Adolescence is the phase of life between childhood and adulthood, from ages 10 to 19. It is a unique stage of human development and an important time for laying the foundations of good health. Adolescents experience rapid physical, cognitive and psychosocial growth. This affects how they feel, think, make decisions, and interact with the world around them.1
Adolescent pain is multidimensional involving “sensory, emotional, cognitive, and behavioral components that are interrelated with environmental, developmental, sociocultural, and contextual factors.”2 Chronic pain in adolescents has been shown to be a major cause of morbidity in society. Adolescents with chronic pain and anxiety have poor school attendance, avoidance, impaired concentration and difficulty performing schoolwork.
Acute pain-less than 30 days: Acute pain affects the nociceptors in damaged tissue, most frequently related to inflammation associated with a musculoskeletal problem, trauma or perioperative pain.4
Chronic pain-more than three months: Chronic pain does not have a common etiology. It can occur after acute medical illness or surgical procedures such as sickle cell disease, juvenile idiopathic arthritis, or neuromuscular disease. It can also be idiopathic or associated with other chronic disease states5 such as Ehlers-Danlos syndrome, amplified musculoskeletal pain, or functional abdominal pain. Chronic headache has multiple etiologies. Many times there is overlap between acute and chronic pain. If the underlying cause of pain has not been corrected it can be masked by the chronic pain state preventing resolution of the pain. Many forms of chronic pain are remitting or recurring. Common diagnoses include juvenile fibromyalgia, chronic headaches, irritable bowel syndrome, functional abdominal pain, Crohn’s disease, chronic widespread pain, amplified musculoskeletal pain syndrome and CRPS may have underlying neurological causes that research over the last 10 years is bringing to light. CRPS is a common cause of pain among adolescents. There are two types of CRPS—CRPS Type1 is defined as a chronic pain due to soft tissue injury without a confirmed nerve injury and CRPS Type 2 is defined as a pain syndrome following a specific nerve injury. Common symptoms of CRPS type 1 and Type 2 are allodynia, edema, abnormal sweating, temperature changes, skin color changes and changes in nail/hair growth.6
Epidemiology including risk factors and primary prevention
Chronic pain is common among adolescents and has been shown to affect 11-38%7, 8,9 of adolescents. However, there is widespread variability in the reported estimates across studies secondary to the different definitions of chronic pain and the underlying causes of pain included in the studies.10 Chronic pain is more common among females than males but there has been an increase in the incidence of pain in males over time. Most adolescents are only mildly affected by chronic pain and it does not affect their overall function. However, 5% of adolescents are severely affected impacting their school attendance, mental/emotional health, interpersonal relationships with friends and family and leisure activities.10,11 In a study of adults with chronic pain, 17% of participants reported their pain originated in childhood or adolescence.10,12
Risk factors include genetic disposition, poor sleep, obesity, drug or alcohol abuse, and several psychosocial correlates such as socioeconomic status, dysfunctional family dynamics, aberrant psychosocial behavior, low self-esteem, depression, anxiety, post-traumatic stress disorder and poor coping skills.10 Early detection of these risk factors will more likely lead to better pain control thus minimizing its impact on the adolescent and his/her family. Primary interventions for chronic pain in adolescents include mindfulness based interventions, cognitive behavioral therapy, and medical treatments to treat the underlying pathology.
There are three major types of pain—nociceptive, neuropathic and idiopathic. Nociceptive pain occurs when tissue injury activates special pain receptors called nociceptors which are sensitive to noxious stimuli and generates a physiological and behavioral response. Nociceptors are sensitive to heat, cold, vibration, stretch stimuli and chemical substances released from tissues in response to oxygen deprivation or inflammation. In acute pain, tissue damage leads to the release of inflammatory mediators by activated nociceptors or non-neural cells that reside within or infiltrate into the injured area, including mast cells, basophils, platelets, macrophages, neutrophils, endothelial cells, keratinocytes and fibroblasts. Signaling molecules released by these cells include serotonin, histamine, glutamate, ATP, adenosine, substance P, Calcitonin-gene related Peptide(CGRP), bradykinin, eicosanoids, prostaglandins, thromboxane, leukotrienes, endocannabinoids, nerve growth factor(NGF), tumor necrosis factor α (TNF-α), interleukin-1β (il-1β), extracellular proteases and protons. These chemicals bind to the nociceptor by binding to different surface receptors to induce the inflammatory cascade.13There are two major classes of nociceptors. A-delta afferents are small diameter myelinated fibers that mediate acute, well-localized pain. The second class of nociceptor includes small diameter unmyelinated “C” fibers that convey poorly localized, slow pain signals.13The small myelinated and unmyelinated nociceptive fibers are implicated in many forms of chronic pain. Persistent pain associated with injury or disease (such as diabetes, arthritis or tumor growth) can result from the alterations in the properties of peripheral nerves. Research suggests that persistent pain can occur through peripheral and central mechanisms.13 Peripheral sensitization commonly results from inflammatory mediators as described above and create hypersensitivity in the various nociceptors. Central sensitization describes a state of hyperexcitability of the central nervous system leading to enhanced processing of nociceptive pain. Various models have been used to describe central sensitization including glutamatergic neurotransmission/NMDA receptor mediated hypersensitivity, loss of tonic inhibitory controls, and glial-neuronal interactions. Nociceptive pain is subdivided into somatic and visceral pain. Somatic pain nociceptors detect pain on the skin surface and deep tissues while visceral pain nociceptors detect pain within internal organs. Neuropathic pain is caused by damage or disease of the nerves that comprise the somatosensory nervous system. Nerve damage could be the result of genetic, metabolic, traumatic, infectious, ischemic, toxic or immune-mediated conditions. Neuropathic pain may result from damage to the peripheral or central nervous system. Idiopathic pain is when the exact underlying cause or mechanism of the pain source cannot be determined.5 Many of the idiopathic pain states are starting to be more clearly identified. Research by Oaklander, et al. and others have demonstrated small fiber neuropathy may be implicated in a portion of the disorders such as fibromyalgia, complex regional pain syndrome-type1, Ehlers-Danlos syndrome, postural orthostatic tachycardia, autoimmune disorders, autonomic neuropathy, and genetic disorders.14,15,16 Many of these syndromes have pain associated with autonomic dysfunction. In addition, channelopathies are being elucidated in many of the inherited forms of neuropathic pain. These include mutations in the SCN9A gene, and alterations in Nav (v) 1.7, 1.8 and 1.9Voltage-gated Na channels. Voltage-gated K+ and Ca++ channels are also under evaluation as causes for chronic pain.17,18,19 20Alterations in the channels causing neuropathic pain may also be implicated in other symptoms, such as gastric immotility and tachycardia associated with many of the chronic pain syndromes.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Disease progression depends on the underlying cause of the pain. The onset of the pain can be acute, gradual or intermittent; related to an initial insult or with no obvious trigger; time of onset can be well defined or vague; pain can be localized or generalized; affecting one or more than one organ or system. Pain can be self-limited in time or it can persist beyond normal time expectancy when chronic in nature. The phases of pain are:
- Acute: Hours to days (less than 30 days); sudden in onset and/or occurs immediately after injury
- Subacute: Pain that continues for weeks but less than 12 weeks.
- Chronic/stable: More than three months in duration; any pain that persists beyond normal expectancy
- Pre-terminal: Weeks to months
Specific secondary or associated conditions and complications
As mentioned earlier, pain can cause wide ranging dysfunctions in adolescents by altering mood, sleep, appetite, energy level, independence, school functioning, socialization, in addition to specific physical limitations. Anxiety and depression are also common among adolescents suffering from chronic pain. While many patients with chronic pain have associated psychological/mood disorders it is always difficult to determine which issue preceded the other. Current understanding of the neurological pathways associated with pain demonstrate that they also have an association with the centers affecting mood and behavior. Chronic pain is often associated with decreased energy and chronic fatigue. Whether the complications are physical, such as sickle cell disease, cystic fibrosis, juvenile idiopathic arthritis or multiple trauma or are primarily emotionally driven, a clear understanding of the psychosocial aspects of pain need to be fully evaluated.
Essentials of Assessment
- A detailed history of the pain characteristics including onset, location, severity, description, timing, alleviating factors, aggravating factors, referral pattern, medications, and treatments tried and associated symptoms should be included.
- The functional impact can be measured by history. Documentation of previous analgesic treatments, previous pain events, comorbidities (including mental health issues) and psychosocial dynamics should be performed. Symptoms of autonomic disorders such as constipation, heat or cold intolerance, tachycardia, shortness of breath and skin changes should be reviewed.
- Pain severity should be measurement using an assessment tool which is developmentally appropriate. There is no single pain measurement tool which is appropriate for all aged children and all types of pain. However, the most common assessment tools for adolescents are the Visual Analogue Scale and the Numerical Rating Scale.
- Emotional assessment including fear, anxiety, depression and stress. Scales such as the PROMIS® (Patient-reported Outcomes Measurement Information System) help evaluate and monitor the physical, mental and social health in adults and children with chronic pain.21
- Family history including history of chronic pain conditions or any psychiatric illnesses. Often family members, especially female family members, report similar symptoms currently or when they were younger. This is especially true of pain disorders with autonomic symptoms such as POTs, Ehlers-Danlos syndrome, and fibromyalgia.
A detailed and meticulous physical exam is recommended. The examiner should pay close attention to how consistent the exam findings are with the description of the pain by the patient. Great emphasis is placed on the neurological and musculoskeletal examination, but the physical exam should be tailored to the history of the adolescent. The autonomic system should be evaluated including documentation of pupil size. The pupil is the only area of the body that is strictly controlled by small fiber nerves. If the patient is found to be tachycardic, orthostatics should be performed. The extremities should be evaluated for poor capillary refill and dependent rubor. This can be a key to small fiber neuropathy as the underlying mechanism. The neurological exam should include complete sensory testing (pinprick, light touch, proprioception, graphesthesia, hot, cold and vibration) and can aid in which pathways underlie the cause of pain. Skin exam should document the location of allodynia and hyperalgesia, as well as document rashes or skin lesions suggestive of psoriatic arthritis or autonomic cause of the pain. Nail beds should be examined for pitting associated with the sponyloarthropathies. Cognitive exam may demonstrate slow processing speed, memory deficits and executive function deficits that may also be involved in the affected pathway. Some additional tests to include are the Drop Arm test (used to asses for a supraspinatus tear and the patient is asked to actively lower their arm from abduction to their side in a slow and controlled manner), Waddell signs (a group of signs which may indicate a non-organic/psychological cause of the underlying pain) and Hoover test (physical exam maneuver to distinguish between organic from non-organic paresis of the leg). These tests and others can assist in outcomes and indicate nonorganic causes of pain. Obesity should be identified since it can exacerbate the impact of pain. The timing of obesity may also reflect metabolic disorders that can lead to chronic pain.
Pain can limit functionality by impacting social life, school attendance and performance, self-esteem, mood, independence, energy level and in general, quality of life. Questionnaires such as the Adolescent Pain Behavior Questionnaire (APBQ) and the Functional Disability Inventory (FDI) can facilitate this evaluation, along with a comprehensive multi-disciplinary team evaluation. Adolescents with chronic pain often suffer significant impairment in physical, emotional, and social domains. Physical measures such as the timed-up-and-go, or a 6 minute walk test can be used to document physical dysfunction. Goal attainment scales can be used to measure independence. Participation scales such as the PROMIS scales can be used to measure multiple domains of function. The Peds-QL has also been evaluated in the pain population to assess quality of life. Other assessment scales are being developed. Recently, Mano et al. demonstrated that patients with chronic musculoskeletal pain show impairments in executive function using the Behavior rating inventory of executive function (BRIEF-2).22 Self-report measures for intensity, acceptance, catastrophizing, kinesiophobia, disability, anxiety/depression and quality of life have been validated in patients with chronic pain.23 McGarrigle et al. demonstrated that acceptance and kinesiophobia partially mediated the effects of pain across measures of disability and quality of life, while catastrophizing mediates the relationship between pain and emotional distress23. These evaluations play a vital role in managing the complexities of patients with chronic pain.
No specific laboratory study is used in the diagnosis of pain. However, some studies are used to identify organic reasons for pain depending on the history and physical exam. For example, a CBC might be helpful if there is concern for an infection. ANA, CRP, and ESR are helpful if there is concern for an inflammatory process. If autoimmune disorders are suspected, such as lupus, thyroid antibodies, or sjogrens ab, antibody panels should be performed based on history and physical exam. For those patients with a history and physical findings suggestive of small fiber neuropathy (abnormal sweating, dizziness, fainting, fatigue, fluctuating blood pressure, allodynia, hyperalgesia in the hands, feet or trunk, rapid heart rate or shortness of breath), skin biopsy or autonomic testing (QSART or Tilt table test) should be performed based on the symptoms.
Imaging is a complement of the physical exam that helps identify various pathologic structures and underlying diagnosis of organic etiology. For example, CRPS has specific radiographic findings which are diffuse osteoporosis with severe patchy demineralization and subperiosteal bone resorption. Imaging, however, is often diagnostic only in later stages of CRPS. Imaging for back pain is the same as that for the adult population. Standard x-ray and MRI are beneficial in abdominal, rheumatoid and inflammatory causes of pain. Functional magnetic resonance imaging (fMRI) is used in pain research to complement behavioral measurements.
Supplemental assessment tools
Observation is an additional tool to assess pain. No single observational measure is broadly recommended for pain assessment in adolescents across all contexts (post-op, in-hospital, critical care, home, recurrent/chronic pain). Pain assessment within each context requires the use of specific scales, with the exception of chronic pain where overt behavioral signs tend to habituate or dissipate as time passes, making them difficult to observe reliably. Numerous pain assessment tools have been developed to objectively measure pain among children and adolescents. Each assessment tool has its advantages and disadvantages. For children three and older one may use the Faces Pain Scale which consists of six cartoon faces beginning with a happy expression on the right and progressing towards a sadder face on the right. The child is asked to point to a face which accurately represents how much pain he currently feels. Additionally, there is the Faces, Legs, Activity, Cry, Consolability (FLACC) pain scale generally used for children age two to seven but could be used for older children as well. The scale uses five criteria—face, legs, activity, cry and consolability—each criteria is scored from 0 to 2 and a score of 0 represents no pain. Additionally, using a numerical scale for pain is helpful to track a patient’s pain over time from one visit to another. One may also ask the child to keep record of his/her pain in a diary recording when the pain occurred, what made it better or worse, associated symptoms etc. Furthermore, asking a child to draw a picture of his/her pain could clearly delineate the type and severity of the pain the child is suffering from. For all children less than three years old it is imperative to observe for signs of pain such as crying, eyebrows raised or hands in flexed position. One must use caution in the use of pain diaries in patients prone to catastrophizing, anxiety and depression as they can reinforce the fear and pain.
Early predictions of outcomes
Bhatia et al. in a survey of clinicians with a specific interest in chronic pain management reported that 75% of the respondents felt that a majority of children with chronic pain have a fair to good prognosis.6 Good outcomes are predictable in the adolescent who is physically active, has good sleep hygiene, compliant with treatment recommendations, has good communication skills, without underlying psychiatric illness or anxiety, capable of using good coping skills and is supported by a stable and supportive family. However, adolescents with chronic pain have an increased risk for persistent pain and mental health disorders especially anxiety and depression. The presence of the Waddell sign predicts poor outcomes. Factors affecting the quality of life in patients with Ehlers-Danlos suggested general fatigue and pain scores were the best predictors of quality of life.24 In a study by Arnstad et al. the group evaluated patients with juvenile idiopathic arthritis over 8 years suggesting that early self-reported, disease-related pain seems to predict persistent pain and unfavorable long-term disease outcomes.25Evaluating patients attending an intensive pain program, Simons et al. evaluated functional disability trajectories and pain trajectories. Two functional disability groups emerged, responders (88%) and nonresponders (12%). For the functional limitation trajectory no baseline variables were early predictors of improvement. Three pain trajectory groups emerged, responders (35%), late treatment responders (38%) and nonresponders (27%). Older age, higher pain scores, fewer social difficulties, higher anxiety levels, and lower readiness to change were characteristic to nonresponders. No significant predictors distinguished the late responders from early responders.
Adolescents with pain can benefit from a positive environment facilitating the use of coping skills to manage the pain and minimize functional limitations. A structured and controlled environment that reinforces appropriate healthy behaviors and promotes allowable physical activity and functionality is recommended. Environmental factors involved in various chronic pain states are beginning to be studies. A recent study looked at the factor associated with migraine and academics. ADHD, learning disabilities, sleep disorders and psychiatric comorbidies were all associated with migraine and poor academic performance.26 Other environmental factors including weather, sleep, travel, and relationships may all impact a person’s response to pain.
Social role and social support system
Parental behaviors have an important impact upon adolescent pain outcomes. Families of children with chronic pain generally have poorer family functioning than healthy populations and pain-related disability is more consistently related to family functioning than is pain intensity. Additionally, the parents’ exaggerated emotional response to their child’s pain can functionally disable the adolescent. Youth pain acceptance, pain self-efficacy and parent psychological flexibility have been highly positively correlated with each other, and with overall youth QOL.27. Use of tools such as the Inventory of Parent Accommodations of Children’s Symptoms (IPACs) can address the extent of accommodation and show the negative impact of parental accommodation on the child’s functional impairment, anxiety, and depression.28 (La Buissonniere-Ariza) In addition, maternal pain catastrophizing was indirectly related to more somatic symptoms, lower physical functioning, and lower psychosocial health in their child via child pain catastrophizing, but only in mothers without chronic pain.29
All treatable sources of pain should be identified in a timely fashion to minimize unwanted permanent and/or long term functional disability. Examples include early detection of chronic pain in adolescents with diagnosis such as psychiatric disorders, connective tissue disease, rheumatoid arthritis and trauma. Many pain approaches validated on adults but lacking a developmental and family focus may be inappropriate or even potentially harmful for adolescents, especially those with chronic pain.
Rehabilitation Management and Treatments
Available or current treatment guidelines
The World Health Organization updated guidelines in December 2020 for the management of chronic pain in children.30
Pain is a complex multidimensional issue. Children with chronic pain and their families and caregivers must be cared for from a multimodal biopsychosocial perspective in a comprehensive and integrated manner involving an interdisclinary team with the patient and family at the center of the team. The evaluation should take into account the child’s developmental stage, other health issues, language, cultural and cognitive abilities. The family dynamics, including preferences, resources and community expectations should also be considered. Communication should be timely and accurate. Medical decision making should account for good opioid stewardship with the goals, risks and benefits of all treatment modalities explained at a level the patient and family can comprehend. The plan should include appropriate monitoring of medications by a professional trained in opioid and pain medication management.30
Recommendations from WHO guidelines for the management of chronic pain in children include the need for physical therapies or combinations of therapy to address the physical aspects of care. Cognitive behavioral therapy, acceptance and commitment therapy, behavioral therapy and relaxation therapies should all be utilized to manage the psychological aspects of pain. “Psychological therapy may be delivered either face-to-face or remotely, or using a combined approach (conditional recommendation, moderate certainty evidence).” Appropriate pharmacological management should be used based upon the specific needs of the patient. For end-of-life-care and for patients with life-limiting conditions morphine may be used under the principles of opioid stewardship. Morphine should never be used as a stand-alone treatment. The management of morphine should be undertaken by an appropriately trained provider secondary to the variable responses between individual patients. Effort should be taken for proper education of the patient and family, risk mitigation and be used at the lowest possible dose and duration with frequent monitoring.30
At different disease stages
- Nonsteroidal anti-inflammatories, acetaminophen, muscle relaxants
- Opioids (by a trained professional using appropriate guidelines)
- Regional nerve blocks after surgical procedures
- Physical or occupational therapy
- Intensify physical activity where medically appropriate and encourage functionality.
- Minimize use of opioids.
- Reinforce the use of appropriate coping skills.
- Consider initiating the use of other medications/interventions listed below in the section on chronic/stable stage of pain.
- Opioids are not recommended due to limited efficacy, risk of tolerance, dependence and decreased cognition.
- Tricyclic antidepressants, such as amitriptyline or nortriptyline.
- Selective serotonin-reuptake inhibitors (SSRI), such as citalopram, sertraline, paroxetine as mood stabilizers and anxiolytics are used. Close monitoring is advised due to increased risk of suicidality in adolescents with these medications. Awareness of serotonin syndrome is also needed. Serotonin syndrome occurs when the serotonin level in the body is too high and common symptoms include diarrhea, elevated body temperature, agitation, sweating and tremor.
- Serotonin-Norepinephrine reuptake inhibitors, such as duloxetine and venlafaxine.
- Anti-seizure medications: pregabalin and gabapentin
- Medical cannabis has been used in the adolescent and adult population, predominantly for chronic musculoskeletal pain. Access to medical cannabis is limited, even though the majority of the patients report significant pain symptom relief. The cognitive deficit with long-term use of medical cannabis must be considered and evaluated in context of the developing brain of the adolescent.
- Immunological therapies for patients found to have an autoimmune basis for chronic pain
- Botulinum toxin injections are FDA approved for chronic migraines in adults.
- Specific pain interventions depending upon chief complaint. For example, occipital nerve block for adolescents suffering from occipital neuralgia. There are many other procedures depending upon the patient’s history, symptoms and clinical picture. Physical therapy/occupational therapy can help to improve mobility and function in all the activities of daily living.
- Psychotherapy: biofeedback and cognitive behavior therapy facilitate coping skills empowering adolescents through better control over their pain.
- Family support and school/community interventions help to optimize family and social dynamics.
- Studies evaluating Alternative therapies including acupuncture, mindfulness based meditation, and yoga, are beginning to demonstrate positive effects on pain.
Coordination of care
- Pain in adolescents should be managed comprehensively and with a multidisciplinary approach. Long-term follow up for some patients may be warranted in order to maintain gains.
- Continuity of care with same providers over time is important.
- Family based treatment integrating the school and community is recommended.
- Outpatient multidisciplinary clinic, day programs, and/or intensive inpatient rehabilitation with emphasis on cognitive behavioral therapy and functionality are valid approaches. These programs should occur after a complete evaluation of the pain has been completed. It is important to explain to the families that these programs are functionally based programs and are not an attempt to “cure” the pain. These programs have had great success with reestablishing the patient back into society and improving their quality of life.
Patient & family education
Educating the patient and family on the probable etiology (if known) and the options for pain management will help facilitate better compliance with the treatment recommendations provided by the team. Education minimizes fear of the unknown, a factor that can indirectly increase the disabling component of pain.
Various questionnaires, such as the Bath Adolescent Questionnaire, the Adolescent Pain Behavior Questionnaire, Functional Disability Inventory and the Brief Pain Inventory look into how pain alters functionality in adolescents in their activities of daily living. The bio-psych-social evaluation should consider the dynamics of the family and the social determinants of health impact on pain and functioning.
Pain’s impact on cognitive function, anxiety and depression can be captured through neuropsychological testing.
Measurement of patient outcomes
Because pain is subjective, specific questionnaires relevant to pain and functionality outcomes should be an integral part of the initial evaluation and all follow-up visits. Serial monitoring of depression and anxiety with tools such as the PHQ-9 and the GAD7 can help correlate the pain symptoms with psychological factors. Simple evaluations such as the timed up and go or six-minute walk test can demonstrate improved mobility.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
- Pain can be present in many heterogeneous conditions, with or without an obvious organic or nonorganic etiology.
- Pain is common in adolescents and independent of its intensity, it can significantly interfere with the adolescent’s quality of life, impacting the functional dynamics of the individual, the family and community.
- Policies should reflect the multidisciplinary complexity and efforts required to assess and treat adolescents with pain.
- Comprehensive, integrated treatment of medical, psychological and social factors may be the most cost-effective approach in the treatment of complex and refractory pediatric pain problems.
Cutting Edge/ Emerging and Unique Concepts and Practice
- Identify pain as a complex, individual entity requiring an active comprehensive and multidisciplinary management approach one that includes psychotherapeutic interventions with family and patients when appropriate and addresses the organic and nonorganic components of pain.
- Enact appropriate use of medications and interventions compliant with evidence-based medicine and challenge current and future practices in pain management.
- Further research in non-invasive pain management interventions for patients who failed medical management.
- Newer technologies are showing promise in management of chronic pain in adults, including modulation therapies such as Transcutaneous Magnetic Stimulation, spinal cord stimulation and deep brain stimulation. Significant research needs to be completed on these therapies before becoming universally accepted.
- The use of IV low dose Ketamine to treat chronic pain is controversial. Some research has shown promise, but an abuse potential exists and no RCT studies in adolescents have been performed.
Gaps in the Evidence- Based Knowledge
The world health organization has identified gaps in research design and execution including a significant lack of research including large multicenter randomized studies, complementary single case design studies, and development of population characteristics. The tools needed for assessment, reassessment and outcome measures for specific pain conditions over various age ranges are also lacking. Further evaluation for biomarkers and specific risk factors that will allow for improved interventions that reduce the disabling features will add significantly to the process. Further medication trials are needed to address the efficacy and safety for use in adolescents for those medications validated in adulthood. Studies of the long-term effects of opioid use and influence on the adolescent brain are vital.30 They have identified gaps relevant to several interventions including treatments in real world settings, feasibility studies in a range of countries, the study of diverse models of delivery, mixed method studies and studies of the cost effectiveness of treatments.30
- Adolescent health. (n.d.). Retrieved March 28, 2021, from https://www.who.int/health-topics/adolescent-health#tab=tab_1
- Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics; Task Force on Pain in Infants, Children, and Adolescents, American Pain Society. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics 2001;108(3):793-7
- Nilsson, Stefan. Rosvall, Per-Åke. Jonsson, Annikki. Adolescent-Centered Pain Management in School When Adolescents Have Chronic Pain-A Qualitative Study. Global Journal of Health Science, Volume 9 No. 4 (8-19)
- Höfel, L., Draheim, N., Schramm, A. et al. Rheumaschmerz und chronischer Schmerz bei Kindern, Jugendlichen und jungen Erwachsenen. Z Rheumatol 80, 234–242 (2021). https://doi-org.proxy1.library.jhu.edu/10.1007/s00393-020-00956-3
- Becker, Andrew J.a,b; Heathcote, Lauren C.c; Timmers, Ingec; Simons, Laura E.c,* Precipitating events in child and adolescent chronic musculoskeletal pain, PAIN Reports: September 2018 – Volume 3 – Issue 7 – p e665 doi: 10.1097/PR9.00000000000006
- “Complex Reginal Pain Syndrome Fact Sheet” NINDS, January 2017, NIH Publication No. 17-4173
- Goodman J.E., McGrath P.J. The epidemiology of pain in children and adolescents: A review. Pain. 1991;46:247–264. doi: 10.1016/0304-3959(91)90108-A.
- King S., Chambers C.T., Huguet A., MacNevin R.C., McGrath P.J., Parker L., MacDonald A.J. The epidemiology of chronic pain in children and adolescents revisited: A systematic review. Pain. 2011;152:2729–2738. doi: 10.1016/j.pain.2011.07.016.
- Stanford E.A., Chambers C.T., Biesanz J.C., Chen E. The frequency, trajectories and predictors of adolescent recurrent pain: A population-based approach. Pain. 2008;138:11–21. doi: 10.1016/j.pain.2007.10.032.
- Tutelman, P. R., Langley, C. L., Chambers, C. T., Parker, J. A., Finley, G. A., Chapman, D., . . . Marianayagam, J. (2021). Epidemiology of chronic pain in children and adolescents: A protocol for a systematic review update. BMJ Open, 11(2). doi:10.1136/bmjopen-2020-043675
- Huguet A, Miró J. The severity of chronic pediatric pain: an epidemiological study. J Pain. 2008;9(3):226–236
- Ho IK, Goldschneider KR, Kashikar-Zuck S, et al. Healthcare utilization and indirect burden among families of pediatric patients with chronic
- Basbaum, A. I., Bautista, D. M., Scherrer, G., & Julius, D. (2009). Cellular and molecular mechanisms of pain. Cell, 139(2), 267-284. doi:10.1016/j.cell.2009.09.028
- Oaklander, A. L., Rissmiller, J. G., Gelman, L. B., Zheng, L., Chang, Y., & Gott, R. (2006). Evidence of focal small-fiber axonal degeneration in complex regional pain syndrome-i (reflex sympathetic dystrophy). Pain, 120(3), 235-243. doi:10.1016/j.pain.2005.09.036
- Boneparth, A., Chen, S., Horton, D. B., Moorthy, L. N., Farquhar, I., Downs, H. M., . . . Oaklander, A. L. (2020). Epidermal neurite density in skin biopsies from patients with juvenile fibromyalgia. The Journal of Rheumatology. doi:10.3899/jrheum.200378
- Farhad, K., & Oaklander, A. L. (2018). Fibromyalgia and small-fiber polyneuropathy: What’s in a name? Muscle & Nerve, 58(5), 611-613. doi:10.1002/mus.26179
- Bartholomew, F., Lazar, J., Marqueling, A., Lee‐Messer, C., Jaradeh, S., & Teng, J. M. (2014). Channelopathy: A novel mutation in the scn9a gene causes insensitivity to pain and autonomic dysregulation. British Journal of Dermatology, 171(5), 1268-1270. doi:10.1111/bjd.13096
- Choi, J., Dib-Hajj, S. D., & Waxman, S. G. (2006). Inherited erythermalgia: Limb pain from an S4 charge-neutral na channelopathy. Neurology, 67(9), 1563-1567. doi:10.1212/01.wnl.0000231514.33603.1e
- Han, C., Huang, J., & Waxman, S. G. (2016). Sodium channel nav1.8. Neurology, 86(5), 473-483. doi:10.1212/wnl.0000000000002333
- Hoeijmakers, J., Merkies, I., Gerrits, M., Waxman, S., & Faber, C. (2012). Genetic aspects of sodium channelopathy in small fiber neuropathy. Clinical Genetics, 82(4), 351-358. doi:10.1111/j.1399-0004.2012.01937.x
- Kashikar-Zuck, S., Carle, A., Barnett, K., Goldschneider, K. R., Sherry, D. D., Mara, C. A., . . . DeWitt, E. M. (2016). Longitudinal evaluation of patient-reported outcomes measurement information systems measures in pediatric chronic pain. Pain, 157(2), 339-347. doi:10.1097/j.pain.0000000000000378
- Jastrowski Mano, K. E., Beckmann, E. A., Fussner, L. M., & Kashikar-Zuck, S. (2020). Executive functioning in adolescents with chronic musculoskeletal pain. Children, 7(12), 273. doi:10.3390/children7120273
- McGarrigle, L., Wesson, C., DeAmicis, L., Connoly, S., & Ferreira, N. (2020). Psychological mediators in the relationship between paediatric chronic pain and adjustment: An investigation of acceptance, catastrophising and kinesiophobia. Journal of Contextual Behavioral Science, 18, 294-305. doi:10.1016/j.jcbs.2020.10.009
- Mu, W., Muriello, M., Clemens, J. L., Wang, Y., Smith, C. H., Tran, P. T., . . . Bodurtha, J. (2019). Factors affecting quality of life in children and adolescents WITH HYPERMOBILE EHLERS-DANLOS syndrome/hypermobility spectrum disorders. American Journal of Medical Genetics Part A, 179(4), 561-569. doi:10.1002/ajmg.a.61055
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Original Version of the Topic
Tamara Zagustin, MD. Rehabilitation Approach to Adolescent Pain. 11/11/2011.
Previous Revision(s) of the Topic
Daniel Sova, MD; Ashot Kotcharian, MD; and M-Irfan Suleman, MD. Rehabilitation Approach to Adolescent Pain. 7/24/2017.
Dennis Hart, MD, MBA
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