The prevalence of recurrent pain in childhood is high and increases with age

During the last decades several population-based surveys have shown a high prevalence of chronic pain among children and adolescents [1], [2], [3], [4], [5], [6], and more and more attention has been paid to this problem. The 2012 American Pain Society Position Statement, “Assessment and Management of Children with Chronic Pain”, indicates that chronic pain in children is the result of a dynamic integration of biological processes, psychological factors, and sociocultural variables, considered within a developmental trajectory. Furthermore, chronic pain includes persistent (ongoing) and recurrent (episodic) pain in children with underlying health conditions and pain that is the disorder itself [6]. Regarding when pain is the disorder itself, primary headache, nonspecific musculoskeletal pain, and functional abdominal pain are the three main categories. They include a number of conditions that have in common to have unknown cause, gradual onset without any clear event, and to some extent co-occur with other pain conditions and symptoms. Across 12–19 years of age, a comprehensive study found that weekly or more frequent rates ranged from 26–32% for headache, 14–22% for stomachache, 18–26% for backache, and 4–11% for multiple pain conditions [2]. Another study found that 4% of adolescents both had headache, abdominal pain, and musculoskeletal pain [5]. Further, many adolescents have multiple musculoskeletal pain conditions, and limb and neck-shoulder pain are in some studies as prevalent at back pain [4], [7].

In this number of Scandinavian Journal of Pain, one study by Gustafsson et al. focuses on recurrent neck-shoulder pain in school children aged 10–15 years, which they find as more prevalent than back pain. The authors present a piece of the puzzle showing that recurrent pain is prevalent in adolescents, increases with age and that girls are more affected regarding neck-shoulder pain. The same cohort of children were followed from the age of 10–15 years, and self-reported daytime sleepiness at the age of 10 predicted neck-shoulder pain at the age of 15.

The study by Gustafsson et al. also reveals that adolescents with recurrent pain have not only co-occurring pain symptoms, but also other types of symptoms as daytime sleepiness and psychological symptoms. The authors have collapsed depression, irritability, bad temper, nervousness, anxiety and dejection into one variable. By doing this merge, one may loose important information, since these symptoms are different. As recent research reveals, the co-occurrence of multiple symptoms could be a symptom cluster. A symptom clusters is defined as a stable group of two or more concurrent symptoms that are related to one another and independent of other symptom clusters [8]. It is assumable that these symptoms impact negatively on each other, and that relieving one of them can impact on the others. This point might be of value when discussing how to relieve pain in these schoolchildren.

A challenge for new studies is that children and adolescents with chronic pain often have both different types of pain conditions as well as many other symptoms. It does not mean that it is not important, as in this study, to concentrate on some symptoms, but the findings must be included in a more holistic approch, as expressed by Gustafsson et al. For example, in their study, it would be of great interest to know more about the participants’ sleep problems. Different studies should be put together, and new studies must include a broader range of symptoms.

A variety of risk factors have been found to be associated with chronic pain in adolescents. The greatest amount of evidence appears to support that anxiety, depression, subjective experience of stress, temperament, passive coping strategies, sleep problems, other somatic-related problems, and parent and/or family factors are important variables [9]. Further research should not only focus on one or few risk factors in isolation, but examine them together to understand the complex interactions.

As pointed out by Gustafsson et al., intervention and prevention of serious sleep problems should start early in collaboration between school nurses, teachers and parents. Future interventions should be directed towards prevention and non-pharmacological treatments of several early symptoms rather than procedures and medications. Prevention should start in childhood, not only to prevent chronicity in adolescents, but also hopefully to reduce chronic pain in adulthood.

Several studies indicate that chronic pain in youth incurs a high risk for the subsequent development of pain and psychological disorders later in life. Seventeen percent of adult chronic pain patients reported a history of chronic pain in childhood or adolescence, with close to 80% indicating that the pain in childhood continued and persisted until adulthood [10]. Studies further show that children with persistent abdominal pain and headaches go on to suffer more physical symptoms, anxiety and depression in adult life than healthy children [11], [12].

Based on this knowledge, a strength of the study of Gustafsson et al. is the longitudinal design, and hopefully the study should continue. Since retrospective studies are subject to recall bias, future research should follow the participants further into adulthood.