Educational Case #51: Adolescent Pain presented by Dr Cara Lewis, Dr Kylie Edwards and Dr Rory Maguire

Chronic pain is estimated to affect 1 in 5 children¹. Pain in children differs from that in adults for physiological, cognitive, developmental and social reasons and as such, a coordinated multi-modal interdisciplinary approach is advocated². Chronic primary pain is defined as pain that persists for longer than three months and is associated with significant emotional distress or functional disability and that cannot be explained by another chronic condition[SP(A1] [SP(A2] [CL3] ³. In children, biopsychosocial risk factors include genetic or family history, poor social support/family conditions, anxiety, stress or mood disorders, previous injury or trauma, previous surgery, hormonal changes, age and gender.

Children have often been reviewed by multiple different medical specialties before referral to a paediatric pain clinic. They may also have experienced unpleasant investigations and/or operations and may have developed distrust and frustration with the healthcare system.  As such, it is vital that the child is listened to, rapport is developed and effort made to put them at ease in their surroundings. 

An initial assessment should be by a specialist multidisciplinary team (MDT). Each member of the pain MDT will have a particular area of focus during the initial assessment, but the overall ethos is shared working towards improved function and quality of life. By having a multidisciplinary assessment, each clinician is able to ask questions specific to their expertise, and to build rapport with the child and their parent/guardian.

This initial assessment may include:

• Pain physician – pain history and past medical history
• Psychologist – impact of pain on life, family dynamics, mood and sleep
• Physiotherapist +/- Occupational Therapist– baseline strength, paediatric Gait, Arms, Legs and Spine (pGALS), physical function and hypermobility assessment
• Pain Clinical Nurse Specialist – global overview of social and development domains including school, friendships, hopes and aims for the future.

Chronic pain should be assessed by validated multi-dimensional scoring tools. The chosen tool must be appropriate for the child’s development and educational stage. An adolescent with normal cognition would be expected to be able to use a verbal rating scale, or numeric rating scale for the intensity of their pain. For possible neuropathic pain, some older teenagers may be able to complete the Leeds Assessment of Neuropathic Symptoms and Signs, whereas others may find the Paediatric Neuropathic Pain Scale©-Five (PNPS©-5)⁴ more appropriate (validated for use in children older than 5 years).

Adolescents’ mood can be assessed using quality of life questionnaires such as the Paediatric Quality of Life Inventory (PedsQL) and the Bath Adolescent Pain Questionnaire (BAPQ). The Paediatric Pain Screening Tool⁵ has been developed to assess the severity of symptoms and allow for allocation of resource according to risk stratification.

Attendance at school is a simple way of establishing social functioning, and attending <80% may represent a cut off for referral to paediatric pain services⁵.

Treatment of chronic primary pain in adolescents should primarily focus on functional restoration; the concept that as function and quality of life is restored, the impact of pain is diminished⁶. Friedrichsdorff et al recommend an interdisciplinary approach to include engagement with:

• A. psychological intervention
• B. physical therapy
• C. pharmacology as part of an integrated approach and
• D. parental coaching.

The overall intervention aims to normalise daily life, using the ‘4 S’s’ of school, sleep, social and sport. As a part of this process, integrative mind body techniques (eg mindfulness) or relaxation strategies, to include engagement with valued activities may be incorporated.

Overall evidence to support the use of specific pharmacological interventions is limited⁷. If a risk:benefit analysis has been carried out, medication can be used to include topical applications (lidocaine, capcaisin and menthol), non-steroidal anti-inflammatory medications, tricyclic antidepressants (including amitriptyline) and Gabapentinoids. Interventional procedures are rarely used but may be considered as part of a multidisciplinary approach.

Evidence supports use of group pain programmes that are targeted to the age and educational level of the patients. For patients refractory to outpatient intervention, access to an intensive form of rehabilitation, should be made available. Such Intensive Pain Rehabilitation programmes, typically delivered over 3-4 weeks, have demonstrated sustained improvements in functional disability with associated pain reduction⁸. Availability of such programmes can represent a barrier to care, as due to the requirement for staff resource they are only available in a limited number of specialist centres⁹.

In summary, adolescent chronic pain should be assessed and treated by a specialist multidisciplinary team, putting the young person at the center of the process and promoting function and a return to independence in the absence or presence of pain.