Society for Pediatric Pain Medicine
Better Care for Children in Pain

A 15-year-old female presents to the multidisciplinary chronic pain clinic for evaluation of widespread body pain, primarily in the back and knees. Her rheumatological testing and imaging were normal. During the physical exam, all orthopedic testing indicated no acute injury. She reports that she has more pain when sitting for a long period of time and after doing a lot of activity. She feels her sleep is nonrestorative and has difficulty initiating sleep. She has little to no pain during an activity she really enjoys, but pays for it the next day. She scores a 9/9 on the Beighton scale for hypermobility and shows mild proximal weakness in the core and hip extensors. Her numeric self-rating of pain is 9/10 at the worst, with an average of 6-7/10. She previously participated in field hockey and volleyball, but discontinued due to pain. She is typically very social but has avoided doing activities with friends because she worries that doing so will lead to increased pain. Psychologically, she describes anxiety about schoolwork, worries that her pain will not get better, and feelings of hopelessness. Standardized measures showed clinical elevation of anxiety and depression.

What course of treatment should be recommended?

A. Genetic testing for Ehlers-Danlos Syndrome-Hypermobility Type, repeat imaging and labs testing for low back pain and ankylosing spondylitis and refer back to rheumatology for a second opinion.
B. Physical Therapy with primary focus on strengthening for joint stability, activity exposure, and pacing.
C. Cognitive-Behavioral Therapy to learn coping strategies for pain and mood/anxiety management and re-enforce increased engagement in functional activities.
D. Consider non-steroidal anti-inflammatory medications as needed for pain and melatonin at bedtime for sleep.
E. A and B
F. B, C, and D

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