187: Characterizing Pain Flares in Youth with Chronic Musculoskeletal Pain

Topic: Clinical Science
Subtopic: Non-specific to any diagnosis, Assessment and Measurement of Pain/Nociception, Digital Health Technologies , Pain in special populations (e.g. neonates, children, teens, elderly, neurodegenerative diseases)

Background and Aims: For the one in five youth living with chronic pain, quality of life is negatively impacted by debilitating and unpredictable pain flares. Pain flares describe the intra- and inter-daily fluctuations in pain level and symptomology across other health domains (eg., sleep, mood, physical activity). These pain flares are not well characterized, making them difficult to predict, treat, and prevent. The purpose of this study was to (1) characterize pain flares in a large sample of youth with chronic musculoskeletal (MSK) pain, (2) compare pain flares as described through both retrospective self-reports and real-time pain flare monitoring.

Methods: Participants (14-24 y.o.) with chronic MSK pain were recruited across the USA through ‘TRAC-Pain,’ a longitudinal observational study (IRB-77005). First, participants retrospectively characterized their pain flares at baseline, defined as a “temporary but noticeable worsening of usual pain and/or symptoms.” Next, participants monitored pain flares in real-time for 12-weeks, during which they completed daily check-ins assessing pain flare occurrence, pain interference (Pain, Enjoyment, General Activity [PEG]), symptoms across other health domains (Numeric Rating Scale [NRS] for stress, fatigue, physical activity, sleep), and mood (Positive Affect Negative Affect Schedule [PANAS-10]). Primary outcomes included frequency of pain flares and prevalence of associated symptoms, quantified using both retrospective self-reports at baseline and real-time monitoring. A minimally important difference (MID) of one-half standard deviation was used to identify significant pain flare-related symptom fluctuations (compared to self-reported ‘non-flare’ days) during the 12-week monitoring phase.

Results: At baseline, 221 participants (18.6±3.3 y.o.; 85% AFAB) completed retrospective pain flare reports. 5.4% reported no flares in the last month, 34.4% reported 1-3 flares/month, 40.3% reported 1-3 flares/week, and 19.9% reported 4+ flares/week. Most participants (94.1%) reported increased pain during a flare and further symptom exacerbation across domains (stress: 59.7%, fatigue: 64.3%, physical function: 78.7%, sleep: 59.7%, mood: 63.8%). At time of analysis, 177 participants (18.4±3.2 y.o.; 84% AFAB) had completed ≥14 daily check-ins. 15.2% reported <1 pain flare/month, 24.3% reported 1-3 flares/month, 50.8% reported 1-3 flares/week, and 9.6% reported 4+ flares/week. Across all participants, 79.1% (IQR: 60.0-100) of flares were associated with increased (MID) pain interference. 38.3% (22.2-57.1) of flares were associated with fatigue, 30.4% (14.3-50.0) with stress, 25.0% (8.4-41.6) with physical activity, 33.3% (16.3-44.7) with sleep quality, and 50.0% (28.6-66.7) with mood.

Conclusions: Overall, the distribution of pain flare frequency was similar across retrospective reports and real-time monitoring, with the largest proportion of participants reporting 1-3 flares/week. When monitored in real-time, significant symptom exacerbations meeting MID were most often seen across pain, mood, and fatigue domains. Interestingly, significant declines in physical activity were not as frequently observed in real-time as participants endorsed at baseline (25.0% vs 78.7%). Current analysis is limited by reliance on self-reports to monitor symptom change. Future analyses will further enrich symptom monitoring capabilities through assessment of physiological, sleep, and activity data collected via smart watch. This multidimensional approach to symptom monitoring may enhance the ability to deliver proactive, just-in-time treatments before pain flare onset, which could reshape pain medicine and self-management for youth with chronic MSK pain.

References: Khanom S, McDonagh JE, Briggs M, Bakir E, McBeth J. Adolescents' experiences of fluctuating pain in musculoskeletal
disorders: a qualitative systematic review and thematic synthesis. BMC Musculoskelet Disord. Oct 02, 2020;21(1):645. doi: 10.1186/s12891-020-03627-1.

Khanom S, McDonagh JE, Briggs M, McBeth J. Characterizing pain flares in adolescent inflammatory and
non‐inflammatory musculoskeletal disorders: A qualitative study using an interpretative phenomenological approach.
Eur J Pain. Jul 19, 2020;24(9):1785-1796. doi: 10.1002/ejp.1626.

Palermo TM, Walco GA, Paladhi UR, et al. Core outcome set for pediatric chronic pain clinical trials: results from a Delphi poll and consensus meeting. Pain. 2021 Oct;162(10):2539-2547. DOI: 10.1097/j.pain.0000000000002241. PMID: 33625074; PMCID: PMC8442740.

Presenting Author: Laura E. Simons
Submitting Author: Anna Bailes

Senior Author: Laura E Simons

IASP 2026 Global Year theme of Neuropathic Pain: No

• Anna H. Bailes: DPT, PhD - Stanford University School of Medicine
• Aliyah Davis: NA - Stanford University School of Medicine
• Sahrish Masood: NA - Stanford University School of Medicine
• Chi-Hung Shu: MEng - Stanford University School of Medicine
• Casey Cashman: NA - US Pain Foundation
• Javed Gill: NA - Patient and Pain Advocacy Partner
• Allison Hill: MD - Children's Hospital of Los Angeles
• Ryan S McGinnis: PhD - Wake Forest University School of Medicine
• Ellen W McGinnis: PhD - Wake Forest University School of Medicine
• Nima Aghaeepour: PhD - Stanford University School of Medicine
• Laura E. Simons: PhD - Stanford University School of Medicine