Adolescence is the period of time following the onset of puberty when a child develops into an adult and involves many physical, mental and emotional changes. Adolescent pain is multidimensional involving “sensory, emotional, cognitive, and behavioral components that are interrelated with environmental, developmental, sociocultural, and contextual factors.”1 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.2
Acute pain-less than 30 days: Most frequently related to a musculoskeletal problem, trauma or peri-operative pain.
Chronic pain-more than three months: Common diagnoses are juvenile fibromyalgia, chronic headaches, irritable bowel syndrome/functional abdominal pain syndrome, complex regional pain syndrome (CRPS), chronic musculoskeletal pain, hypermobility/Ehlers-Danlos syndrome, juvenile idiopathic arthritis, neuromuscular diseases, sickle cell disease, migraines and cancer. 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.3
Epidemiology including risk factors and primary prevention
Chronic pain is common among adolescents and has been shown to affect 20-25% of adolescents. 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 but 5% of children are severely affected impacting their school attendance, mental/emotional health, interpersonal relationships with friends and family and leisure activities.4
Risk factors include obesity, drug or alcohol abuse, dysfunctional family dynamics, aberrant psychosocial behavior, depression, anxiety and poor coping skills. 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.
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. 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 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
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
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 is also common among adolescents suffering from chronic pain.
2. ESSENTIALS OF ASSESSMENT
- A detailed history that includes pain characteristics, functional impact, previous analgesic treatments, previous pain events, comorbidities (including mental health issues) and psychosocial dynamics.
- Pain measurement using an assessment tool which is developmentally and age 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.
- Family history including history of chronic pain conditions or any psychiatric illnesses.
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. 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.
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.
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, rheumatoid factor, ANA if there is concern for an underlying rheumatology component and CRP, ESRif there is an inflammatory process.
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. 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 partient’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.
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.
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.
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.
All treatable sources of pain should be identified in a timely fashion to minimize unwanted permanent and/or long term functional disability. 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.
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
- Facilitate an interdisciplinary and comprehensive approach.
- Educate patient and family on pain and treatment options.
- Establish a diagnosis when possible.
- Establish common goals.
- Target specific symptoms to optimize function.
- Reestablish function through the use of graded exposure, desensitization and shaping of healthy behaviors, focus on functionality and less on pain.
- Incorporate family and school/community interventions.
- Apply pharmacotherapy as needed.
- Incorporate physical therapy/aerobic exercise.
- Incorporate psychotherapy.
- Incorporate psychiatry assessment as needed.
- Perform specific interventional procedures to alleviate pain if deemed necessary and potentially beneficial
- Hypnotherapy and alternative therapies are optional due to weak evidence on effectiveness.
At different disease stages
- Nonsteroidal anti-inflammatories, acetaminophen, muscle relaxants
- Regional nerve blocks after surgical procedures
- Physical 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 anxiolitics 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.
- Monoamine uptake inhibitors (MOAI), 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.
- 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.
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.
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.
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.
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.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge 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.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
- Classification of children or adolescents with pain by specific risk factors or identifiable bio-markers that explain who or why some will develop chronic pain over time and what interventions could be provided to minimize this process with its disabling features.
- Identification of interventions unique to adolescents in the management of pain.
- Studies of medications and interventions utilized and approved for pain management in adults to evaluate appropriateness, efficacy and safety in adolescents.
- Data regarding long-term opioid use among adolescents and its side effects and risk for addiction.
- 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)
- “Complex Reginal Pain Syndrome Fact Sheet” NINDS, January 2017, NIH Publication No. 17-4173
- Huguet A, Miró J. The severity of chronic pediatric pain: an epidemiological study. J Pain. 2008;9(3):226–236
- WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children with Medical Illnesses. Geneva: World Health Organization; 2012.
- Bhatia, A., Brennan, L., Abrahams, M., & Gilder, F. (2008). Chronic pain in children in UK: A survey of pain clinicians and general practitioners. Paediatric Anesthesia, 18(10), 957-966.
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Original Version of the Topic
Tamara Zagustin, MD. Rehabilitation Approach to Adolescent Pain. 11/11/2011.
Daniel Sova, MD
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Ashot Kotcharian, MD
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M-Irfan Suleman, MD
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