Management of musculoskeletal pain in children and young people with mental health or neurodivergent comorbidity (CLIMB Study)

Problem

Previous research has shown children and young people (CYP) with a mental health condition or neurodiversity have higher rates of musculoskeletal pain than CYP without. There are currently no studies that investigated whether CYP with musculoskeletal pain are managed differently if they have a comorbid mental health condition or neurodiversity. The aim of our study was to investigate whether CYP with musculoskeletal pain are managed differently in primary care if they have comorbid mental health conditions or neurodiversity compared to young people with musculoskeletal pain only.

Approach

Data were obtained from national primary care records for patients aged 8-18 years in 2005-2019 with consultations for musculoskeletal pain (index date). Individuals consulting on or within the 2 years prior to the index date for depression or anxiety were categorised as having a comorbid mental health condition while consultations for autism spectrum disorder or attention deficit hyperactivity disorder were categorised as neurodiverse. A random sample of 25,000 CYP per calendar year was obtained. Management outcomes included referrals to secondary care, imaging and analgesia prescribed on or within 2 years of the index date. Robust Poisson regression estimated the relative risk of outcomes in those with musculoskeletal pain and comorbid mental health or neurodiversity versus musculoskeletal pain only. Models were adjusted for age, gender, region, ethnicity and deprivation, and are presented with 95% confidence intervals.

Findings

375,000 CYP were recorded with musculoskeletal pain. Compared to those with musculoskeletal pain only (median age 12, 47.9% female) individuals with comorbid mental health conditions were older and more commonly female (median age 15, 65.2% female) while those with neurodiversity were a similar age and more commonly male (median age 13, 17.9% female).Outcomes were common in those with musculoskeletal pain only with 21.2% referred, 17.1% imaged and 33.7% prescribed analgesia within 2 years, although there were differences for those with comorbid mental health conditions (26.0%, 20.8% and 39.0%, respectively) and neurodiversity (26.6%, 17.5% and 29.2%, respectively).The adjusted risk ratios for those with comorbid mental health conditions compared to those with musculoskeletal pain only were 1.16 (1.10, 1.22) for referrals, 1.15 (1.09, 1.22) for imaging, and 1.06 (1.02, 1.10) for analgesia; and for those with neurodiversity compared to those with musculoskeletal pain only were 1.23 (1.18, 1.29) for referrals, 1.00 (0.944, 1.06) for imaging, and 0.939 (0.901, 0.978) for analgesia.

Consequences

Musculoskeletal pain is managed differently in those with comorbid mental health conditions or neurodiversity. Individuals with comorbid mental health conditions were significantly more likely to be referred, imaged or prescribed analgesia with increased referrals, decreased prescribing of analgesia and no association with imaging for neurodiverse individuals. Determining differences in management is useful for healthcare planning to inform targeted and effective primary care.