Adolescent chronic pain and functional symptoms — branching viva

Stem

The examiner will test whether you can run a validating, function-first chronic-pain pathway under pressure — refusing both over-investigation and dismissal. [1] [2]

Branch 1 — First presentation and validation

Examiner: A 15-year-old has had daily widespread pain, broken sleep and four months of increasing school absence, with normal bloods and a normal spine MRI. The mother is convinced something is being missed. What do you do first? [1]

Strong answer: See the adolescent alone, state conditional confidentiality with its lawful limits, and validate that the pain is real and not her fault. Take a focused pain history and a HEEADSSS-tailored psychosocial history (mood, sleep, school, peers, family, adversity), screen for suicidality, and examine for allodynia and hyperalgesia with a neurological screen. Screen once for red flags — weight loss, failure to grow, systemic features, new neurological deficit, nocturnal pain — and, with the normal tests already in hand, avoid a further cascade. [1] [8]

Branch 2 — Reframing with central sensitisation

Examiner: The mother asks, "If the tests are normal, what is wrong with her?" How do you explain this? [3]

Strong answer: Explain central sensitisation — the nervous system has become more responsive to normal input, so ordinary movement and touch generate amplified pain; the problem is altered processing, not ongoing damage. Reframe the normal tests as "reassuring because her body is healthy, not because nothing is wrong." Avoid "it is all in her head." This validation is itself therapeutic and opens the recovery pathway. [3] [1]

Branch 3 — The function-first interdisciplinary plan

Examiner: Walk me through your management plan. [4]

Strong answer: Set shared functional goals (school, sleep, movement, friends), not a pain-elimination target. Coordinate physiotherapy (graded activity and exposure — movement is the medicine), psychology (CBT or ACT; Cochrane evidence shows psychological therapies reduce pain and disability), a sleep reset, and a graded school-led return-to-school plan. Treat comorbid mood. Use simple analgesia adjunctively within local guidance; state that opioids generally have no place in chronic primary adolescent pain. [4] [5]

Branch 4 — School absence and family factors

Examiner: She has stopped attending school entirely. The family accommodates her staying home. What is your approach? [6]

Strong answer: Treat school absence as a clinical marker of severity and a primary treatment target, not a coping choice. Build a graded, school-led return-to-school plan with education liaison. Engage the family without blame: parental distress and inadvertent sick-role reinforcement perpetuate disability, so the family is part of the intervention. Logan and colleagues show school impairment tracks severity and recovery, and family factors shape school functioning. [6] [7]

Branch 5 — Red-flag challenge

Examiner: Six weeks later she reports new weight loss and pain waking her from sleep. How does this change your plan? [8]

Strong answer: These are red flags that override a pure functional frame. Re-enter the diagnostic pathway with targeted bloods (including inflammatory markers) and directed imaging for the specific concern; reassess for organic disease, including malignancy and inflammatory illness. Do not abandon the functional plan if organic disease is again excluded, but never let a functional label stop you from thinking — document the reassessment and the reasoning. [8] [1]

Branch 6 — Crisis: suicidality

Examiner: She now discloses thoughts of ending her life because the pain will not stop. [1]

Strong answer: Do not leave her alone. Perform a same-visit suicide and safety assessment — ideation, plan, intent, means, prior attempts, protective factors — remove means, and arrange urgent mental-health or crisis pathway care. Chronic pain and self-harm cluster, so this is a recognised emergency. Document the safety plan and who was informed, and tell her what you must do and why. [1]

Examiner extras

• Function is the goal, not pain elimination — say it early. [1]
• School reintegration is a clinical outcome, not an administrative detail. [6]
• Opioids have no routine place in chronic primary adolescent pain. [1]
• Always assess suicidality in a distressed adolescent with chronic pain. [1]
• Never dismiss the pain as "just stress," and never let a functional label stop you from ruling out organic disease once. [8] [3]