Adolescent chronic pain and functional symptoms — formative SAQs

SAQ 1 — 15-year-old with four months of widespread pain and school absence (10 marks)

A 15-year-old girl presents with four months of daily widespread body pain, broken sleep, fatigue and gradually increasing school absence (now attending only two days a week). She has had normal blood tests and a normal MRI of her spine. She and her mother are distressed and convinced "something is being missed." She has low mood but no current self-harm plan. [1] [2]

Questions

1. Outline your initial assessment, including the key elements of the history, examination and the red flags you must screen for once. (4 marks) [1]
2. Explain the concept of central sensitisation in language you would use with this adolescent and family, and why the normal investigations are reassuring rather than dismissive. (3 marks) [3]
3. Describe the function-first interdisciplinary management plan, including the role of opioids. (3 marks) [4]

Model answer

Assessment (4). Secure time alone and validate the pain as real; take a focused pain history (onset, distribution, course, triggers, previous investigations) and a HEEADSSS-tailored psychosocial history emphasising mood, sleep, school attendance, peers and family function; screen for suicidality at this contact. Examine generally and the affected regions, looking for allodynia and hyperalgesia, and complete a neurological screen. Screen once for red flags — weight loss, failure to grow, fever or night sweats, a new or progressive neurological deficit, and nocturnal pain waking from sleep — with targeted tests; normal results already available make further imaging low-value without a new red flag. [1] [8]

Central sensitisation explanation (3). Explain that the nervous system has become more responsive to normal input, so ordinary touch, movement and temperature generate pain and a small stimulus is amplified — the problem is altered processing rather than ongoing tissue damage. Frame the normal tests as "reassuring because they show your body is healthy, not because nothing is wrong," which validates the symptom as real while opening a recovery pathway. Avoid stigmatising language such as "it is all in your head." [3] [1]

Function-first interdisciplinary plan (3). Set shared functional goals (school, sleep, movement, friends), explicitly not a pain-elimination goal. Coordinate physiotherapy (graded activity and exposure — movement is the medicine), psychology (cognitive behavioural or acceptance-and-commitment therapy, with Cochrane evidence for reducing pain and disability), a sleep reset, and a graded school-led return-to-school plan with education liaison. Treat comorbid low mood. State that opioids generally have no place in chronic primary adolescent pain because the risks of dependence and adverse effects outweigh any long-term benefit; simple analgesia may be adjunctive within local guidance. [4] [6]

SAQ 2 — Adolescent with complex regional pain syndrome refractory to outpatient care (10 marks)

A 14-year-old has had severe right leg pain for three months after a minor ankle sprain. The leg is cool, discoloured and exquisitely tender to light touch; she cannot weight-bear and uses crutches. She has not attended school for six weeks and is becoming socially withdrawn. Targeted bloods and imaging have excluded fracture and infection. [8] [1]

Questions

1. What is the most likely diagnosis, and how do you distinguish it from ongoing tissue injury? (3 marks) [8]
2. Outline the definitive interdisciplinary management and the indications for intensive rehabilitation. (4 marks) [1]
3. How do you address the school absence and the family's expectation of further investigation? (3 marks) [6]

Model answer

Diagnosis (3). Complex regional pain syndrome, within the spectrum of amplified musculoskeletal pain. The features — severe limb pain out of proportion to the original injury, allodynia, colour and temperature change, trophic change and impaired function — fit CRPS, and the normal imaging and exclusion of fracture and infection distinguish it from ongoing tissue injury. Explain to the family that the limb's changes reflect altered nervous-system processing rather than a new injury, and that the pain is real. [8]

Interdisciplinary management (4). The cornerstone is early mobilisation and graded exposure through physiotherapy — desensitisation and progressive weight-bearing reverse deconditioning and retrain the nervous system — supported by psychology (CBT/ACT for pain-related fear and catastrophising) and a sleep reset. Simple analgesia within local guidance is adjunctive; opioids are avoided. Intensive interdisciplinary pain rehabilitation (day-program or inpatient) is indicated for refractory presentations, complete school absence or severe disability, and works because it interrupts the fear-avoidance loop on every front at once. [1]

School absence and family expectations (3). Treat the six-week absence as a clinical marker of severity and a primary treatment target; build a graded, school-led return-to-school plan with education liaison, since Logan and colleagues show school impairment tracks severity and recovery. Address the family's expectation of further investigation by validating that the suffering is real and the targeted exclusion is complete, then bring them into the sensitisation explanation gradually rather than arguing — further imaging without a new red flag is low-value and reinforces a disease model. [6] [7]