Severe chronic pain is defined as pain persisting for three months or more that significantly impacts daily functioning. It is highly prevalent, occurring in 100,000 to 160,000 youth. If left unmanaged it can lead to persistent pain and mental health problems in adulthood, posing enormous costs to society ($7.2 billion CAD/year). In 2014, health professionals at the Alberta Children's Hospital (ACH) established a pediatric Intensive Pain Rehabilitation Program (IPRP) to target youth with severe chronic pain and consequent functional disability who do not respond to outpatient pain therapies. The IPRP at the ACH is a three-week intensive day-treatment intervention provided by an interdisciplinary team, which helps youth resume engagement in normal daily functioning. Following IPRP, youth reported less anxiety, less depressive symptoms, and greater function, although their self-reported pain remained unchanged. In August 2016, the investigators began to explore brain areas related to severe chronic pain in youth. The investigators scanned a subset of youth at the start (baseline) and end (discharge) of IPRP (23 youth with 2 brain scans). From baseline to discharge, the investigators saw decreases in activity in the dorsolateral prefrontal cortex (DLPFC). Decrease in DLPFC activity was related to better mental health outcomes. The DLPFC is a well-known target for non-invasive brain stimulation. Repeated brain stimulation has been used to treat adults, but not youth with chronic pain. For the first time, the investigators will use image-guided brain stimulation (37 minutes/day, 5 days/week) to enhance the brain changes observed with IPRP. The investigators will examine whether three weeks of brain stimulation helps to reduce pain symptoms in youth. The investigators will also compare pain, brain, and mental health outcomes to our historical program data. By adding brain stimulation to our pain intervention, the investigators have the chance to target an area of the brain investigators know to be altered by chronic pain to improve outcomes.
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Pain Presence
Timeframe: This outcome will be measured at baseline.
Pain Frequency
Timeframe: This outcome will be measured at baseline.
Pain Duration
Timeframe: This outcome will be measured at baseline.
Pain Intensity
Timeframe: This outcome will be measured at baseline.
Pain Interference
Timeframe: This outcome will be measured at baseline.
Brain imaging
Timeframe: This outcome will be measured at baseline (upon admittance into the program).
Functional disability
Timeframe: This outcome will be measured at baseline.
Anxiety and Depressive Symptoms
Timeframe: This outcome will be measured at baseline.
Posttraumatic Stress Disorder (PTSD) Symptoms
Timeframe: This outcome will be measured at baseline.
Pediatric Transcranial Magnetic Stimulation (TMS) Safety and Tolerability
Timeframe: This outcome will be measured at Day 1.
Pain Presence
Timeframe: This outcome will be measured at discharge from the program, which is approximately 3 weeks from the time of admittance.
Pain Frequency
Timeframe: This outcome will be measured at discharge from the program, which is approximately 3 weeks from the time of admittance.
Pain Duration
Timeframe: This outcome will be measured at discharge from the program, which is approximately 3 weeks from the time of admittance.
Pain Intensity
Timeframe: This outcome will be measured at discharge from the program, which is approximately 3 weeks from the time of admittance.
Pain Interference
Timeframe: This outcome will be measured at discharge from the program, which is approximately 3 weeks from the time of admittance.
Brain imaging
Timeframe: This outcome will be measured at discharge from the program, which is approximately 3 weeks from the time of admittance.
Functional disability
Timeframe: This outcome will be measured at discharge from the program, which is approximately 3 weeks from the time of admittance.
Anxiety and Depressive Symptoms
Timeframe: This outcome will be measured at discharge from the program, which is approximately 3 weeks from the time of admittance.
Posttraumatic Stress Disorder (PTSD) Symptoms
Timeframe: This outcome will be measured at discharge from the program, which is approximately 3 weeks from the time of admittance.
Pediatric Transcranial Magnetic Stimulation (TMS) Safety and Tolerability
Timeframe: This outcome will be measured at Day 6.
Pediatric Transcranial Magnetic Stimulation (TMS) Safety and Tolerability
Timeframe: This outcome will be measured at Day 11.