Pain. 2011 (Oct); 152 (10): 2259–2266 ~ FULL TEXT
Gry Børmark Hoftun, Pål Richard Romundstad, John-Anker Zwart, Marite Rygg
Department of Laboratory Medicine,
Children's and Women's Health,
Faculty of Medicine,
Norwegian University of Science and Technology,
The aim of this study was to determine the prevalence of self-reported chronic idiopathic pain among adolescents in relation to age and gender, and to explore how pain interferes with daily activities. The study was performed in Nord-Trøndelag County, Norway in 2006–2008. All adolescents were invited to participate; the response rate was 78%. Participants completed a comprehensive questionnaire, including questions about pain and interference with everyday life. Chronic idiopathic pain was defined as pain at least once a week during the last 3 months, not related to any known disease or injury. The final study population, with complete pain questionnaires, consisted of 7,373 adolescents aged 13–18 years. Chronic pain was reported by 44.4% of the participants, and 25.5% reported pain in at least 2 locations. Chronic idiopathic musculoskeletal pain was most prevalent (33.4%), and the neck/shoulder was most commonly affected. Musculoskeletal pain in 3 or more locations was reported by 8.5%. Pain almost daily was reported by 10.2%. More girls than boys reported pain. In girls, the prevalence of pain increased with age. A high number of pain-associated disabilities were reported, and 58.5% described difficulties doing daily activities in leisure time. Subjective disabilities were higher in girls, and increased with the frequency of pain and the number of pain locations, as shown by high disability in adolescents with musculoskeletal pain in 3 or more locations. Chronic idiopathic pain, especially multisite pain, is common among adolescents, and those suffering from it report a major impact on several areas of daily living.
From the FULL TEXT Article:
Pain is a common complaint among children and adolescents
[7, 16, 35, 40, 46]. The prevalence of chronic idiopathic pain, at least
once a week, varies among studies, ranging from 12% to 35%
[40, 43, 46]. Similarly, the prevalence of weekly musculoskeletal
pain ranges from 9% to 32% [6, 35]. The wide variations in prevalence
are probably due to differences in pain definition, study design,
and study population. Studies on pain impact have shown
that children with chronic pain report similar or more disabilities
in daily life than children with chronic somatic disorders [15, 26].
Limitations in social functioning, school participation, sports activities,
and/or sleeping problems are often reported by children with
chronic pain [7, 26, 46]. Chronic pain in adolescents is also a burden
to their families and to society [7, 19, 39]. Pain in adulthood is
known to have severe economic consequences [30, 31], but even
in adolescence, chronic pain may have extensive financial consequences
. Follow-up studies have demonstrated that pain complaints
in childhood tend to persist [4, 11, 12, 15, 20, 41, 51], and a
considerable number of patients will have persistent or recurrent
pain into adulthood [4, 7, 13, 56]. Also, among children treated in
specialized clinics, persistence rates are high . Studies have
shown that children often report pain in more than one location
[35, 40, 43, 46], and that the negative impact of pain [35, 44, 50]
and the risk of persistence  increase as the number of painful
Most studies on pain have focused on specific locations of pain,
such as low back pain, neck pain, or headache [3, 16,3 7], and studies
on multisite pain in adolescents have been recommended .
A recent report showed that number of pain sites is relatively
stable through adulthood , and this finding highlights the need
to look at the situation in adolescence. Some studies have focused
on the impact of different pain conditions on the adolescents’
everyday activities, but few studies have assessed self-reported
pain and disabilities in a large, unselected, nonclinical population.
The high prevalence, the reduced quality of life, the financial consequences,
and the importance of searching for factors associated
with pain, justify further research in these areas.
The aim of this study was to estimate the prevalence of self-reported
chronic pain, and especially the prevalence of chronic idiopathic
musculoskeletal pain, single-site as well as multisite pain, in
a large, unselected adolescent population in relation to age and
gender. A second aim was to explore how pain interferes with daily
Study design and population
The study took place in Nord-Trøndelag county in the middle of
Norway, with approximately 132,000 inhabitants . The county
consists of both rural and urban areas, and does not differ considerably
from other counties in Norway with regard to demographic
factors, geography, and industry .
During the years 2006–2008, all the county’s adolescents, aged
13–19 years, were invited to participate in the youth part of the
Nord-Trøndelag Health Study ("Helseundersøkelsen i Nord-
Trøndelag [HUNT]"). Of 10,485 invited, 8,200 (78%) participated.
The field work took place from October 2006 to June 2008. During
a school lesson, the students completed a comprehensive questionnaire
with more than 100 health-related items. Adolescents not
attending school (apprentices and dropouts, n = 412 [3.9%]) were
also invited (n = 57 participated). Students not at school on the
day of the study could complete the questionnaire at a later clinical
examination. The questionnaires were identical, except for one extra
page for high school students. Reasons for not participating
were mainly being absent from school on the day of the study,
not wanting to participate, or lack of written consent from parents.
Some 12–year-old children, who had entered junior high school,
participated but were excluded due to the low number (n = 27).
Only 260 of the 19–year-olds were reached, and they were also excluded.
Of 7,913 participants in the target age groups of
13–18 years, 7,373 (93%) completed the pain questions and thus
constituted the final study population in the present study.
The study was approved by the Regional Committee for Medical
Research Ethics and the Norwegian Data Inspectorate Board. Written
consent was obtained from the adolescents or from both child
and parents if the child was younger than 16 years old.
The questionnaire included questions about whether they had
experienced pain, not related to any known disease or injury, during
the last 3 months. Participants were asked to specify if they had
experienced headache/migraine, abdominal pain, or pain in the
neck/shoulder, upper back, low back/buttocks, chest, upper and/
or lower extremities, with locations marked on a figure beside
the questions. The frequency of pain in each location was specified
as; never/seldom, once a month, once a week, more than once a
week, or almost every day. Chronic idiopathic pain was defined
as pain not related to any known disease or injury, for at least once
a week during the last 3 months. Chronic idiopathic musculoskeletal
pain was defined as chronic idiopathic pain in the musculoskeletal
locations (neck/shoulder, upper back, low back/buttocks,
chest, upper and/or lower extremities). The criteria for diffuse idiopathic
pain  were chronic idiopathic pain affecting at least 3
musculoskeletal locations (areas) of the body.
To assess to what extent pain interfered with the adolescents’
everyday life, participants were asked to indicate if they agreed
with one or more of the following statements:
(1) I have difficulties falling asleep because of pain and/or pain disturbs my sleep;
(2) because of pain I have difficulties sitting during a lesson;
disturbs me if I walk more than 1 km and;
(4) pain disturbs me during physical exercise class. The statements were adapted from
Mikkelsson et al. in order to calculate a subjective disability index
. The fifth phrase to establish the index was converted to a
question: "All things considered, has pain made it difficult to do
daily activities in leisure time?" This is slightly different from the
(5) "Pain and aches disturb my hobbies ."
The subjective disability index is calculated from the answers to
the 5 statements, with one point for each verified statement, and
a maximum of 5 points .
The data were analyzed using PASW 17 (Predictive Analytics
Software; SSPS Inc, Chicago, IL, USA). For estimation of exact confidence
intervals for binomially distributed variables, we used STATA
(STATA Corp, College Station, TX, USA). Descriptive statistics
were computed for pain in relation to age and gender, and for subjective
A total of 7,373 adolescents, 3,748 girls and 3,625 boys, completed
the pain questions. Of these, 4,084 were aged 13–15 years
(junior high school) and 3,289 were 16–18 years (high school).
Mean age was 15.8 years (SD 1.6).
Pain in any location, at least once a week during the last
3 months, was reported by 44.4% of the adolescents (Table 1).
Chronic idiopathic musculoskeletal pain was the most prevalent
condition, experienced by 33.4% of the adolescents, while headache/
migraine (21.8%) and abdominal pain (11.3%) were less frequently
reported. The neck/shoulder was the most commonly
affected musculoskeletal location in both genders and both age
groups, followed by lower extremities in the 13– to 15–year-olds
and low back/buttocks in the 16– to 18–year-olds.
The prevalence of pain was higher in girls than in boys for all
pain locations (Table 1). Girls reported twice as much headache/
migraine and 3 times as much abdominal pain as boys. Pain prevalence
was also, for the most part, higher in 16– to 18–year-old adolescents
compared to 13– to 15–year-olds. However, in lower
extremities, pain prevalence was higher in the youngest age group.
Increase with age was most evident for pain in the neck/shoulder
and low back/buttocks. The increase in pain prevalence with age
was due to an increase in pain among girls (Figure 1). Also, the gender
difference in specific age groups increased with age, and was most
pronounced at the age of 16 years.
Chronic pain in more than one location was reported by 25.5%
(Table 1). In all pain locations, multisite pain was more prevalent
than single-site pain. Chronic idiopathic musculoskeletal pain in
3 or more locations was reported by 8.5% of the adolescents, fulfilling
the criteria for diffuse idiopathic pain . Headache/migraine
was associated with abdominal pain and musculoskeletal pain,
especially in the neck/shoulder region (Table 2). Moderate correlations
were also found between pain in the neck/shoulder and
upper and low back/buttocks. Pain in the chest and upper and lower
extremities showed weak correlations with the other pain
Pain once a week was reported by 19.1% of the adolescents,
15.0% reported pain more than once a week, and 10.2% reported
pain almost daily (Table 3). Pain almost daily in 3 or more locations
was reported by 1.5% of the adolescents. There was no gender or
age difference among the adolescents reporting pain once a month.
However, with increasing frequency of pain from once a week to
almost daily, the gender difference increased.
Of all the adolescents reporting chronic pain of any location,
79.7% (data not shown) reported one or more disabilities. Adolescents
with multisite pain reported more disabilities than those
with pain in only one location (Table 4). Difficulties in daily activities
during leisure time were the most frequently reported disability
in all pain locations, reported by approximately 60%, followed
by difficulties sitting during a school lesson, reported by about
50%. Sleeping difficulties and problems during physical exercise
class were also frequently reported. The adolescents with musculoskeletal
pain in 3 or more locations, fulfilling the criteria of diffuse
idiopathic pain, reported most pain-associated disabilities, but also
within this group, disabilities increased when including other pain
locations, like headache/migraine and/or abdominal pain. Overall,
more girls than boys experienced disabilities; differences between
age groups were small (Table 5).
Subjective disability index
The proportion of adolescents with no disabilities decreased
with increasing number of pain locations (Table 6). Among those
reporting pain in at least 5 locations, two-thirds reported maximal
disability (disability index 3–5). The more frequent the musculoskeletal
pain, the higher the scores on the subjective disability index
(Table 7). Of the 558 adolescents reporting musculoskeletal
pain almost daily (7.6% of the study population), 58.4% reported
maximal disability. Among the adolescents reporting chronic idiopathic
pain almost daily in 2 or more locations, or 3 or more locations,
66.9% and 75.0%, respectively, reported maximal disability
(data not shown).
This study confirms chronic idiopathic pain as common in adolescents.
The overall prevalence of 44.4% is even higher than in
other comparable studies [40, 43, 46]. In the study by Roth-Isigkeit
et al. , 35.2% of the children and adolescents reported pain at
least once a week. A high prevalence of chronic pain among adolescents
in Norway is in agreement with a study on adult chronic pain
performed in 15 European countries, where the prevalence in Norway
was among the highest . Whether these differences are due
to organization of health services, economy, cultural differences, or
other factors, is not known.
The definitions of recurrent and chronic pain vary in different
studies [17, 21, 28, 40, 44], from pain at least once a month  to
pain occurring weekly or more , and from recurrent or continuous
pain for more than 3 months  to pain lasting at least 1 day
during the last month . These different definitions make comparison
between studies difficult. We chose to focus on idiopathic
pain at least once a week during the last 3 months, as pain of this
frequency and duration was presumed to be of more clinical relevance. Headache, abdominal, and musculoskeletal pain were considered in the same way because they may all be regarded as part
of the spectrum of idiopathic pain. The use of the term "medically
unexplained symptoms" is controversial .
One-third of the adolescents reported chronic idiopathic musculoskeletal
pain, which is higher than reported from Sweden ,
but consistent with results from Finland . The neck/shoulder
region was the most reported musculoskeletal location, followed
by low back/buttocks and lower extremities. The Finnish study
 reported pain in the lower extremities as most common, followed
by neck pain. These differences are probably due to the
age difference in the study populations (10–12 vs 13–18 years),
as our results show that neck/shoulder pain increases and pain in
lower extremities decreases with age. The high prevalence of
chronic neck/shoulder pain is worrying, as neck/shoulder pain is
a predictor of widespread pain (WSP)  and tends to persist
more often than pain in other locations . The prevalence of
headache/migraine was consistent with some [2, 42], and slightly
lower than other studies . Pain almost daily in one or more
locations was reported by 10.2%, compared to 5.5% in the
Roth-Isigkeit study .
The majority of adolescents with chronic pain reported pain in
more than one location. High levels of multisite pain are reported
in several studies [6, 27, 35, 40, 43, 50]. The design of the questionnaire
made it impossible to evaluate the prevalence of WSP as defined
by the American College of Rheumatology . However, the
American College of Rheumatology criteria have not been validated
in children . We chose to use the criteria suggested by Yunus
and Masi , further defined as diffuse idiopathic pain syndrome
by Malleson et al.  and preferred by several [7, 8, 25, 48]. Little
research has been done on diffuse idiopathic musculoskeletal pain
in children/adolescents in the general population, despite the fact
that this represents a common pain condition in clinical pediatric
rheumatology practice . In our study, the prevalence of chronic
idiopathic musculoskeletal pain in 3 or more locations was high
and, though not comparable, consistent with reported prevalence
of childhood WSP . Also, in adults, musculoskeletal pain is
mostly reported as multisite pain , and a recent study indicates
that the number of pain locations is a strong predictor of later disability
Consistent with other studies [3, 10, 40, 45, 50, 52, 57, 60], the
prevalence of chronic idiopathic pain was higher in girls than in
boys, and this gender difference increased with age [3, 18, 40, 45].
Several explanations for gender differences in pain prevalence have
been proposed [1, 14, 25, 55]. Reporting pain once a month showed a
different pattern, being equally prevalent among girls and boys.
The prevalence of chronic idiopathic pain in most locations increased
with age, consistent with previous studies
[3, 18, 40, 45, 52]. In our study, these age differences were mostly
attributable to increased pain prevalence in girls, a result recently
supported by others .
Adolescents with chronic idiopathic pain experienced disabilities
in several areas of daily life, supporting other studies
[19, 26, 44, 46]. It is alarming that almost half of the adolescent
population reports some sort of chronic pain, and of these,
nearly 60% describe pain-associated difficulties in leisure time.
Sleeping difficulties, reported by one-third, might affect several
areas of life . Difficulties sitting during a school lesson, reported
by nearly 50%, are likely to influence attention and
Adolescents with chronic pain in more than one location reported
distinctly more disabilities than those with single-site pain,
consistent with a Swedish report . In our study the number of
pain locations was more important for the subjective disability
than the localization of pain. It is important to know that about
two-thirds of adolescents with, for instance, headache/migraine
also have pain in other locations, which will have major impact
on their disability reports. It may be difficult to analyze the effects
of one single pain location without asking for pain in other locations.
Overall, a higher proportion of girls than boys reported disabilities,
also supporting earlier studies [44, 46], although
different measures for disabilities were used.
In accordance with Mikkelsson et al. , the subjective disability
index increased with the frequency of musculoskeletal pain,
however, our results showed a higher score for adolescents with
pain at least once a week. For adolescents reporting pain almost
daily, nearly 60%, compared to 20% in the Finnish study , reported
maximal disability score. The results are not totally comparable
due to the minor difference in the fifth statement of the
index, but it is unlikely that this explains the large difference in results.
A more likely explanation may be the age difference between
the study populations (10–12 years vs 13–18 years). Maximal disability
score increased with the frequency of pain and the number
of pain locations. As a high score on the disability index has been
shown to predict pain persistence , this suggests that the more
frequent and multisite, the higher the possibility for pain
Adolescents reporting musculoskeletal pain once a month had a
low score on the disability index. This might be an important result
regarding the different definitions on recurrent/chronic pain in the
literature. Pain once a month might be a normal experience, rather
than recurrent or chronic pain .
This is, to our knowledge, the only study on pain and disability
including a complete adolescent population. The high participation
rate and the fact that the county did not differ considerably
from other counties in Norway make the results fairly representative
for the country’s adolescent population. Our strict definition
of chronic idiopathic pain is one of the strengths of the study,
as it probably excluded minor pain due to everyday harmless
accidents or "normal" life events, and also pain due to known
diseases or injuries. Another strength is the inclusion of several
aspects of pain, different pain locations, single-site as well as
Pain and disabilities might be more prevalent among adolescents
not participating in the study, and this, together with the
low participation among apprentices and dropouts, might signal
a selection bias. Even though our definition of chronic pain is strict,
it can be argued that pain once a week for the last 3 months does
not necessarily indicate a chronic condition. The cross-sectional
design of the study made it impossible to evaluate pain persistence.
Follow-up studies are needed for this purpose. Answering
the questionnaires relies on recollections from the last 3 months,
and recall bias cannot be excluded, but others have shown that
adolescents are able to accurately recall and report pain experiences
. Another limitation in our study is the focus on frequency
of pain, and not on pain intensity. However, it has been
shown that frequency of pain also reflects intensity fairly well
. The study was based on self-report and, as pain is a subjective
phenomenon, other ways of measuring would be inaccurate .
While the subjective disability index was designed for musculoskeletal
pain, we also used the index for headache and abdominal
pain. Disability report was regarded as pain-associated, as the
questions should be answered only by those who had reported
pain in the last 3 months, but we missed the opportunity to compare
disabilities between adolescents with and without pain. The
study focused on the prevalence of pain, and did not include psychosocial
factors, such as depression, which is known to be associated
with pain. The general health focus on the questionnaire
resulted in rather simple pain questions compared to more multidimensional
This study shows that chronic idiopathic pain in adolescence is
common, particularly among girls, and may have a major negative
impact on everyday life, with high disability. The disability increases
with frequency of pain and number of pain locations;
and adolescents with musculoskeletal pain in 3 or more locations,
as well as those with daily pain, constitute a group with high subjective
disability index. Further studies are needed to analyze
pain-associated factors, such as psychosocial and lifestyle factors,
in order to suggest appropriate intervention strategies.
Conflict of interest statement
The authors declare that there are no financial or other relationships
that might lead to a conflict of interest.
This work was funded by the Norwegian Women’s Public
Health Association (Norske Kvinners Sanitetsforening, N.K.S.). We
thank the adolescents participating in The Nord-Trøndelag Health
Study (HUNT), which is a collaboration between HUNT Research
Centre, The Faculty of Medicine, Norwegian University of Science
and Technology (NTNU), The Norwegian Institute of Public Health,
and Nord-Trøndelag County Council. We are also grateful to Marja
Mikkelsson for letting us use the subjective disability statements
and index, and for helping with the translation of the index from
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