Patients with myofascial pain syndromes frequently undergo extensive medical testing because of the concern for underlying inflammatory disease. These tests are invariably normal. Children may have a false-positive antinuclear antibody, which is found in 20% of the normal pediatric population.
The diagnosis of myofascial pain syndrome is based on the presence of multiple tender points in the absence of other illness. To fulfill strict criteria for a diagnosis of fibromyalgia, the patient must have a history of diffuse pain for at least 3 months and the presence of 11 of 18 specific tender points on examination. It is important to exclude underlying inflammatory diseases, such as systemic lupus erythematosus, or the post-infectious fatigue that characteristically follows Epstein-Barr virus and influenza virus infection. Mood and conversion disorders also should be considered.
Treatment consists of pain control, usually using NSAIDs, physical therapy, relaxation techniques, and education regarding sleep hygiene. Patients may require low doses of medications, such as amitriptyline to regulate sleep or gabapentin to reduce pain sensitivity. Education and reassurance are crucial.
Because of the disability associated with myofascial pain syndromes, patients and parents frequently believe that the child has a serious underlying condition and may be resistant to reassurance. It should be emphasized that there is no simple cure, and time and perseverance are required.
The long-term outcomes in the myofascial pain syndromes vary. Patients and families who focus on therapy and are positive in their approach tend to have better outcomes. Patients who demand prolonged evaluations, especially from multiple health care providers, may do more poorly. Overall children with fibromyalgia and myofascial pain syndromes have better prognoses than their adult counterparts.
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Matthew P. Kronman and Sherilyn Smith 16
Overlapping clinical symptoms caused by infectious and noninfectious illnesses make the diagnosis of some diseases difficult. Clinicians are concerned that an untreated minor infection may progress to a life-threatening illness, if appropriate treatment is not given. However unnecessary treatment with antimicrobial agents may lead to a serious problem—emergence of antimicrobial resistant organisms. Accurate diagnosis of infectious and noninfectious diseases and providing specific treatment only as indicated reduce the unnecessaryuse of antibiotics.
A thorough assessment of the patient, including a detailed history, complete physical examination, and appropriate diagnostic testing is the cornerstone of optimal care.
The ability to diagnose specific infections accurately begins with an understanding of the epidemiology; risk factors, including exposures to sick contacts or environmental risks (e.g., zoonosis); and age-related susceptibility reflecting the maturity of the immune system. Obtaining a thorough history and physical examination identifies most of these elements (Tables 93-1 and 93-2) and guides appropriate use of other diagnostic tests.