Acupuntura em adolescentes com fibromialgia juvenil

Objective: To describe the use of acupuncture in the treatment of adolescents with juvenile fibromyalgia. Methods: Retrospective study of patients with juvenile fibromyalgia (American College of Rheumatology criteria) submitted at least to 11 weekly sections of acupuncture. The evaluations before and after acupuncture included: demographic data, musculoskeletal pain findings, pain


Introduction
Juvenile fibromyalgia is a chronic musculoskeletal pain syndrome that affects more females than males and is of unknown etiopathogenesis.The syndrome is characterized by widespread musculoskeletal pain and by the presence of specific points that are tender when touched (1)(2)(3) .Prevalence in the pediatric age group ranges from 1.2 to 6.2% (2)(3)(4)(5)(6) .
Juvenile fibromyalgia is treated with one or more treatments such as physical exercises, psychotherapy, medications and physiatrics (1,6,7) and has rarely been studied in the pediatric population.A recent 12-week pilot study with controls found that children and adolescents with juvenile fibromyalgia suffered less pain after taking part in a program of aerobic exercise (8) .Nevertheless, despite scientific evidence that physical exercises can lead to improvements, it is known that many patients with fibromyalgia cannot tolerate or do not engage in sport.
Another treatment method of relevance to fibromyalgia is acupuncture, as stated in an international consensus on the applications of acupuncture (based on level A and B evidence) (9) .Indeed, adult patients treated with this Traditional Chinese Medicine method exhibit reductions in the number of tender points and improvements in pain scores, when compared with conventional treatments, and these results have been confirmed by a recent systematic review of controlled studies (level A evidence) (10)(11)(12)(13)(14) .However, another meta-analysis (level A evidence), which was also conducted recently and assessed the efficacy of acupuncture for fibromyalgia treatment, did not find evidence that acupuncture provided greater benefits than placebo (15) .
At the Instituto da Criança's Pediatric Rheumatology Unit, acupuncture has been used to treat children and adolescents with musculoskeletal syndromes that are not inflammatory or chronic, such as complex regional pain syndrome (16) .To date, however, no studies have been conducted of adolescents with fibromyalgia treated with acupuncture.
Therefore, the objective of this retrospective study is to describe the use of acupuncture with adolescents with juvenile fibromyalgia.

Method
This was a retrospective study based on analysis of medical records and routine assessment results from acupuncture treatment charts, for children and adolescents with juvenile fibromyalgia.Over an 8-year period, 38 patients aged 10 to 18 were seen with a diagnosis of juvenile fibromyalgia at the Instituto da Criança's Pediatric Rheumatology Unit at the Universidade de São Paulo (USP) Medical Faculty's Hospital das Clínicas.They were referred for acupuncture treatment of juvenile fibromyalgia to the Acupuncture Clinic, which is in the Pain and Palliative Care Unit of the Instituto da Criança at the USP Medical Faculty's Hospital das Clínicas.
Only patients who met the criteria defined by the American College of Rheumatology (ACR) were recruited: a history of chronic (pain lasting more than 3 months) widespread musculoskeletal pain (affecting all regions of the locomotor and axial apparatus) and associated with tenderness to the touch in a minimum of 11 of the 18 specific points.These specific points are considered positive for tenderness if digital palpation with a force of 4kg causes pain and all are assessed bilaterally (17) .The points are as follows: occiput (at the suboccipital muscle insertions), low cervical (bilateral, at the anterior aspects of the intertransverse spaces at C5-C7), trapezius (at the midpoint of the upper border), supraspinatus: (at origins, above the scapula spine near the medial border), second ribs (at the second costochondral junctions), lateral epicondyles of elbows (2cm distal to the epicondyles), gluteal (in upper outer quadrants of buttocks ), greater trochanters (posterior to the trochanteric prominences) and knees (at the medial fat pad proximal to the joint line).
During the study period patients were allowed to take analgesics (paracetamol every 8 hours, if necessary) and were instructed to engage in unsupervised aerobic physical activity.Amitriptyline (25mg/day) was considered for cases in which patients did not improve for 2 consecutive months.None of the patients required psychological care.
The original total of 38 patients with juvenile fibromyalgia was reduced by 23 because of incomplete medical record data and by a further 2 patients who were lost to follow-up when they moved to other states in Brazil.No participants were lost because of intolerance of needles.Seven of the 23 patients whose data were incomplete also had secondary juvenile fibromyalgia: juvenile idiopathic arthritis (n=1), premature puberty (n=1), autoimmune hepatitis (n=1), epilepsy (n=1), Henoch-Schönlein purpura (n=1), adrenal hyperplasia (n=1) and Hashimoto's thyroiditis (n=1).Therefore, 13 patients completed the acupuncture treatment and are analyzed here.
This retrospective study was approved by the Research Ethics Committee at the USP Medical Faculty's Hospital das Clínicas (protocol nº 0519/10).
Patients were treated with due care and consideration and before treatment they received explanations about the acupuncture method, about safety, use of sterile, disposable needles, the need to attend weekly and the likely duration of the treatment.Acupuncture was only initiated if the patients and a guardian both gave written consent.
The acupuncture treatment began by applying from two to four needles at the least painful points, with a progressive increase in needles during the second and third sessions until the pattern of points was totally complete by the fourth session.During the first session, anxious patients were treated with a device developed by Han (18) , which makes it possible to stimulate the classic acupuncture points without using needles.This electro-stimulation device has two pairs of adhesive plates through which intermittent electrical currents are passed.The frequency used was 2/100 Hz at an intensity tolerated by the patient and the session lasted 30 minutes.
Acupuncture sessions were conducted by three acupuncturists (MHPD, EA and DTYT), once a week, using a total of 14 points (eight ventral points and six dorsal points) (19) alternating between the ventral pattern 1 week and the dorsal the next.
The following ventral points were used (20) : 1) EX-HN3 -on the forehead, on the medial anterior line at the midpoint between the eyebrows; 2) LI-11 -with the elbow bent, located at the end of the crease, at the midpoint of a line joining the crease on the radial side of the biceps brachii tendon to the epilateral condyle; 3) TE-6 -on the dorsal side of the forearm and on the line connecting the dorsal crease of the wrist and the tip of the olecranon, 3 cuns proximal to the dorsal crease of the wrist, between the ulna and radius; 4) LI-4 -on the dorsal surface of the hand, between the 1st and 2nd metacarpal bones, on the radial border of the mid-point of the 2nd metacarpal bone; 5) CV-12 -on the upper abdomen, along the anterior medial line, four cuns above the center of the umbilical scar; 6) ST-36 -on the anterior surface of the lower leg, three cuns below the lower edge of the kneecap, 1 cun lateral to the anterior crest of the tibia; 7) GB-34 -located on the side of the leg, in a depression anterior and inferior to the head of the fibula; 8) LR-3 -on the top of the foot, in the depression at the posterior end of the joint of the 1st and 2nd metatarsal bones, two cuns above the junction of the 1st and 2nd toes.The measurement unit "cun" is the width of the patient's thumb.
With the exception of EX-HN3 and CV-12, all of these points were needled bilaterally.
Each patient had at least 11 acupuncture sessions in consecutive weeks.They were assessed for possible adverse events associated with acupuncture, such as: pain, fainting, dizziness, nausea, pallor and diaphoresis, among other possibilities.
Each patient underwent two systematic pain assessments (baseline and final).These assessments covered: demographic data and musculoskeletal pain indicators -number of fibromyalgia points (NFP) by digital pressure, algometry of the same points to calculate a myalgic index (MI) and an analogue visual pain scale (AVPS) with a range from 0 (no pain) to 10 (intense pain -maximum).Algometry was conducted using Fischer's pressure algometer (21) .A myalgic index (MI) was also calculated from the mean algometry results.An increase in MI represents a fall in pain level (13) .
The sample was selected by convenience.Data are summarized in tables and graphs showing not only median (range), but also mean and standard deviation for each variable, in order to provide a better illustration of the central tendency and of the dispersion of results, since, for this sample, variables exhibited normal distribution according to the Kolmogorov-Smirnov test.Nevertheless, in view of the small sample size, all of the variables were analyzed using Wilcoxon's nonparametric test for repeated measures with the α significance level set at 0.05.For categorical variables, Fisher's exact test was used with the same significance level.

Results
Mean and median ages of the 13 patients with juvenile fibromyalgia at the outset of treatment with acupuncture were 13.7±2.5 and 14 (10.4-18)years, respectively.Mean and median total number of acupuncture sessions were 11.5±1.1 and 11 (11-15), respectively.Just one of the 13 adolescents was male.Just two cases required amitriptyline.
Table 1 lists demographic data, pain assessment indicators and total number of acupuncture sessions.It will be observed that these parameters differ across the patient sample.Seven of the 13 patients had improvements in all three parameters analyzed, four had improvements in two parameters and one patient had improvement in one parameter.Just one of the patients deteriorated, with no change to one parameter and deterioration in the other two.
It was also observed that, in this pilot study, although eight patients were still reporting pain in the final week, in seven of these it had improved from generalized to localized pain and only one patient was still complaining of generalized pain.
One noteworthy feature of this study is that the medians for the number of tender points and for AVPS were significantly greater at the start of treatment when compared with after the course of acupuncture treatment (14 [11-18] vs. 10 [0-15], p=0.005; 6 [2-10] vs. 3 [0-10], p=0.045; respectively).In counterpoint, median MI was significantly lower at the start than at the end of treatment (3.4 [2.49-4.39] vs. 4.2 [2.71-5.99],p=0.02) (Table 2).It will also be observed, from Table 2, that symptoms associated with fibromyalgia such as headaches and tiredness exhibited statistically significant differences when before and after treatment are compared.However, the same was not true of quality of sleep.
After treatment, two patients were free from pain, nine had localized pain and two had widespread pain.None of the patients with fibromyalgia suffered adverse events related to acupuncture.

Discussion
This retrospective study found evidence that acupuncture was a beneficial treatment for some patients with juvenile fibromyalgia.Furthermore, it was well-tolerated and accepted by the young fibromyalgia patients seen at a tertiary pediatric hospital.Juvenile fibromyalgia is a common cause of chronic widespread pain in the Brazilian population of children and adolescents.Our team recently assessed 791 well-nourished adolescents in the city of São Paulo and found chronic widespread pain in 4% and fibromyalgia in 1% (2,3) .The syndrome is more prevalent among females, which was also observed in the present study (1)(2)(3)5,6) .
For the purposes of this study, the fibromyalgia criteria proposed by the ACR for adults were used, since they have previously been used with adolescents with this syndrome (2,3) .Notwithstanding, other systems have been proposed for the pediatric age group and some authors have used the Yunus and Masi criteria (22) .In this study two different reliable methods of assessing fibromyalgia were employed: the analogue visual pain scale and the MI based on Fisher algometry.Both are routinely used both in pediatric studies (23,24) and in research into adults (13) with this chronic pain syndrome.Patients with fibromyalgia very often suffer from pain of moderate to strong intensity, reducing their health-related quality of life, and that of their relatives, and possibly causing absenteeism from school (25) .The patients in this study all had elevated results for the pain indicators (high NFP, low MI and high AVPS score), which underscores their need for prompt treatment.
Treatment for fibromyalgia includes medications (analgesics and antidepressants), psychotherapy, scaled aerobic exercises and acupuncture (26) .The medications offer a modest and short-lasting benefit and psychotherapy (combined with other treatments) has moderate efficacy over the medium and long terms (26,27) .Additionally, education of the family and the adolescent and interventions that reduce pain and stress and improve the quality of sleep are of fundamental importance (26)(27) .None of the patients in this study required referral to a psychologist.
To date, routine and unsupervised aerobic exercise has proven the best treatment option for juvenile fibromyalgia (7,8) .However, adolescents with fibromyalgia may have low rates of compliance with physical exercise regimes and so need to be supervised and stimulated daily, as was shown recently in a study of chronic cervical and lumbar pain (27) .
In the retrospective study described here, the children and adolescents had good compliance with the acupuncture treatment and suffered no significant adverse events, indicating that acupuncture can be combined with the other treatments for juvenile fibromyalgia.The Instituto da Criança is a pioneer in this movement and has been using acupuncture for 14 years consecutively, including to treat patients with chronic musculoskeletal incapacitating and intense pain due to other etiologies (16) .
Even so, the efficacy of acupuncture and the number of sessions needed when treating adults with fibromyalgia are still under debate.A controlled study (11) and a metaanalysis demonstrated improvements over placebo (14) ; but another meta-analysis -which included analysis of true acupuncture, sham acupuncture (acupuncture with needling to a minimal depth) and electroacupuncturefound no benefit from its use (15) .Acupuncture appears to improve health-related quality of life in adults with fibromyalgia, as shown in a randomized study conducted at the USP Medical Faculty (13) .Nevertheless, new studies with significantly larger populations of cases and uniform methodology are still required.
Another relevant feature of acupuncture is that many patients feel a sensation of relaxation like mild drowsiness during and/or after the sessions, which undoubtedly improves compliance with the treatment.Subjectively, they also form relationships with the acupuncturists involving closeness and wellbeing.However, since this was a retrospective study, no attempt was made to ensure that there was only one treating physician and a total of three physicians divided the work between them.
It is possible that some of the patients were still experiencing a certain degree of pain because a moderate number of acupuncture sessions were administered (11 sessions).Indeed, Targino et al (13) .found evidence of greater efficacy after 20 sessions.Another relevant factor is that efficacy may be increased by using two sessions per week, as has been observed in the past with adults with fibromyalgia (13) .
One criticism to which this study is open is that it is based on retrospective analysis of a small population of patients with juvenile fibromyalgia from which many subjects were excluded.Additionally, neither compliance with other treatments (such as physical exercise) nor health-related quality of life of patients and their families were systematically analyzed.A randomized study is currently being conducted of acupuncture for juvenile fibromyalgia at three pediatric rheumatology centers in the city of São Paulo and includes a control group and a wide-ranging assessment of pain and of health-related quality of life.
Acupuncture is therefore a method from Traditional Chinese Medicine that can be used as a treatment option for pediatric patients with fibromyalgia.Further studies are needed with large patient populations and control groups.

Table 2 -
Results of the statistical analysis of change in pain assessment indicators and associated symptoms, from baseline to end of acupuncture treatment, in 13 adolescents with juvenile fibromyalgia

Table 1 -
Demographic data, change in pain assessment indicators and total number of acupuncture sessions for 13 adolescents with juvenile fibromyalgia AVPS: analogue visual pain scale.*Mean for tender points as measured with a Fischer algometer.**Score reported by patient for week prior to assessment.