Welcome back to the Healing Pain Podcast with Anabela G. Silva PT, PhD

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Musculoskeletal Pain In Children And Adolescents With Anabela G. Silva PT, PhD

My guest is Dr. Anabela Silva. She is a Physiotherapist as well as an Adjunct Professor and the Director of the Physiotherapy Program at the University of Aveiro in Portugal. Her research interests include the effectiveness of pain, neuroscience education, exercise, and the exploration of factors associated with the onset of pain and the maintenance of pain in children and adolescents.

We’ll discuss some of her recent investigations regarding pain and children and adolescents. We’ll discuss the specific factors associated with the onset, the persistence of musculoskeletal pain in children and adolescents, and how to assess and identify these factors at an early age. Without further ado, let’s begin and let’s meet Dr. Silver and learn about pain in children and adolescents.

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Anabela, welcome to this episode of the show. It’s great to have you here.

It’s my pleasure to be here. Thank you for inviting me and I’m very excited to have this chat about the importance of looking at the factors associated with chronic pain in adolescents.

We are excited to have you here as well. We try to reach out to a broad range of professionals, especially physiotherapists from all around the globe. You are probably our first expert speaker from Portugal. We are excited to bring that international collaboration to this. The other thing that we are excited about here is to talk about musculoskeletal factors that impact children and adolescents because there’s still not a whole bunch in the literature.

It’s still relatively new as chronic pain research, in general, has started to arise in adults and non-cancer pain. We are also seeing the literature rise in children and adolescents trying to figure out the bio-psycho-social factors that impact them and what processes we can change in our patients. What’s the importance of knowing those factors that are associated with pain at an early age?

The amount of literature that is out there looking at children and adolescents is not that much compared to adults. Contrary to common belief, pain and chronic pain, in particular musculoskeletal chronic pain, is high in these age groups. If we look at the later adolescence, the figures can reach pretty much the figures that we see in adults.

In addition to that, some of the painful conditions I have been raising in terms of prevalence in the necks, the decades. For example, if we look at neck pain, the literature shows an increase in terms of prevalence for neck pain. We also have to consider the impact pain has at this age group, and we know that it impacts not only the relationships with the family and the peers but also school attendance and grades.

In addition to that, we also know that having pain in adolescents increases the odds of reporting pain in adults. Interestingly, some reports show that having pain during adolescence increases your probability of being a less successful adult, for example, in terms when looking at socioeconomic status.

In this age group, pain is not only highly prevalent, it also has a current impact but also a long-term impact. Knowing the factors that affect pain also helps us when designing preventive interventions and monitoring interventions. Hopefully, if they aren’t directed at the needs and characteristics of these age groups, they will at least have the chance of being more successful.

The work that you are leading and the work other researchers are leading looking at pain in children and adolescents helps us to gain some clarity around ways we can prevent pain from an early age. Ways we can identify pain in children and adolescents, so we can treat it early. If we can prevent, identify, and treat early, we can prevent its persistence into adulthood, leading to poor quality of life and resilience and poor growth in adults.

It’s important not only for this age group but also for helping transition to adults and minimizing the impact of pain in adults.

The word factor is thrown around a lot. You hear it in research and on the news. Maybe you can give us an overview of the factors that are starting to rise to the surface when we are looking at the severity and the maintenance of pain in children and adolescents.

We have conducted a number of studies looking at the different factors. Some of them with a more biomechanical nature, for example, posture or a physical activity. Also, psychosocial factors and our research and the research, in general, show that psychosocial factors include factors such as sleep, for example. They tend to be more relevant or at least explain a little bit more of the variance and the probability of reporting pain at a later stage, and also explain the high levels of pain associated and associated disability among the factors we have standardized.

For example, the time spent in terms of using a computer and other technologies. Also, physical activity and sleep. Psychosocial factors have a chance and self-efficacy, also fear of movement, for example. In our latest studies, we have also looked at central sensitization symptoms, which have been explored in adults but not in adolescence.

You mentioned postural factors and more factors related to physical capacity. Do those play a role? In the research on psychosocial factors, we know what they are at this point. You are mapping those to children and adolescents, but do we throw out the biomechanical factors in children and adolescents, especially since they have growing skeletons and a growing human body?

In the research that we have conducted, and we conducted a systematic review looking at the factors associated with pain, including the more biomechanical factors, we found no association between pain and posture. We have to look at the evidence with some reservations because the quality of the studies was not very good. Our evidence shows that posture is not a particularly relevant factor in terms of both pain intensity and maintenance in terms of long-term and probability.

These factors that we are talking about, is there a difference between the factors of onset of pain, so why pain begins versus the ones that cause pain to persist or become chronic, which would be those that typically persist more than 3 to 6 months?

I would say that there are similarities and differences. Some factors tend to be common to both models to go to the models that explore the association with the pain that I feel now and with the odds of reporting a new episode of chronic pain. It’s quite difficult to mop the research, including our studies with previous studies, because the variables that have been studied are relatively different. This is difficult to show.

In general, what seems to emerge from the research is that psychosocial factors are relevant both in terms of the pain that I report now, the disability associated with that pain, and the odds of reporting pain in the future. However, in this study that we have conducted looking at the factors that are associated with a new onset, we were a little bit puzzled. The only factor that remained in the model were symptoms of central sensitization, which included some questions that covered some psychosocial factors too. This might have been one of the reasons.

We are talking about children and adolescents, and that’s a broad term. We are identifying that pain does become persistent in children. Have we identified how young of an age this can begin, barring things like cancer? Childhood cancer could cause chronic pain, but if we look at musculoskeletal pain or what all of us, as physiotherapists, would identify as musculoskeletal pain, do you have an idea how young of an age that can start and when we start to see this?

In our group, we have not looked at that. We have worked mainly with adolescents with ages between 15 and 18 years old. Our examples were not that big. We found that almost half of the adolescents still report pain in a follow-up of six months, and approximately 40% of those that didn’t have pain will report being at a follow-up of six months. The figures are high, at least in our studies. Whether these figures are similar when we look into younger groups is not something that we have looked into.

I’d love to hear some research around that to see when we should intervene. How young should we be intervening and trying to educate children and their caregivers on factors that can cause pain to persist? The thing you have identified in your research is that neck pain has come up as one region where adolescents report pain over and over again. Are there other regions that we should be aware of other than neck pain?

Neck pain is quite interesting because when we think about the most prevalent painful body signs, we tend to think of low back pain. Our research has suggested that neck pain comes first when we look at this age group, and also, when we look at the evidence that is out there, there’s a very nice systematic review whose authors I can’t remember the name. They looked at the prevalence of neck pain at these age groups over the last decades. There is a constant trend towards an increase of neck pain prevalence and low back pain came second. Low back pain or thoracic pain come second to neck pain.

It’s similar to adults. Most adolescents do not report pain at a single body site. They tend to report pain at multiple body sites. What is quite interesting, one of the studies that we conducted looked at the association between painful body sites, especially when you also take into account psychosocial factors.

The results suggest that having a painful body site is more important in terms of association with other painful body sites. Psychosocial factors suggest that it is important to prevent pain because once you have one painful body site, then there is a tendency for the pain to spread. What we know from the neurophysiology of pain is that it’s something that is easily explained, but I would say that it reinforces the need for knowing more, designing, and assessing the effectiveness of preventive strategies targeting this age group.

The age group you are studying is about 15 to 18, so teenagers and adolescents. What should we start to look at with regard to the school setting? The teen years can be a stressful time for students. A lot of changes are happening in their life and physical body, which might lead us to think that maybe there is a more neurophysiological event that’s happening because puberty involves a number of hormonal changes, so we can’t ignore that. What factors are associated with pain in the school setting?

All those factors that you have mentioned are very important in looking at puberty stages. Although it’s a little bit difficult to implement because of the tools, the ones we should use to assess puberty levels are not easy. In addition to that, I would say that looking at the family’s history in terms of pain, it’s something that is likely to be very relevant in looking at self-efficacy in general, for example.

Also, genetics clearly also plays a role here. Looking at the sensitivity of the nervous system in general, not only related to being might be something that is also relevant. Looking for other complaints about the development, in general, might be factors that impacted or at least changed the probability of reporting pain.

We are now designing a study, looking and exploring a little bit more of the factors that we have not taken into account in our reviews and research, and exploring whether these factors are adding to the psychosocial variables are able to explain a little bit more in terms of probability of reporting pain in the future.

Is there anything else that we are missing along the life course of a child and adolescent? There are many things that come up. Anything that we are missing if a parent is reading this and they have a child who has pain and are saying, “Psychosocial factors, what does that mean?” What can I walk away from this episode with regard to helping their child or their adolescent finds a cure? We don’t want children to suffer and be in pain. A cure for their pain.

I would say that it is important to listen to them, to pay attention to them. Not too much attention either. This is a tricky question. We are not sure how parents should behave and how parents’ behavior impacts pain. One of the things we came across when recruiting students for our studies is that people generally believe they don’t have pain. This is an age group that is perfectly held into.

I had a few people asking me, “Why are you studying pain at this age group? For sure, they don’t have pain.” Listen to them. Try to understand how they feel both in terms of pain and in general, whether they are stressed or anxious and whether they are behaving in a way that is also adjusted to their pain. Try to find where they are not doing some of the things they would like to do that is normal that adolescents do when they are not doing them because of their pain.

I would say, from both a parent perspective, that we need to listen to what they say. If we find it appropriate to look for professional advice that can guide us as parents to help them both in terms of how we are addressing their complaints, but also someone that can educate our children and design and help them self-manage their pain also.

It’s interesting to think about the feedback that you receive, and why are you studying pain in such a young demographic. This makes us think that when people say that they think that pain only exists in people who are middle-aged or older, when in fact, we all have a nervous system and sometimes that nervous system becomes overloaded and the outcome of that could be chronic pain of various sorts.

It was quite interesting. I found that recruiting adolescents at a school setting was also a form of raising awareness. Weeks later, the same person would come and say, “Now that I have paid a little bit more attention to them, I have realized that some of them are in pain and that pain is interfering with some of their activities.” It is a way of raising awareness for pain in this age group so that people pay a little bit more attention and get asked for help when appropriate.

What are the clinical implications for physiotherapists and other practitioners when you start to put the pieces of your research together for them?

The overall key message would be that pain and chronic pain is achieving prevalence rates that are high despite this common sense that they don’t have pain. The other would be that we need to look at the person in a whole person approach instead of looking at the single body site in a biopsychosocial approach. We do have to look to the person, not the complaint or the body site where that complaint is being reported to.

These would be the two main things. There seem to be key factors that are relevant. For example, the anxiety or fear of movement. Sleep also seems to be something of an important factor in terms of pain maintenance. That should be part of our regular assessment of this age group. In a later study, we looked at the factors associated with pain. It seems to suggest that finding a tool that allows us to assess the sensitivity of the nervous system, in general, may also be a way to screen for those with a higher probability of reporting pain in the future. I would say that is probably something that we need to consider when assessing pain and its implications and designing programs aiming to prevent and manage pain in this group.

That was a question I had way back earlier in the episode here on our interview because you mentioned central sensitization. I’m not sure which self-report measure you use, but I think one that is validated for children, is that something that we should start to look at in our research or do we have that tool already?

We have used the central sensitization inventory that we have translated the English version to Portuguese and validated it in this age group.

In Portugal’s population?

Yes. We know that central sensitization inventory has some shortcomings, if I can say it that way. It’s not a bulletproofed instrument. It gives some indications, but we know that it’s also associated with psychosocial factors. What we are now looking at is we are designing the study where we are getting to quantitative sensory testing, which is a bit harder to have a larger sample using quantitative sensory testing. This is something that we are now looking at.

We are also exploring the association in this age group between the central sensitization inventory and GST and measures. That’s why I said earlier that we need to look very cautiously at our results because they have some limitations and using the central sensitization inventories is one of them. It’s a very practical tool that gives some indications.

When we looked at the items, we used both the total score of the instrument. Then we look at the items that were more strongly associated with the probability of reporting pain in the future. There were three items too more linked to the psychosocial aspects, and there was another item that is related to memory complaints. Those that reported pain in the long-term reported more difficulties with their memory.

The memory of learning, which is important for children.

That’s a practice that is important for that age group. We are now looking at a more general sense of central sensitization instruments in trying to see how they relate to the central sensitization inventory. When looking at those instruments and using those instruments, these associations are still in place or there are other associations that emerged from the data analysis.

As I sit here in the United States and you are there in Portugal, we should discuss the research that you are finding in that particular age range of 15 to 18-year-old adolescents. Is that consistent in what we would consider the “Western world,” as well as maybe third world countries that might have other factors that are working for or against the persistence of pain? What does the research say about that?

The research that is out there shows a high prevalence. The figures that have been published are slightly lower than those that we have found in our studies. I’m not sure how this can be explained, whether it’s more of a cultural thing or more related to the adolescent’s lifestyle that might be different across the country and certainly across continents. The results are not different, but the figures in terms of prevalence and pain reporting in terms of long-term are slightly lower in the studies that are out there when you compare them to our figures.

It also makes me think in certain countries is access to care is different, which might impact the statistics that we see in that particular age group.

That might be one explanation. The other explanation might be methodological because we asked a question for each body site in our studies. We clearly asked whether you have pain in the neck, shoulder, and lower back. Some of the studies use more general questionnaires. The methodology is not exactly the same. This also might be another explanation for the results that we see, but certainly, the question that you are raising is very important. Looking at whether different cultures, lifestyles, and access to care have an influence on these results is something that is very interesting.

Thank you for joining us and telling us about your growing research around the important factors associated with pain in adolescents. It’s an area that we will continue to follow because we need more research in this area if we can help children and adolescents and their families in the school settings where they function in. If people want to learn more about you and your work, how can they follow you?

Thank you again for inviting me. If people want to learn a little bit more about what I have been doing, they might find me in Orcid, Scopus and on Facebook. They can also email me if they want a little bit more detail about something or some of the studies that we have been in or conducting.

If you are interested in Anabela’s work, you can reach out to her. You can also follow me on Instagram. My handle is @DrJoeTatta, where I post all of our episodes and little snippets of the videos that we recorded together. Make sure you hop on over there. If you enjoy this episode, take a screenshot and tag me on Instagram and I will make sure to tag you back. I will see you next episode.

Important Links

• Dr. Anabela Silva
• Orcid
• Scopus
• @DrJoeTatta – Instagram

About Anabela G Silva

Anabela G Silva, physiotherapist and Adjunct Professor (PhD) at the School of Health Sciences, University of Aveiro, Portugal, for over 20 years. She is the Director of the BSC in Physiotherapy and of the Postgraduation in Musculoskeletal Physiotherapy. Member of the executive board of the Special Interest Group on Pain, Mind, and Movement, International Association for the Study of Pain. She has 110 Scopus indexed publications and has presented at national and international conferences. She serves as Associate Editor and reviewer for a number of journals on a regular basis. Her research interests include the effectiveness of pain neuroscience education and exercise and the exploration of factors associated with pain onset and maintenance in children and adolescents.