Pain flares in adolescents with inflammatory and non-inflammatory musculoskeletal disorders

  • Sonia Khanom

Student thesis: Phd


Background: Musculoskeletal pain represents one of the top three presentations to primary care among adolescents. Juvenile idiopathic arthritis (JIA) is an inflammatory rheumatic disorder that can cause musculoskeletal pain in this age group. However, even when underlying disease processes are controlled for with medication, adolescents with JIA continue to report pain. In paediatric rheumatology settings, adolescents also present with pain of a non-inflammatory origin and of which no obvious organic cause can be found; these are referred to as chronic idiopathic pain syndromes (CIPS). Pain (both inflammatory and non-inflammatory) tends to be persistent, but is dynamic and undergoes periods of acute exacerbation or worsening, colloquially referred to as pain flares by patients and clinicians. These pain flares may be unrelated to disease activity and can negatively impact adolescents' lives, including their level of confidence, identity and independence in daily living and social activities. It is therefore important to target interventions and treatments specifically to reduce pain flare severity and/or frequency, and the impact of pain flares on adolescents' lives. However, this goal is problematic with little known about the nature and experiences of these flares in adolescents with musculoskeletal disorders. Aim: The overall purpose of this research is to explore the characteristics of pain flares in adolescents with inflammatory and non-inflammatory musculoskeletal disorders. Methods: A three-phase mixed methods study has been completed to understand pain flares. Firstly, since the literature on the experience of pain flares is non-existent, the first study aimed to systematically search the published and grey literature on adolescents' experiences of pain in order to identify knowledge gaps to inform future research on pain flares. The second study, using semi-structured interviews and visual aids, aimed to explore adolescents' lived experience of pain flares, including what pain flares are, why they occur, how they are managed and what lasting effects they have on adolescents. The third study aimed to further explore the components of a pain flare by exploring to what extent disease activity contributes to symptoms and characteristics commonly experienced in a flare using multiple hierarchical regression. Results: 32 studies (n= 536) were included in the systematic review. The results of the systematic review showed that there is limited research on pain flares and of varying quality. What is known is that adolescents live with a daily background level of symptoms which fluctuate and are associated with functional and emotional difficulties. It was not clear whether these symptoms and challenges were experienced as part of 'typical' fluctuations in pain, or whether they reflect symptom exacerbations classified as 'flares'. The results of the qualitative study on 10 young people with musculoskeletal pain disorders found that pain flares were described as a multifaceted experience that often occurred in the absence of changes in inflammation and which could be marked by 1) an increase in the intensity, area, duration and/or quality of pain; 2) an increase in other unpleasant symptoms such as fatigue, psychological symptoms, headaches and/or sickness; 3) and a reduction in physical, emotional, cognitive and/or social functioning. Thus, the term 'symptom flare' was considered to be more appropriate than 'pain flare' to capture the complex multidimensional nature of flares which relate to factors associated with, and independent of, pain intensity. Symptom flares were perceived to be difficult to alleviate, requiring elevated management techniques such as taking time off school and seeking parental and medical help. These findings suggest that not all flares are associated with noticeable joint swelling, and flare severity might not necessarily reflect the degree of disease activity. The third study found that disease-relate
Date of Award1 Aug 2023
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorMichelle Briggs (Supervisor), John Mcbeth (Supervisor) & Janet Mcdonagh (Supervisor)

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