From One Pain to Many: The Emergence of Overlapping Pains in Children and Adolescents

Adverse childhood experiences and multisite pain among adolescents in the United States

Introduction

Childhood adversity can have a lasting negative impact throughout one's life. Youth with pain conditions consistently report a higher rate of adverse childhood experiences (ACEs) when compared with their healthy peers. Adolescents experiencing pain in more than 1 region tend to have greater symptom burden and reduced quality of life. Research on the association between ACEs and multisite pain in adolescents is sparse.

Objectives

The objective of our study was to investigate the association between cumulative ACEs and self-report of multisite pain in early adolescence using data from the Adolescent Brain Cognitive Development study.

Methods

We used a 19-region body map to evaluate the presence of regional pain (1-2 regions) and multisite pain (≥3 regions). We analyzed data using multinominal logistic regression, adjusting for sociodemographic factors including pubertal status, sex, race/ethnicity, and income-to-needs ratio.

Results

We included a total of 7582 children aged 12 to 13 years, with 33.4%, 24.0%, 13.2%, and 8.6% reporting 1, 2, 3, and 4+ ACEs, respectively. Moreover, 30.7%, 24.2%, 15.2%, and 10.1% of children with multisite pain reported 1, 2, 3, and 4+ ACEs, respectively. Those with 4+ ACEs (adjusted odds ratio 1.62, 95% confidence interval 1.24-2.12) and 3 ACEs (adjusted odds ratio 1.44, 95% confidence interval 1.14-1.82) were more likely to report multisite pain compared with the children with no ACEs.

Conclusion

We showed a potential dose-response relationship between cumulative ACEs and multisite pain, suggesting that the impact of ACEs on pain, particularly multisite pain, may emerge earlier than previously documented. Keywords: Adverse childhood experiences, Multisite pain, Adolescent pain.

Youth with high-frequency headaches due to migraine are more vulnerable to non-cephalic pain complaints

We examined clinic data from a large sample of children and teens with migraine to see how common it was for these patients to also experience other types of body pain. We found that almost one quarter of youth with migraine also reported pain in an additional body location; youth with more frequent and severe headaches were more likely to have pain in body locations besides the head, with youth with constant or continuous headache being most at risk for additional body pain difficulties. Youth with migraine headaches that are severe or happen a lot of the time should be evaluated for other body pain to make sure that they get all the medical care they need to best manage pain.

Sociodemographically Differential Patterns of Chronic Pain Progression Revealed by Analyzing the All of Us Research Program Data

The differential progression of ten chronic overlapping pain conditions (COPC) and four comorbid mental disorders across demographic groups have rarely been reported in the literature. To fill in this gap, we conducted retrospective cohort analyses using All of Us Research Program data from 1970 to 2023. Separate cohorts were created to assess the differential patterns across sex, race, and ethnicity. Logistic regression models, controlling for demographic variables and household income level, were employed to identify significant sociodemographic factors associated with the differential progression from one COPC or mental condition to another. Among the 139 frequent disease pairs, we identified group-specific patterns in 15 progression pathways. Black or African Americans with a COPC condition had a significantly increased association in progression to other COPCs (CLBP->IBS, CLBP->MHA, or IBS->MHA, OR≥1.25, adj.p≤4.0x10-3) or mental disorders (CLBP->anxiety, CLBP->depression, MHA->anxiety, MHA->depression, OR≥1.25, adj.p≤1.9x10-2) after developing a COPC. Females had an increased likelihood of chronic low back pain after anxiety and depression (OR≥1.12, adj.p≤1.5x10-2). Additionally, the lowest income bracket was associated with an increased risk of developing another COPC from a COPC (CLBP->MHA, IBS->MHA, MHA->CLBP, or MHA->IBS, OR≥1.44, adj.p≤2.6x10-2) or from a mental disorder (depression->MHA, depression->CLBP, anxiety->CLBP, or anxiety->IBS, OR≥1.50, adj.p≤2.0x10-2), as well as developing a mental disorder after a COPC (CLBP->depression, CBLP->anxiety, MHA->anxiety, OR=1.37, adj.p≤1.6x10-2). To our knowledge, this is the first study that unveils the sociodemographic influence on COPC progression. These findings suggest the importance of considering sociodemographic factors to achieve optimal prognostication and preemptive management of COPCs.

Influence of chronotype on pain incidence during early adolescence

ABSTRACT

During adolescence major shifts in sleep and circadian systems occur with a notable circadian phase delay. Yet, the circadian influence on pain during early adolescence is largely unknown. Using 2 years of data from the Adolescent Brain Cognitive Development study, we investigated the impact of chronotype on pain incidence, moderate-to-severe pain, and multiregion pain 1 year later in U.S. adolescents. Based on the Munich ChronoType Questionnaire, chronotype was calculated as the midpoint between sleep onset and offset on free days, corrected for sleep debt over the week. Adolescents reported pain presence over the past month, and if present, rated pain intensity (0-10 numerical rating scale; ≥ 4 defined as moderate-to-severe pain) and body site locations (Collaborative Health Outcomes Information Registry Body Map; ≥2 regions defined as multiregion pain). Three-level random intercept logistic regression models were specified for each pain outcome, adjusting for baseline sociodemographic and developmental characteristics. Among 5991 initially pain-free adolescents (mean age 12.0 years, SD 0.7), the mean chronotype was 3:59 am (SD 97 minutes), and the 1-year incidence of pain, moderate-to-severe pain, and multiregion pain was 24.4%, 15.2%, and 13.5%, respectively. Each hour later chronotype at baseline was associated with higher odds of developing any pain (odds ratio [OR] = 1.06, 95% confidence interval [CI] = 1.01, 1.11), moderate-to-severe pain (OR = 1.10, 95% CI = 1.05-1.17), and multiregion pain (OR = 1.08, 95% CI = 1.02-1.14) during 1-year follow-up. In this diverse U.S. adolescent sample, later chronotype predicted higher incidence of new-onset pain.

The Children's Somatic Symptoms Inventory-8: Psychometric Properties of a Brief Measure of Somatic Distress

BACKGROUND

Children often present to primary and specialty care clinics with multiple somatic symptoms of nonspecific origin that can be highly distressing and prompt significant health service use. We evaluated the psychometric properties of the eight-item Children's Somatic Symptoms Inventory (CSSI-8) as a brief measure of somatic distress that could be easily integrated into clinical systems.

METHOD

Eight items from the 24-item CSSI were selected based on their representation of multiple bodily systems, association with high base rates, and ability to maximize the separation of the items' Rasch measure scores. The psychometric quality of the eight-item scale was evaluated in 876 pediatric patients with chronic abdominal pain and a nonclinical sample of 954 school children using methods from three psychometric models (the classical test theory, Rasch modeling, and confirmatory factor analysis).

RESULTS

The CSSI-8 showed good measurement properties on an extensive array of psychometric criteria, had adequate Rasch person separation reliability for a brief instrument (rsep = 0.74-0.75), and distinguished between clinical and nonclinical youth. Girls in both groups had significantly higher CSSI-8 scores than boys. Norms for the clinical sample are presented.

CONCLUSIONS

The CSSI-8 is a psychometrically sound measure suitable for use as a brief dimensional assessment of pediatric somatic distress.

Pediatric Pain

OBJECTIVE

This article reviews pain disorders encountered in pediatric neurology practice and provides current information regarding the assessment and treatment of pediatric chronic pain.

LATEST DEVELOPMENTS

Data about pediatric pain management remain sparse, owing to a dearth of controlled trials and longitudinal studies in these patients. However, the field of pain management and understanding of central and peripheral pain processing has expanded to allow more effective treatment of a broad group of children and adolescents with pain associated with neurologic disease. Neuroimaging visualizes sensory and nonsensory systems, and genetic markers of sensitivity and disease may guide specific therapy. The concept of central sensitization in chronic pain disorders has supported the development of multidisciplinary paradigms for the comprehensive care of these patients.

ESSENTIAL POINTS

Pain involves sensory activation and central nervous system modulation in pediatric patients. Pediatric neurologists should be prepared to define, investigate, and treat pain disorders in this complex patient population. Appropriate interventions during childhood may attenuate or prevent chronic pain later in life. Current interventions include behavioral, physical, and pharmacologic approaches, as well as potential noninvasive tools for neuromodulation. Research is progressing in sensory measurement, neuroimaging, genetics, and neuroinflammation to guide future targeted therapies.

Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion

It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated with restricted neural mobility. Intermittent (dynamic) nature of cPNL may be essential in chronic pain, because healed (i.e., fibrotic) lesions are physiologically silent and, consequently, cannot provide nociceptive input. Not all patients may be equally susceptible to develop cPNL, because occurrence of cPNL may vary as vary patients' predisposition to musculoskeletal impairment. Sensitization is accompanied by pressure pain threshold decrease and consequent mechanical allodynia and hyperalgesia, which can cause unusual local pain via natural pressure exerted by space occupying lesions or by their examination. Worsening of local pain is similarly explainable. Neuroma pain may be due to cPNL-induced axonal mechanical sensitivity and hypersensitivity of the nociceptive nervi nervorum of the nerve trunk and its stump. Intermittence and symptomatic complexity of cPNL may be the cause of frequent misdiagnosis of chronic pain.

Pain Widespreadedness, and Not Primary Pain Location, is Associated With Comorbid Symptoms in Children With Chronic Pain

OBJECTIVES

Pediatric chronic pain represents heterogeneous diagnoses; often, primary pain location informs research classifications and treatment. In contrast, recent research has highlighted the role of widespread pain and this perspective has been adopted in assessments in specialty pediatric pain clinics. The lack of direct comparison between these 2 methods of categorizing pediatric chronic pain may hinder the adoption of evidence-based practices across the spectrum of care. Therefore, this study aimed to compare whether primary pain location or pain widespreadedness is more informative for pain-related symptoms in pediatric chronic pain.

METHODS

Youth (n=223) between the ages of 8 to 23 years (M=15.93, SD=2.11, 83% female) completed surveys upon intake at the pediatric chronic pain clinic. Free-text entries of primary pain location were coded into categories: headache, abdominal pain, and musculoskeletal pain. Additional domains assessed included widespread pain, pain interference, kinesiophobia, catastrophizing, anxiety, depression, sleep, and fatigue.

RESULTS

Differences based on primary pain location only emerged for kinesiophobia, F(2150)=8.20, P<0.001, with the highest scores among those with musculoskeletal pain. In contrast, controlling for sex, age, and pain intensity, pain widespreadedness was associated with pain interference, pain catastrophizing, fatigue, anxiety, and depression (P<0.05).

DISCUSSION

Pain widespreadedness was more consistently associated with pain-related outcomes among pediatric chronic pain patients than primary pain location, and body maps may be useful in determining a nociplastic pain mechanism to inform treatment. Improved assessment of pediatric pain mechanisms may help advance more precise treatment delivery.

Biopsychosocial Attributes of Single-region and Multi-region Body Pain During Early Adolescence: Analysis of the ABCD Cohort

OBJECTIVES

Multi-region pain during adolescence is associated with a higher symptom burden and lower quality of life. The purpose of this study was to describe and compare the biopsychosocial attributes of single-region and multi-region pain among healthy young adolescents.

MATERIALS AND METHODS

We analyzed data from 10,320 children aged 10.6 to 14 years who self-reported pain in the Adolescent Brain and Cognitive Development Study. Pain was coded as single-region or multi-region based on body map data.

RESULTS

One in 5 young adolescents indicated recent multi-region pain. Sequential regression supported improved model fit when psychological and sociocultural factors were added to a biological model of pain; however, these models improved the classification of multi-region but not single-region pain. A significant interaction effect of sex and puberty remained constant across models with increased odds of pain at each advancing pubertal stage for both sexes compared with prepuberty, but no difference between girls and boys at late puberty (adjusted odds ratio [OR]=2.45 [1.72, 3.49] and adjusted OR=1.63 [1.20, 2.23], respectively). Psychological factors improved the classification of multi-region pain with significant effects of anxiety, somatic symptoms, and somnolence. Finally, compared with White and non-Hispanic children, Black and Hispanic children were less likely to report pain (adjusted OR=0.70 [0.61, 0.80]; adjusted OR=0.88 [0.78, 0.99], respectively) but had significantly higher pain interference when pain was present (adjusted OR=1.49 [1.29, 1.73] and adjusted OR=1.20 [1.06, 1.35], respectively).

DISCUSSION

Pain is a biopsychosocial phenomenon, but psychological and sociocultural features may be more relevant for multi-region compared with single-region pain during early adolescence.

Functional improvement in children and adolescents with primary headache after an interdisciplinary multimodal therapy program: the DreKiP study

BACKGROUND

More than 2/3 of children and adolescents in Germany regularly suffer from headaches. Headache-related limitations in everyday life, school drop-out and educational impairment are common. Structured therapy programs for young headache patients are widely missing.

METHODS

One hundred eleven patients with frequent migraine and/or tension type headache were treated in a 15 hour group program in afternoons, parallel with school, parents received 7 hours of therapy. At the beginning of the program (T0), 6 (T1) and 12 months (T2) after completion, data on headache related disability (PedMidas), headache frequency, intensity, and pediatric pain disability score (PPDI) were prospectively collected to investigate the effects of the therapy.

RESULTS

Seventy-five patients (9-19 years, median = 14; 66.7% female) and their parents provided patient reported outcome measures showing at T1 (65 patients) and T2 (47 patients) reduced headache frequency (last 3 months headache days median T0: 30 days; T1: 18 days, reduction of median 12 days since T0; T2: 13 days, reduction of median 17 days since T0). Linear mixed models revealed significant reduction (T0/T1 p = 0,002; T0/T2 p = 0,001). Reduced headache disability has been reported at T1 and T2 (PedMidas median T0 = 30, T1 = 15, T2 = 7; p < 0,001, p < 0,001 respectively). Follow up data of a subgroup of patients 24 months after the treatment point to sustainable effects.

CONCLUSIONS

The interdisciplinary multimodal headache therapy program DreKiP reduces headache frequency and headache related disability significantly 6-12 months following its completion.

TRIAL REGISTRATION

DRKS00027523, retrospectively registered.