Scientific/Clinical Article| Volume 31, ISSUE 2, P206-214, April 2018

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Evaluation of pain in pediatric upper extremity conditions


      • This article highlights one approach to evaluate upper extremity pain in children to help identify those with or at risk of, chronic pain.
      • A detailed description of how to map sensory thresholds and sensory disturbances is provided.
      • Recommended outcome measures for self-reported pain intensity, location, descriptors, and interference are discussed.


      Study Design

      Narrative Review.


      Hand surgeons and therapists play an important role in the early identification of children at risk of developing chronic or recurrent pain after an upper extremity injury. Early identification of children at risk of developing a pain syndrome is critical because their physical, psychological, and/or social functioning may decline quickly without proper management due to the multidimensional nature of pain.

      Purpose of the Study

      This article outlines one approach to evaluating upper extremity pain in children to help identify those with, or at risk of, chronic pain.


      An assessment framework that recognizes the biological, sensory, emotional, and psychosocial components of pain is described.


      The key components of a screening evaluation include obtaining a detailed history and a thorough physical examination that involves: systematic upper extremity mapping of sensory thresholds, mapping of sensory disturbances, and screening of self-reported pain intensity, location, descriptors, and interference.

      Discussion and Conclusion

      The evaluation approach described will enable hand therapists to identify children with upper extremity pain that are at risk of developing a chronic pain and make an early referral to a multidisciplinary pain team that provides education, pharmacological pain management, physical rehabilitation, and psychological treatments.


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        • Manworren R.C.
        • Stinson J.
        Pediatric pain measurement, assessment, and evaluation.
        Semin Pediatr Neurol. 2016; 23: 189-200
        • Drendel A.L.
        • Lyon R.
        • Bergholte J.
        • Kim M.K.
        Outpatient pediatric pain management practices for fractures.
        Pediatr Emerg Care. 2006; 22: 94-99
        • Pediatric Chronic Pain Task Force
        Assessment and Management of Children with Chronic Pain: A Position Statement from the American Pain Society.
        American Pain Society, Illinois, USA2012
        • Treede R.D.
        • Rief W.
        • Barke A.
        • et al.
        A classification of chronic pain for ICD-11.
        Pain. 2015; 156: 1003-1007
        • Stanford E.A.
        • Chambers C.T.
        • Biesanz J.C.
        • Chen E.
        The frequency, trajectories and predictors of adolescent recurrent pain: a population-based approach.
        Pain. 2008; 138: 11-21
        • King S.
        • Chambers C.T.
        • Huguet A.
        • et al.
        The epidemiology of chronic pain in children and adolescents revisited: a systematic review.
        Pain. 2011; 152: 2729-2738
        • Tan E.C.
        • Zijlstra B.
        • Essink M.L.
        • Goris R.J.
        • Severijnen R.S.
        Complex regional pain syndrome type I in children.
        Acta Paediatr. 2008; 97: 875-879
        • Kachko L.
        • Efrat R.
        • Ben Ami S.
        • Mukamel M.
        • Katz J.
        Complex regional pain syndromes in children and adolescents.
        Pediatr Int. 2008; 50: 523-527
        • Gauntlett-Gilbert J.
        • Eccleston C.
        Disability in adolescents with chronic pain: patterns and predictors across different domains of functioning.
        Pain. 2007; 131: 132-141
        • Holley A.L.
        • Wilson A.C.
        • Palermo T.M.
        Predictors of the transition from acute to persistent musculoskeletal pain in children and adolescents: a prospective study.
        Pain. 2017; 158: 794-801
        • Jones G.T.
        • Power C.
        • Macfarlane G.J.
        Adverse events in childhood and chronic widespread pain in adult life: results from the 1958 British Birth Cohort Study.
        Pain. 2009; 143: 92-96
        • Walker L.S.
        • Dengler-Crish C.M.
        • Rippel S.
        • Bruehl S.
        Functional abdominal pain in childhood and adolescence increases risk for chronic pain in adulthood.
        Pain. 2010; 150: 568-572
        • Ho E.S.
        • Ponnuthurai J.
        • Clarke H.M.
        The incidence of idiopathic musculoskeletal pain in children with upper extremity injuries.
        J Hand Ther. 2014; 27: 38-43
        • Hoftun G.B.
        • Romundstad P.R.
        • Zwart J.A.
        • Rygg M.
        Chronic idiopathic pain in adolescence–high prevalence and disability: the young HUNT Study 2008.
        Pain. 2011; 152: 2259-2266
        • Briggs E.
        Assessment and expression of pain.
        Nurs Stand. 2010; 25: 35-38
        • Finnerup N.B.
        • Haroutounian S.
        • Kamerman P.
        • et al.
        Neuropathic pain: an updated grading system for research and clinical practice.
        Pain. 2016; 157: 1599-1606
        • Taxonomy ITFo
        Part III: pain terms, a current list with definitions and notes on usage.
        in: Merskey H. Bogduk N. Classification of Chronic Pain. IASP Press, Seattle2012
        • Birklein F.
        • O'Neill D.
        • Schlereth T.
        Complex regional pain syndrome: an optimistic perspective.
        Neurology. 2015; 84: 89-96
        • Lewandowski A.S.
        • Palermo T.M.
        • Stinson J.
        • Handley S.
        • Chambers C.T.
        Systematic review of family functioning in families of children and adolescents with chronic pain.
        J Pain. 2010; 11: 1027-1038
        • Oakes J.M.
        • Rossi P.H.
        The measurement of SES in health research: current practice and steps toward a new approach.
        Soc Sci Med. 2003; 56: 769-784
        • Huguet A.
        • Tougas M.E.
        • Hayden J.
        • McGrath P.J.
        • Stinson J.N.
        • Chambers C.T.
        Systematic review with meta-analysis of childhood and adolescent risk and prognostic factors for musculoskeletal pain.
        Pain. 2016; 157: 2640-2656
        • Mann E.G.
        • Johnson A.
        • VanDenKerkhof E.G.
        Frequency and characteristics of healthcare visits associated with chronic pain: results from a population-based Canadian study.
        Can J Anaesth. 2016; 63: 411-441
        • Haanpaa M.
        • Attal N.
        • Backonja M.
        • et al.
        NeuPSIG guidelines on neuropathic pain assessment.
        Pain. 2011; 152: 14-27
        • Thibault A.
        • Forget R.
        • Lambert J.
        Evaluation of cutaneous and proprioceptive sensation in children: a reliability study.
        Dev Med Child Neurol. 1994; 36: 796-812
        • Mulcahey M.J.
        • Gaughan J.
        • Betz R.R.
        • Johansen K.J.
        The international Standards for neurological classification of spinal cord injury: reliability of data when applied to children and youths.
        Spinal Cord. 2007; 45: 452-459
        • Sethna N.F.
        • Meier P.M.
        • Zurakowski D.
        • Berde C.B.
        Cutaneous sensory abnormalities in children and adolescents with complex regional pain syndromes.
        Pain. 2007; 131: 153-161
        • Hudson D.A.
        • Bolitho D.G.
        • Hodgetts K.
        Primary epineural repair of the median nerve in children.
        J Hand Surg Br. 1997; 22: 54-56
        • Bell-Krotoski J.
        • Weinstein S.
        • Weinstein C.
        Testing sensibility, including touch-pressure, two-point discrimination, point localization, and vibration.
        J Hand Ther. 1993; 6: 114-123
        • Ho E.S.
        Evaluation of pediatric upper extremity peripheral nerve injuries.
        J Hand Ther. 2015; 28 (quiz 143): 135-142
        • Weinstein S.
        Fifty years of somatosensory research: from the Semmes-Weinstein monofilaments to the Weinstein Enhanced Sensory Test.
        J Hand Ther. 1993; 6 (discussion 50): 11-22
        • McRae R.
        Segmental and Peripheral Nerves of the Upper Limb. Clinical Orthopaedic Examination.
        3rd ed. Churchill Livingstone, London, UK1990: 9-25
        • Valencia J.
        • Leyva F.
        • Gomez-Bajo G.J.
        Pediatric hand trauma.
        Clin Orthop Relat Res. 2005; : 77-86
        • Low A.K.
        • Ward K.
        • Wines A.P.
        Pediatric complex regional pain syndrome.
        J Pediatr Orthop. 2007; 27: 567-572
        • Bleasel A.F.
        • Tuck R.R.
        Variability of repeated nerve conduction studies.
        Electroencephalogr Clin Neurophysiol. 1991; 81: 417-420
        • Chaudhry V.
        • Cornblath D.R.
        • Mellits E.D.
        • et al.
        Inter- and intra-examiner reliability of nerve conduction measurements in normal subjects.
        Ann Neurol. 1991; 30: 841-843
        • Dyck P.J.
        • Albers J.W.
        • Wolfe J.
        • et al.
        A trial of proficiency of nerve conduction: greater standardization still needed.
        Muscle Nerve. 2013; 48: 369-374
        • Meier P.M.
        • Berde C.B.
        • DiCanzio J.
        • Zurakowski D.
        • Sethna N.F.
        Quantitative assessment of cutaneous thermal and vibration sensation and thermal pain detection thresholds in healthy children and adolescents.
        Muscle Nerve. 2001; 24: 1339-1345
        • Stinson J.N.
        • Jibb L.A.
        • Nguyen C.
        • et al.
        Construct validity and reliability of a real-time multidimensional smartphone app to assess pain in children and adolescents with cancer.
        Pain. 2015; 156: 2607-2615
        • Jacob E.
        • Mack A.K.
        • Savedra M.
        • Van Cleve L.
        • Wilkie D.J.
        Adolescent pediatric pain tool for multidimensional measurement of pain in children and adolescents.
        Pain Manag Nurs. 2014; 15: 694-706
        • Bouhassira D.
        • Attal N.
        • Alchaar H.
        • et al.
        Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4).
        Pain. 2005; 114: 29-36
        • Melzack R.
        The McGill pain questionnaire: from description to measurement.
        Anesthesiology. 2005; 103: 199-202
        • Varni J.W.
        • Thompson K.L.
        • Hanson V.
        The Varni/Thompson Pediatric Pain Questionnaire. I. Chronic musculoskeletal pain in juvenile rheumatoid arthritis.
        Pain. 1987; 28: 27-38
        • Yeung K.K.
        • Engle L.
        • Rabel A.
        • Adamson K.
        • Schwellnus H.
        • Evans C.
        It just feels weird!: a qualitative study of how children aged 10-18 years describe neuropathic pain.
        Disabil Rehabil. 2017; 39: 1695-1702
        • Ho E.S.
        • Curtis C.G.
        • Clarke H.M.
        Pain in children following microsurgical reconstruction for obstetrical brachial plexus palsy.
        J Hand Surg. 2015; 40: 1177-1183
        • Kingsnorth S.
        • Townley A.
        • Provvidenza C.
        • et al.
        Chronic Pain Assessment Toolbox for Children with Disabilities: Section 3.0: Chronic Pain Assessment Tools.
        Hospital HBKR, Toronto, Canada2014
        • University N. PROMIS
        Patient-Reported outcomes measurement information system.
        (Available at:)
        Date: 2017
        Date accessed: October 26, 2017
        • Clinch J.
        • Eccleston C.
        Chronic musculoskeletal pain in children: assessment and management.
        Rheumatology. 2009; 48: 466-474
        • Malleson P.N.
        • Connell H.
        • Bennett S.M.
        • Eccleston C.
        Chronic musculoskeletal and other idiopathic pain syndromes.
        Arch Dis Child. 2001; 84: 189-192

      JHT Read for Credit

      Quiz: #541

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to There is only one best answer for each question.
      • #1.
        The purpose of the article is describe a method to
        • a.
          prevent chronic pain in at risk children
        • b.
          identify children at risk to developing chronic pain following injury
        • c.
          treat pain in at risk children
        • d.
          identify the roles of surgeons, OTs, and PTs in treating at risk children
      • #2.
        The authors anticipate the management of chronic pain will include
        • a.
        • b.
          physical rehab
        • c.
          patient psychological counseling and education
        • d.
          all of the above
      • #3.
        The authors recommend managing the pain by
        • a.
          referral to a psychologist specializing in upper extremity pain
        • b.
          the same staff who performed the initial evaluation
        • c.
          referral to a multidisciplinary pain team
        • d.
          referral to the nearest university children’s hospital
      • #4.
        The effect of pain on the psychosocial and function of the child is best measured by
        • a.
          a trained psychologist
        • b.
          self-report instruments
        • c.
          electrodiagnostic tools
        • d.
          experienced CHTs
      • #5.
        Central to the evaluation process is mapping of sensory disturbances and pain thresholds
        • a.
        • b.
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.