidepressants, and selective serotonin reuptake inhibitors (SSRIs). Some evidence reports that pain and symptom management with nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with antidepressants and nonaddictive analgesics is effective.

Low-dose antidepressants, such as amitriptyline (Elavil), and skeletal muscle relaxants, such as cyclobenzaprine (Flexeril), help decrease the hyperarousal mechanisms in fibromyalgia and, in turn, help the child and adolescent sleep better. Both medications are administered at bedtime or 1-2 hours before bedtime. Some debate surrounds which medication should be initially used. Some suggest the use of cyclobenzaprine first in treatment, whereas others suggest beginning medication therapy with low-dose tricyclic antidepressants. ^[14]

Duloxetine (Cymbalta) was approved by the US Food and Drug Administration (FDA) in April 2020 for fibromyalgia in adolescents aged 13-17 years. In a randomized, placebo-controlled trial, a total of 184 patients with juvenile fibromyalgia received duloxetine (N = 91) or placebo (N = 93), of which 149 patients (81%) completed the 13-week double-blind treatment period. Results showed significantly more patients on duloxetine compared with placebo had at least a 30% or 50% reduction in pain severity. ^[22]

An adult study found the combination of a low-dose tricyclic antidepressants (amitriptyline) and the SSRI fluoxetine (Prozac) to be effective in improving sleep quality and alleviating pain and fatigue. ^[23] A current level 3 clinical trial of fluoxetine to test its efficacy in treating JPFS is under way.

Depending on which medication is started first, either skeletal muscle relaxants or low-dose tricyclic antidepressants have been used when the child or adolescent does not respond to the initial medication. An NSAID or acetaminophen is used in conjunction with the muscle relaxants or antidepressants in some cases that are unresponsive to the mainstay therapies alone. Active investigation is underway to look at the potential role for S-adenosylmethionine (SAMe) and the SSRIs in the adult population.

A double-blind placebo controlled study of pregabalin in adults older than 18 years found reduction in pain intensity ratings as well as an improvement in reported sleep outcomes and an improvement in the quality of sleep. ^[24] In 2007, the FDA approved pregabalin for treatment of fibromyalgia in adults, and this drug became the first FDA-approved treatment for fibromyalgia.

Pregabalin monotherapy is used to treat pain and other fibromyalgia-related symptoms in adults. Evidence suggests that pregabalin improves daily function for some patients with fibromyalgia. The FDA states that the manufacturer of pregabalin (Pfizer) may conduct studies of pregabalin in children with fibromyalgia and in breast-feeding women, but such studies have not been completed at this time.

Bennett and Tayag-Kier et al suggested that a sleep analysis in children is helpful in determining treatable causes of sleep disturbance and periodic limb movement in sleep (PLMS). ^{[2, 17]} Few studies have involved children; however, low-dose tricyclic antidepressants or cyclobenzaprine has been used to help promote deeper sleep. Gedalia et al first tried cyclobenzaprine at bedtime to help promote sleep and then switched to low-dose antidepressants when 25% of the patients did not respond to the muscle relaxant. ^[14]

The goal of an exercise regime is to improve cardiovascular health and musculoskeletal fitness through nonimpact aerobic activity. An essential component of the treatment regimen, routine exercise consists of moderate exercise, such as brisk walking for 20 minutes 3 times per week and progression as tolerated. In 2000, Gedalia et al recommended physical therapy guidance to low-impact exercises, such as stretching, walking, biking, and swimming, for at least half an hour per day, to improve cardiovascular fitness. ^[14]

Returning to normal activity is imperative for the child who has stopped sport and social activities because of pain; this helps to modulate the pain. A physical therapist may be extremely helpful in establishing a reasonable exercise and activity regime. Maintaining the child’s physical conditioning is imperative for achieving the best possible long-term outcome of FMS.

The literature supports the therapeutic use of exercise and activity as an important treatment aspect of JPFS. A meta-analysis by Rossy et al found better outcomes with the use of cognitive-behavioral interventions (see Psychotherapy) and exercise than with medication. ^[25] Degotardi et al studied JPFS using exercise and a cognitive-behavioral approach and also found that cognitive-behavioral therapy strategies helped children effectively manage musculoskeletal pain associated with the disorder. ^[26]

One study evaluated 34 participants to determine whether physical activity was predictive of brain responses to experimental pain in FMS using functional magnetic resonance imaging (fMRI). Using self-reported measures of physical activity and fMRI of painful heat stimuli, the results found that greater physical activity was significantly associated with decreased pain ratings, suggesting that physically active FMS patients appear to maintain their ability to modulate pain while those who are less active do not. ^[27]

A study by Sherry et al concluded that children with fibromyalgia can be successfully treated without medications with a very intensive physical and occupational therapy and psychotherapy program. ^{[28, 29]}  A pilot trial that included 40 adolescents with juvenile fibromyalgia evaluated a program that combines cognitive-behavioral therapy with specialized neuromuscular exercise training and reported significant decreases in pain in the combined group. ^[30]

Although a better understanding of what causes FMS would be helpful in determining treatment options, a holistic approach to the child and family living with this problem is the current recommendation.

Supporting the child and family to maintain as normal a lifestyle as possible is important because they live with a potentially chronic disorder. Emphasis on both the child’s and the family’s understanding of the disorder is helpful in learning to live with and overcome the problems. Attendance at school and other usual activities is imperative. Modifying participation or attendance may be necessary in light of the child’s ability to keep up with the expected activities.

Cognitive-behavioral therapy has proven helpful in some cases. Conte et al compared children who had JPFS with healthy children and those who had arthritis. ^[18] The children and adolescents with JPFS showed increased levels of anxiety and depression, greater temperamental instability, higher pain sensitivity, and less family cohesion than healthy children or those with arthritis.

Degotardi et al studied 67 children with JPFS by using an educational and behavioral approach that addressed sleep difficulties, pain management, and exercise. They found significant differences in all physicals between preintervention status and postintervention status. ^[26]

Walco and Ilowite found that the use of a cognitive-behavioral program showed improvement in symptoms over a 4- to 24-month period. ^[31] Likewise, Vereker studied the use of counseling, behavioral techniques, and physical activity in 5 children who had shown improvement in symptoms.

Kashikar-Zuck et al found that children with JPFS had higher levels of depression than children with nonmalignant back pain, possibly because of the longer time taken for those with JPFS to receive specialty care and treatment for the problem. ^[32]

A study by Tran et al suggested that a combination of cognitive-behavioral therapy that emphasizes pain coping strategies and a specially tailored exercise program reduces fears that exertion will worsen pain in teenagers with juvenile fibromyalgia. ^{[33, 34]}

Other modalities found to be helpful in modulating pain include hypnotherapy and transcutaneous electrical nerve stimulation (TENS). Using palliative measures to treat symptoms and minimizing physical disability is an important treatment mainstay.

Because of the multifaceted symptoms that present, the patient may be referred to the following subspecialists for evaluation and treatment:

• Physical medicine and rehabilitation specialist

• Rheumatologist

• Psychiatrist/psychologist

• Pulmonary medicine specialist for evaluation of sleep disorders that may cause fatigue and the presence of PLMS

• Orthopedist