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]