Author(s): Josue Martes, Glendaliz Bosques, MD
Originally published: November 11, 2011 Last updated: June 27, 2024
Jump to:

Disease/Disorder

Definition

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.3

Etiology

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.3,4

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 states such as Ehlers-Danlos syndrome, amplified musculoskeletal pain, or functional abdominal pain.5 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 chronic regional pain syndrome (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: (1) Type1 is defined as a chronic pain due to soft tissue injury without a confirmed nerve injury; (2) 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%of adolescents.6 Studies published before 2019 varied widely in their definitions of chronic pain, if the term was defined at all. Although chronic pain has been considered as lasting more than three months in clinical practice since 1994, and more than six months in research.  It was not until 2019 when chronic pain was included in ICD-11.7 This has caused 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.8 Chronic pain is more common among females than males but there has been an increase in the incidence in males over time. Most adolescents, in developed countries, are only mildly affected by chronic pain and it does not affect their overall function. Yet, the inaugural systematic review of pediatric chronic pain in low- to middle-income countries uncovered varying levels of impact on affected populations. Adolescents with persistent pain scored significantly worse on self-esteem, stress, loneliness, lack of sleep, school absence, pain and health-related quality of life (HRQOL) compared to adolescents with shorter pain duration.9

Risk factors include genetic disposition, neonatal history, 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.8,10 Studies have shown that up to 17% of adults with chronic pain reported their pain originated in childhood or adolescence.8 Younger patients are more likely to recover. Hence, primary interventions for chronic pain in adolescents include mindfulness-based interventions, cognitive behavioral therapy, and medical treatments to treat the underlying pathology especially during initial stages of its progression.

Patho-anatomy/physiology

There are three major types of pain—nociceptive, neuropathic and nociplastic. (Table 1)

Nociceptive pain, describes the pain caused by tissue damage and/or inflammation, which activates receptors called nociceptors. The sensation can be sharp, pricking, dull, or aching, depending on what caused the damage or inflammation.11 Nociceptors can be found on multiple parts of the body, including skin, joints, viscera, and muscles. Nociceptors can be activated by a wide variety of chemical substances (i.e., globulin and protein kinases, arachidonic acid, histamine, nerve growth factor, substance P, calcitonin gene-related peptide (CGRP), potassium, serotonin, acetylcholine, low-pH solutions, ATP, and lactic acid), in addition to extremes in temperature, high pressures, and tissue damage causing inflammation. They may be further subdivided based on the type of information they are relaying: high threshold mechanoreceptors, thermal receptors, chemical receptors, and polymodal receptors, and so forth. There are two major types of nociceptive nerve fibers: (1) A delta fibers are lightly myelinated and have small receptive fields, which allow them to initially perceive pain; (2) C fibers are unmyelinated and have large receptive fields, which allow them to relay pain intensity. Persistent inflammation decreases the threshold for pain and enhances responsiveness to pain. Neuropeptides, such as substance P, bradykinin, and glutamate mediate the increased activity of secondary nociceptive neurons in the pain circuitry, leading to enhanced pain perception.12

Neuropathic pain is caused by nerve damage due to an injury or disease. Nerve damage could be the result of genetic, metabolic, traumatic, infectious, ischemic, toxic or immune-mediated conditions. Neuropathic pain sensations are often described as burning, tingling, shooting, or ‘electric’. Examples of conditions that cause neuropathic pain are diabetic neuropathy, shingles, and sciatica.11

Nociplastic pain is caused by changes in how the nervous system processes pain. The changes that cause nociplastic pain are not linked with a clear injury, tissue damage, inflammation, or disease. The sensations related to this kind of pain vary widely. Examples of nociplastic pain include fibromyalgia, irritable bowel syndrome, and tension headaches.11 Researchers have proposed three mechanisms underlying nociplastic pain: supraspinal, spinal, and peripheral. First category includes supraspinal mechanisms such as hyperresponsiveness to pain stimuli, hyperactivity, and connectivity between regions of the brain responsible for pain perception (e.g., medial prefrontal cortex and rostral (mPFC), the anterior cingulate cortex (ACC), and the thalamus and secondary somatosensory cortices). Additionally, decreased activity and connectivity of brain areas responsible for pain inhibition, that is, the connection between mPFC and ACC and insula, are believed to be present. Other supraspinal mechanisms include an increased concentration of substance P and glutamine levels in cerebrospinal fluid and inhibition of GABAergic transmission. The second category includes spinal mechanisms that involve regional clustering and convergence of signals from different pain loci, spinal cord reorganization, amplified spinal reflex transmission, decreased spinal inhibition, winding up and temporal summation, and immune system activation among other glial cells. The third and last category includes peripheral mechanisms related to the proliferation of sodium channels and sympatho-afferent coupling. In clinical practice, pain signaling involves main compartments that can contribute to the development of pain in all three sites.13

Table 1. Evolution in nomenclature of different pain states. Nociceptive and neuropathic pain has stayed consistent; idiopathic pain has transitioned to nociplastic pain under new classification. (Created by Josue Martes)

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

History

  • 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.
  • Patient’s neonatal history due the possible alterations in pain sensitivity.  Newer studies have identified pain sensitivity associations with early-life events. For example, a study was done to compare the ratings of self-reported and parent-reported pain sensitivity between early preterm (EP), moderately-late preterm (MLP) and full-term (FT). This study found increased pain sensitivity reported by 18% of EP compared with 12% of MLP adolescents, and 7% of FT adolescents.14
  • 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 measured using an assessment tool which is developmentally appropriate. There is no single pain measurement tool appropriate for all aged children and all types of pain. However, the most common assessment tools for adolescents are the Visual Analogue Scale (VAS) and the Numerical Rating Scale (NRS). It is important to note that these tools may be limited in the assessment of pain to a specific dimension, type of pain or age of patient.15
  • 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.16
  • 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 postural orthostatic hypotension syndrome (POTS), Ehlers-Danlos syndrome, and fibromyalgia.
  • Social history including toxic habits, sexual activity, hobbies and extracurricular activities is an important component to consider and should be continuously followed when evaluating an adolescent with pain.17–19

Physical examination

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. Neck examinations should be performed to evaluate thyroid disorders, which are often related to obesity, weight loss and 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 spondyloarthropathies. Cognitive examination 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 assess 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 functional or psychogenic cause of the underlying pain) and Hoover test (physical exam maneuver to distinguish between organic from functional or psychogenic paresis of the leg). (See Table 2) These tests and others can assist in outcomes and indicate functional or psychogenic causes of pain. Obesity and weight loss should be identified since it can be a result of metabolic disorders that can lead to chronic pain.

Table 2. Maneuvers and tests which suggest a functional component of pain. (Created by Josue Martes)

Functional assessment

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 Pediatric Quality of Life InventoryTM (PedsQL) 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 (BRIEF2).20 Self-report measures for intensity, acceptance, catastrophizing, kinesiophobia, disability, anxiety/depression and quality of life have been validated in patients with chronic pain.21 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 distress.21 These evaluations play a vital role in managing the complexities of patients with chronic pain.

Laboratory studies

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 Sjögren’s antibody ab, antibody panels should be performed based on history and physical examination.  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 and other specialized testing

Imaging is a complement of the physical examination 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. X-rays and CT scans can also be used to screen for cancer, if suspected. Functional magnetic resonance imaging (fMRI) is used in pain research to complement behavioral measurements.  Electrodiagnostic studies (EDX) are a common tool in physiatric practice. EDX may be indicated in adolescents when presenting with unexplained symptoms suggestive of undiagnosed neuromuscular dysfunction, such as unexplained muscle weakness, numbness, pain or other abnormal sensations that follow anatomical structural patterns.  These studies may be useful in diagnosing neuropathies, radiculopathies or entrapment syndromes.  Proper clinical assessment and consideration of the adolescent’s overall health and development are important when deciding to perform these studies.

Table 3.  Warning signals that require further work-up for most common pain syndromes in adolescents. (Created by Josue Martes)

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. Some of the most commonly used unidimensional pain scales include VAS, NRS, and Wong-Baker FACES pain scales (FPS). For children three and older one may use the Wong-Baker FACES Pain Scale (FPS) which consists of six cartoon faces beginning with a happy expression on the right and progressing towards a sadder face on the right. For adolescents, VAS and NRS are more commonly used. In a study by Thompson et al., most pediatricians used parent report (87.1%) followed by patient self-report (84.2%), visual or numerical pain rating scales (55.5%), nonverbal scales (66.7%), and the pain diary (49.5%).22

Early predictions of outcomes

Most clinicians who manage chronic pain in children may report that patients have a fair (decreased pain intensity with some functional improvement or good (significant functional improvement and decreased pain intensity) prognosis.22,23 However, this does not match data reported by Hassett et al. who found that 1 in 6 adults with chronic pain reported onset during childhood or adolescence and persistence through adulthood, suggesting an less favorable  prognosis.22,24 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. In studies with patients with Sjögren’s syndrome and hypermobile Ehlers-Danlos, persistent pain and fatigue appear to be significant predictors for poor quality of life.25,26 Similar findings have been reported in patients with juvenile idiopathic arthritis, suggesting that early self-reported, disease-related pain seems to predict persistent pain and unfavorable long-term disease outcomes.27 Simons et al. evaluated functional disability trajectories and pain trajectories in a group patients participating in an intensive multidisciplinary daily pain program. The majority of the patients who completed the program, responded with mild disability at discharge and maintenance through 1-year follow-up.  No predictors were found between early responders and late responders of the program.  Nonresponders were characterized by older, higher pain scores, fewer social difficulties, higher anxiety levels, and lower readiness to change.28 A recent study of patients with Adolescent Idiopathic Scoliosis (AIS) explored child and parent risk and resilience factors as predictors of long-term post-surgical recovery. Pain and adolescent pain catastrophizing were identified as risk factors for negative health-related quality of life, long-term function and pain intensity.  Adolescent and parental psychological flexibility, and adolescent pain acceptance were identified as resilience factors, predicting improved pain intensity and quality of life at 1-year follow-up. These findings highlight the importance of comprehensively assessing adolescent’s risk factors and targeting these when treating pain.29

Environmental

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 studied. A recent study looked at the factors associated with migraine and academics. ADHD, learning disabilities, sleep disorders and psychiatric comorbidities were all associated with migraine and poor academic performance.30  Other environmental factors including weather, sleep, travel, and relationships may all impact a person’s response to pain.

Social role and social support system

Research suggests that media consumption plays a vital role in children’s socialization, including the socialization of painful experiences. A study extracted a cross-section of popular adolescent media, selected based on popularity, and pain instances were coded using two established observational coding schemes assessing sufferer pain characteristics and observer responses. Across 616 instances of pain, there was a preponderance of violence and injuries, whereas everyday, chronic-type, and medical/procedural types of pain were seldomly represented. Individuals from marginalized (i.e., gender diverse, girls) and minority groups (individuals with racialized identities) were underrepresented in pain instances. Furthermore, regardless of observed gender or “race”, observers displayed a lack of empathy for sufferers and rarely engaged in prosocial behaviors. An opportunity exists to harness popular media to adaptively and accurately portray pain to adolescents.31 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.32  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.33 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.34

Early Detection

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.35

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 interdisciplinary team with the patient and family at the center of the team. (Figure 1) 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.35

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, face-to-face or remotely delivered, should all be utilized to manage the psychological aspects of pain. 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. Providers administering opioids must have a clear plan for the continuation, tapering or discontinuation of the medication according to the child’s condition.  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.35

At different disease stages

New onset/acute

  • Nonsteroidal anti-inflammatories, acetaminophen, muscle relaxants, alpha-2 agonists
  • Opioids (by a trained professional using appropriate guidelines)
  • Regional nerve blocks after surgical procedures
  • Physical or occupational therapy

Subacute

  • 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.

Chronic/stable

  • Opioids are not recommended due to limited efficacy, risk of tolerance, dependence and decreased cognition.
  • Tricyclic antidepressants, such as amitriptyline or nortriptyline. Despite frequent use in pediatrics, the evidence supporting amitriptyline use for pain is not very strong. In pediatric functional abdominal pain, amitriptyline has shown improved quality of life, reduced right lower quadrant pain (but not other locations of abdominal pain), and reduced anxiety.36
  • Selective serotonin-reuptake inhibitors (SSRI), such as citalopram, sertraline, paroxetine as mood stabilizers and anxiolytics may be used. Close monitoring is advised due to increased risk of suicidality in adolescents with these medications. Awareness of serotonin syndrome is also needed; common symptoms include diarrhea, elevated body temperature, agitation, sweating and tremor. SSRIs have not been studied for pediatric and adolescent chronic pain outside of the study of citalopram to treat pediatric functional abdominal pain.36
  • Serotonin-Norepinephrine reuptake inhibitors, such as duloxetine and venlafaxine, may reduce pain intensity. Only one placebo-controlled trial on duloxetine for juvenile fibromyalgia exists and it demonstrated no statistically significant difference in their primary outcome measure of reduced 24h average pain when compared to placebo; it did show a statistically significant increased likelihood of achieving 30% and 50% reductions in average pain. No studies have evaluated the role of venlafaxine or milnacipran to treat pediatric pain or headache.
  • Anti-seizure medications: pregabalin, gabapentin and topiramate (only approved for migraines). Despite topiramate’s FDA-approval for pediatric migraine, a multicenter double blind, cross-over controlled trial (CHAMP)37 and a meta-analysis have shown that there is little evidence supporting the efficacy in migraine prevention.38
  • 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.  Up to one third of youth with complex medical conditions reported use of non-prescribed marijuana for pain-related symptom management.39 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.  There have been emerging studies in the efficacy of chronic headaches in youth with promising results, though further research is needed.39–41
  • 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.  The Comfort Ability® Program has been designed as a method for youth and parents to better understand, cope and manage chronic pain.  This program has shown cross-institutional and sustainability.42 Due to COVID-19, behavioral health suffered from significant access limitations to physical provision of care, for which a virtual pathway was developed and undergoing additional research.43 
  • Family support and school/community interventions help to optimize family and social dynamics.
  • Studies evaluating alternative therapies including acupuncture, mindfulness based meditation, and yoga have demonstrated promise in the past; very limited literature is available.

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 the same providers over time is important.
  • Family-based treatment integrating the school and community is recommended.
  • Outpatient multidisciplinary clinics, day programs, and/or intensive inpatient rehabilitation with emphasis on cognitive behavioral therapy and functionality are valid approaches. These programs should occur after a thorough 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.

Figure 1.  Primary, secondary and tertiary interventions in the management of pain with goals to prevent pain, manage acute pain effectively, and provide comprehensive care for chronic pain. (Created by Glendaliz Bosques, MD)

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.  The Comfort Ability Program has taken an evidence-based approach into providing this integral part of chronic management.42

Emerging/unique interventions

Impairment-based measurement

Various questionnaires, such as the Pediatric Pain Profile (PPP), Bath Adolescent Questionnaire, the Adolescent Pain Behavior Questionnaire, Functional Disability Inventory (mBPI) and the Brief Pain Inventory look into how pain alters functionality in adolescents in their activities of daily living. A biopsychosocial evaluation should consider the dynamics of the family and the social determinants of health impact on pain and functioning. A systematic review of these questionnaires’ psychometric properties found only the PPP to have validity and consistency with children and adolescents who are unable to self-report. The Patient-Reported Outcome Measurement Information System (PROMIS) Pediatric Proxy Pain Interference Scale, Bath Adolescent Pain Questionnaire for Parents and mBPI are promising but require further investigation for patients who are unable to self-report. 

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. It is important to follow changes in all domains which may be impacted or may affect pain, not only pain severity, but also pain-related difficulties with daily living, overall well-being, emotional and physical functioning and sleep quality. 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.  Recently updated recommendations mention the importance of including core outcomes and assessment measures for clinical trials of chronic pain in youth.44(Figure 2)

Figure 2.  Recommended core outcome measures for clinical trials in pediatric chronic pain.44 (Created by Glendaliz Bosques, MD)

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.
  • Programs and 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 biopsychosocial 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 fail medical management.
  • Digital health interventions offer promise for expanding access and reach to adolescent populations without access to psychological treatments. The Comfort Ability® Program42 and Web-based Management of Adolescent Pain (WebMAP) Mobile app45 and website are examples of online and virtual interventions. These digital health interventions may be alternative methods to reach and optimize the management of populations of adolescents experiencing pain, but further research is needed.
  • Newer technologies are showing promise in management of chronic pain in adults, including modulation therapies such as Transcutaneous Magnetic Stimulation, spinal cord stimulation, deep brain stimulation and noninvasive vagal nerve stimulation. Significant research and reviews of their existing treatment protocols and stimulation parameters applied to pediatric patients 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. FDA studies in children and adolescents are limited. Research is needed in order for FDA-approvals to reflect the standard of care within the pediatric population. Studies of the long-term effects of opioid use and cannabinoids, and their influence on the adolescent brain are vital. There are 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.35

References

  1. Adolescent health. Accessed April 27, 2024. https://www.who.int/health-topics/adolescent-health#tab=tab_1
  2. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health, Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108(3):793-797. doi:10.1542/peds.108.3.793
  3. Adolescent-Centered Pain Management in School When Adolescents Have Chronic Pain-A Qualitative Study. Paperpile. Accessed April 27, 2024. https://paperpile.com/app/p/2082abce-b7bd-0802-9ca6-49878e2a032a
  4. Höfel L, Draheim N, Schramm A, Georgi M, Haas JP. [Rheumatic pain and chronic pain in children, adolescents and young adults]. Z Rheumatol. 2021;80(3):234-242. doi:10.1007/s00393-020-00956-3
  5. Becker AJ, Heathcote LC, Timmers I, Simons LE. Precipitating events in child and adolescent chronic musculoskeletal pain. Pain Rep. 2018;3(Suppl 1):e665. doi:10.1097/PR9.0000000000000665
  6. Complex Regional Pain Syndrome. National Institute of Neurological Disorders and Stroke. Accessed April 27, 2024. https://www.ninds.nih.gov/health-information/disorders/complex-regional-pain-syndrome
  7. The IASP classification of chronic pain for ICD-11: chronic primary pain. Paperpile. Accessed April 27, 2024. https://paperpile.com/shared/BO81Uo
  8. Tutelman PR, Langley CL, Chambers CT, et al. Epidemiology of chronic pain in children and adolescents: a protocol for a systematic review update. BMJ Open. 2021;11(2):e043675. doi:10.1136/bmjopen-2020-043675
  9. Paediatric chronic pain prevalence in low- and middle-income countries: A systematic review and meta-analysis. Paperpile. Accessed April 27, 2024. https://paperpile.com/shared/93cnzr
  10. Self-reported sensitivity to pain in early and moderately-late preterm-born adolescents: A community-based cohort study. Paperpile. Accessed April 27, 2024. https://paperpile.com/shared/WCewrP
  11. Pain. National Institute of Neurological Disorders and Stroke. Accessed April 27, 2024. https://www.ninds.nih.gov/health-information/disorders/pain
  12. Physiology, Nociceptive Pathways. Paperpile. Accessed April 27, 2024. https://paperpile.com/shared/1Lyqwt
  13. Kendroud S, Fitzgerald LA, Murray IV, Hanna A. Physiology, Nociceptive Pathways. StatPearls Publishing; 2022. Accessed April 27, 2024. https://www.ncbi.nlm.nih.gov/books/NBK470255/
  14. van Dokkum NH, de Kroon MLA, Reijneveld SA, Bos AF. Self-reported sensitivity to pain in early and moderately-late preterm-born adolescents: A community-based cohort study. Paediatr Neonatal Pain. 2021;3(2):59-67. doi:10.1002/pne2.12053
  15. Lee RR, Rashid A, Ghio D, Thomson W, Cordingley L. Chronic Pain Assessments in Children and Adolescents: A Systematic Literature Review of the Selection, Administration, Interpretation, and Reporting of Unidimensional Pain Intensity Scales. Pain Res Manag. 2017;2017:7603758. doi:10.1155/2017/7603758
  16. Kashikar-Zuck S, Carle A, Barnett K, et al. Longitudinal evaluation of patient-reported outcomes measurement information systems measures in pediatric chronic pain. Pain. 2016;157(2):339-347. doi:10.1097/j.pain.0000000000000378
  17. Forgeron PA, Evans J, McGrath PJ, Stevens B, Finley GA. Living with difference: exploring the social self of adolescents with chronic pain. Pain Res Manag. 2013;18(6):e115-e123. doi:10.1155/2013/120632
  18. Parsons RD, McParland JL, Halligan SL, Goubert L, Jordan A. Flourishing among adolescents living with chronic pain and their parents: A scoping review. Paediatr Neonatal Pain. 2022;4(4):158-168. doi:10.1002/pne2.12088
  19. Wild M, Nestor B. Associations Among Social Behavior, Pain Intensity, And Functional Outcomes In Adolescents. J Pain. 2023;24(4, Supplement):97. doi:10.1016/j.jpain.2023.02.277
  20. Jastrowski Mano KE, Beckmann EA, Fussner LM, Kashikar-Zuck S. Executive Functioning in Adolescents with Chronic Musculoskeletal Pain. Children. 2020;7(12). doi:10.3390/children7120273
  21. Ludwig NN, Sil S, Khowaja MK, Cohen LL, Dampier C. Executive Functioning Mediates the Relationship Between Pain Coping and Quality of Life in Youth With Sickle Cell Disease. J Pediatr Psychol. 2018;43(10):1160-1169. doi:10.1093/jpepsy/jsy057
  22. Pico M, Matey-Rodríguez C, Domínguez-García A, Menéndez H, Lista S, Santos-Lozano A. Healthcare Professionals’ Knowledge about Pediatric Chronic Pain: A Systematic Review. Children. 2023;10(4). doi:10.3390/children10040665
  23. Bhatia A, Brennan L, Abrahams M, Gilder F. Chronic pain in children in the UK: a survey of pain clinicians and general practitioners. Paediatr Anaesth. 2008;18(10):957-966. doi:10.1111/j.1460-9592.2008.02710.x
  24. Hassett AL, Hilliard PE, Goesling J, Clauw DJ, Harte SE, Brummett CM. Reports of chronic pain in childhood and adolescence among patients at a tertiary care pain clinic. J Pain. 2013;14(11):1390-1397. doi:10.1016/j.jpain.2013.06.010
  25. Dias LH, Miyamoto ST, Giovelli RA, de Magalhães CIM, Valim V. Pain and fatigue are predictors of quality of life in primary Sjögren’s syndrome. Adv Rheumatol. 2021;61(1):28. doi:10.1186/s42358-021-00181-9
  26. Mu W, Muriello M, Clemens JL, et al. Factors affecting quality of life in children and adolescents with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders. Am J Med Genet A. 2019;179(4):561-569. doi:10.1002/ajmg.a.61055
  27. Arnstad ED, Rypdal V, Peltoniemi S, et al. Early Self-Reported Pain in Juvenile Idiopathic Arthritis as Related to Long-Term Outcomes: Results From the Nordic Juvenile Idiopathic Arthritis Cohort Study. Arthritis Care Res . 2019;71(7):961-969. doi:10.1002/acr.23715
  28. Simons LE, Sieberg CB, Conroy C, et al. Children With Chronic Pain: Response Trajectories After Intensive Pain Rehabilitation Treatment. J Pain. 2018;19(2):207-218. doi:10.1016/j.jpain.2017.10.005
  29. Thorsell Cederberg J, Bartels SL, Thulin M, Beeckman M, Wicksell RK, Goubert L. Child and Parent Risk and Resilience Factors as Predictors of Long-term Recovery in Youth Undergoing Spinal Fusion Surgery. Clin J Pain. 2024;40(5):278-287. doi:10.1097/AJP.0000000000001200
  30. Langdon R, DiSabella M, Strelzik J, Fletcher A. Pediatric Migraine and Academics. Curr Pain Headache Rep. 2020;24(8):40. doi:10.1007/s11916-020-00869-5
  31. Cormier A, Mueri K, Pavlova M, et al. The sociocultural context of adolescent pain: portrayals of pain in popular adolescent media. Pain. Published online March 27, 2024. doi:10.1097/j.pain.0000000000003216
  32. Lee S, McMurtry CM, Summers C, Edwards K, Elik N, Lumley MN. Quality of Life in Youth With Chronic Pain: An Examination of Youth and Parent Resilience and Risk Factors. Clin J Pain. 2020;36(6):440-448. doi:10.1097/AJP.0000000000000820
  33. La Buissonnière-Ariza V, Hart D, Schneider SC, et al. Quality and Correlates of Peer Relationships in Youths with Chronic Pain. Child Psychiatry Hum Dev. 2018;49(6):865-874. doi:10.1007/s10578-018-0802-z
  34. Van Lierde E, Goubert L, Lammens T, Ben Brahim L, Van den Bussche E, Vervoort T. The Interplay of Parent and Child Coping Responses in Understanding Child Functioning in the Context of Living With a Parent With or Without Chronic Pain. Clin J Pain. 2020;36(4):238-248. doi:10.1097/AJP.0000000000000801
  35. Guidelines on the Management of Chronic Pain in Children. World Health Organization; 2020. https://www.ncbi.nlm.nih.gov/pubmed/33433967
  36. Windsor RB, Sierra M, Zappitelli M, McDaniel M. Beyond Amitriptyline: A Pediatric and Adolescent Oriented Narrative Review of the Analgesic Properties of Psychotropic Medications for the Treatment of Complex Pain and Headache Disorders. Children. 2020;7(12). doi:10.3390/children7120268
  37. Powers SW, Coffey CS, Chamberlin LA, et al. Trial of Amitriptyline, Topiramate, and Placebo for Pediatric Migraine. N Engl J Med. 2017;376(2):115-124. doi:10.1056/NEJMoa1610384
  38. Locher C, Kossowsky J, Koechlin H, et al. Efficacy, Safety, and Acceptability of Pharmacologic Treatments for Pediatric Migraine Prophylaxis: A Systematic Review and Network Meta-analysis. JAMA Pediatr. 2020;174(4):341-349. doi:10.1001/jamapediatrics.2019.5856
  39. Kossowsky J, Magane KM, Levy S, Weitzman ER. Marijuana Use to Address Symptoms and Side Effects by Youth With Chronic Medical Conditions. Pediatrics. 2021;147(3). doi:10.1542/peds.2020-021352
  40. Akbar A, Ford J, Tripathi S. The Use of Botulinum Toxin Type A in Medically Refractory Pediatric Patients With Chronic Daily Headaches and Its Impact on the Quality of Life. J Child Neurol. Published online February 13, 2024:8830738241227061. doi:10.1177/08830738241227061
  41. Horvat DE, Shields JM, Young WWC, Eye PG. Botulinum Toxin for Pediatric Migraine: A Retrospective Multisite Cohort Study. Pediatr Neurol. 2023;147:68-71. doi:10.1016/j.pediatrneurol.2023.07.005
  42. Coakley R, Bujoreanu S. Mobilizing the psychology evidence base for the treatment of pediatric chronic pain: The development, implementation, and impact of the Comfort Ability Program. Paediatr Neonatal Pain. 2020;2(4):148-159. doi:10.1002/pne2.12019
  43. Hale AE, Bujoreanu S, LaVigne TW, Coakley R. Rapid Mobilization of an Evidence-Based Psychological Intervention for Pediatric Pain during COVID-19: The Development and Deployment of the Comfort Ability® Program Virtual Intervention (CAP-V). Children. 2023;10(9). doi:10.3390/children10091523
  44. Palermo TM, Li R, Birnie KA, et al. Updated recommendations on measures for clinical trials in pediatric chronic pain: a multiphase approach from the Core Outcomes in Pediatric Persistent Pain (Core-OPPP) Workgroup. Pain. 2024;165(5):1086-1100. doi:10.1097/j.pain.0000000000003105
  45. Palermo TM, de la Vega R, Murray C, Law E, Zhou C. A digital health psychological intervention (WebMAP Mobile) for children and adolescents with chronic pain: results of a hybrid effectiveness-implementation stepped-wedge cluster randomized trial. Pain. 2020;161(12):2763-2774. doi:10.1097/j.pain.0000000000001994

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. Rehabilitation Approach to Adolescent Pain. 6/8/2021

Author Disclosures

Josue Martes
Nothing to Disclose

Glendaliz Bosques, MD
Nothing to Disclose