Chronic primary and secondary pain in children: Viva

This is a branching oral built to probe the reasoning that places a biopsychosocial explanation and an interdisciplinary rehabilitation plan at the centre, and to expose the candidate who reaches for analgesia and more scans instead. The questions escalate from the framing to the assessment, the plan, the opioid counselling, and the special scenarios. [7]

Opening question: framing the problem

The examiner opens with the eight-month history and the folder of normal tests, and asks how you frame this in a single sentence, and what the diagnosis is. [1]

A strong answer names chronic primary pain, defines it by the three-month threshold, and explains that the normal tests are exactly what is expected because the mechanism is nociplastic. [2]

Model answer. This is chronic primary pain, ICD-11 code MG30.0: pain in multiple regions for more than three months with significant distress and functional disability that is not better explained by another condition. The mechanism is nociplastic, driven by central sensitisation, which is why the tests are normal and the pain is nonetheless real. The disability, with two days of school a week, is the part that needs urgent attention. [1][2]

Probe one: the mechanism

The examiner presses on what central sensitisation actually is, and why the pain moves between sites. [1]

A strong answer explains that after prolonged nociceptive input the spinal cord and brain become more responsive, the threshold for pain drops, allodynia and hyperalgesia develop, and descending inhibition weakens. The pain migrates because the sensitised system is not tied to one injured tissue; it generates pain across regions. [1]

Pitfall probe. The examiner asks why the normal magnetic resonance image does not contradict the pain. Because nociplastic pain is altered nervous-system function without ongoing tissue damage, so a normal scan is the expected finding and is used to reassure the family that there is no dangerous disease, not to dismiss the pain. [7]

Probe two: the assessment and red flags

The examiner asks exactly what you assess and what red flags you hunt for before accepting the primary pain diagnosis. [7]

A strong answer covers the seven biopsychosocial domains of pain, mood, sleep, school and activity, family response and history, prior treatments, and the child's goals, and names the red flags of weight loss, night pain, fever, fatigue out of proportion, neurological signs, bowel or bladder dysfunction, and raised inflammatory markers. [7]

Pitfall probe. What would change your plan? Any red flag would demand investigation for malignancy, inflammatory disease, infection or structural neurological disease before a primary pain diagnosis is accepted. Their documented absence is what allows the rehabilitation plan to proceed with confidence. [7]

Probe three: the rehabilitation plan

The examiner asks you to build the plan, and to state the goal. [7]

A strong answer states that the goal is restored function, sleep, mood, school and participation, not a pain score of zero, and builds three pillars: graded physical reactivation with pacing, a sleep and routine plan, and a staged return to school; psychological therapy, chiefly cognitive behavioural therapy or acceptance and commitment therapy, the best-evidenced intervention; and judicious, mechanism-based pharmacology. [7][9]

Pitfall probe. Why is the return to school treated as a treatment, not just a goal? Because school return is both a marker and a driver of recovery; the child who is back at school is re-engaging with normal activity and the nervous system is being retrained by doing. [7]

Branch one: the request for stronger painkillers

The examiner pivots to the mother's request for stronger painkillers and asks how you respond. [7]

A strong answer states that opioids are not recommended for chronic primary, non-cancer pain in children, that the WHO 2020 guidelines do not recommend initiating strong opioids for chronic primary pain, and that the harms of dependence, adverse effects and lost function outweigh any absent benefit. The request is reframed into the recovery plan of movement, sleep, mood and school, with full validation that the pain is real. [7]

Branch two: juvenile fibromyalgia

The examiner asks how the picture would change if this were a clear juvenile fibromyalgia, and how it is managed. [11]

A strong answer describes the widespread pain with severe fatigue, unrefreshing sleep and cognitive fog, confirms the diagnosis clinically after exclusion of inflammatory and endocrine disease, and manages it with an aerobic exercise, sleep and cognitive behavioural programme that improves function even when pain persists. [11]

Branch three: complex regional pain syndrome

The examiner pivots to an eleven-year-old with a painful, cold, swollen, guarded limb after a minor ankle sprain and asks what it is and the cornerstone of management. [7]

A strong answer names complex regional pain syndrome type one, with sensory, vasomotor and motor changes and no nerve lesion, and states that the cornerstone is early active mobilisation and graded sensory-motor therapy; prolonged immobilisation, casting and escalating procedures worsen outcomes. [7]

Branch four: chronic secondary pain in serious illness

The examiner asks how the approach changes for a child with a life-limiting illness and chronic pain. [1]

A strong answer states that the frame shifts to chronic secondary and palliative pain: the disease is the driver, appropriate analgesia including opioids is legitimate and often necessary, and the goal shifts from rehabilitation to comfort and quality of life, while the biopsychosocial principles of mood, family and function still apply. [1]

Closing question: counselling the family

The examiner closes by asking how you explain all this to the family in a way they can hold. [7]

A strong answer describes the validating reframe: the pain is real, it is generated by a sensitised nervous system, the tests are normal because there is no dangerous disease, and the way out is movement, sleep, mood and school, not a prescription. Delivered with conviction and a written plan, that conversation is often the first step of recovery. [7]