Long-term impact of adolescent chronic pain on young adult educational, vocational, and social outcomes

Quality Improvement Initiative to Implement Anxiety Screening for Children and Teens With Headache and Epilepsy

Background and Objectives

We conducted a quality improvement initiative to implement standardized screening for anxiety among adolescents with headache and/or epilepsy receiving outpatient neurology care at a quaternary health care system, consistent with recommendations from the American Academy of Neurology. Our SMART (Specific, Measurable, Achievable, Relevant, and Time-Based) aim was to screen ≥90% of established patients aged 12 years or older seen by a participating health care professional using a standardized anxiety screener by February 2024.

Methods

This initiative was conducted in patients seen for follow-up by 17 participating neurology health care professionals. Health care professional opinions were assessed before and after implementation of the Generalized Anxiety Disorder-7 (GAD-7), administered as a previsit questionnaire distributed using the electronic health record. The integrated workflow included a best practice advisory (BPA) alert that permitted easy access to interventions and automatic population of education materials into the after-visit summary. After 12 months of use (March 2023 to February 2024), we assessed demographic and diagnostic information, GAD-7 completion rates, anxiety symptom severity, BPA utilization, and health care professional acceptance of the intervention.

Results

The GAD-7 was completed for 64% of 3,671 encounters and by 71% of 2031 unique patients. The GAD-7 was more often completed for encounters if the patient was female, younger, or White or had a headache diagnosis. Among unique patients, anxiety symptoms were minimal in 50%, mild in 24%, moderate in 17%, and severe in 10%. Severe anxiety symptoms were more often present in female patients or those with a headache diagnosis. Among patients with severe anxiety symptoms, 66% had established behavioral health care plans and, for remaining patients, referrals were made to community behavioral health care professionals (11%), or pediatric psychologists (4%) or social workers (3%) within neurology. Clinicians indicated that the approach was easy to use and improved the quality of patient care.

Discussion

We implemented standardized EHR-based screening for anxiety symptoms for pediatric neurology patients, most of whom had headache or epilepsy. Screening was feasible, and approximately one-quarter of patients had moderate or severe anxiety symptoms. Future work will focus on improving completion rates of previsit questionnaires including the GAD-7 and optimizing clinician actions based on the screening data.

Pain predicts past-month co-use of alcohol and cannabis among emerging adults: Results from the Population Assessment of Tobacco and Health (PATH) Study

Alcohol use, cannabis use, and pain are public health concerns among emerging adults (18-24 years old). Co-use of alcohol and cannabis is of particular concern since individuals who co-use alcohol and cannabis use more of each substance and experience greater substance-related harm. Pain and substance use frequently co-occur, and a growing body of literature indicates pain is unique risk factor for substance use. The goal of the current study was to examine moderate/severe pain (vs. no/low pain) as a prospective predictor of engaging in co-use of alcohol and cannabis among emerging adults, and to test sex as a moderator of this hypothesized relationship. Data were drawn from Waves 1-5 of the Population Assessment of Tobacco and Health Study (n = 3544). Unadjusted logistic regression revealed that those with moderate/severe pain at baseline were 1.4 times more likely to engage in past-month co-use of alcohol and cannabis over the next four years (p = .046). The effects of pain on co-use were no longer significant after inclusion of covariates and a pain∗sex interaction term, which was also nonsignificant (ps > .05). These findings provide initial support for pain as a risk factor for engaging in co-use of alcohol and cannabis during emerging adulthood. Future research should continue investigating how pain may motivate co-use of alcohol and cannabis, exploring how pain is associated with other measures of co-use, and determining how providers can incorporate pain-substance use psychoeducation for emerging adults in clinical settings.

Haves and have-nots: socioeconomic position improves accuracy of machine learning algorithms for predicting high-impact chronic pain

ABSTRACT

Lower socioeconomic position (SEP) is associated with increased risk of developing chronic pain, experiencing more severe pain, and suffering greater pain-related disability. However, SEP is a multidimensional construct; there is a dearth of research on which SEP features are most strongly associated with high-impact chronic pain, the relative importance of SEP predictive features compared to established chronic pain correlates, and whether the relative importance of SEP predictive features differs by race and sex. This study used 3 machine learning algorithms to address these questions among adults in the 2019 National Health Interview Survey. Gradient boosting decision trees achieved the highest accuracy and discriminatory power for high-impact chronic pain. Results suggest that distinct SEP dimensions, including material resources (eg, ratio of family income to poverty threshold) and employment (ie, working in the past week, number of working adults in the family), are highly relevant predictors of high-impact chronic pain. Subgroup analyses compared the relative importance of predictive features of high-impact chronic pain in non-Hispanic Black vs White adults and men vs women. Whereas the relative importance of body mass index and owning/renting a residence was higher for non-Hispanic Black adults, the relative importance of working adults in the family and housing stability was higher for non-Hispanic White adults. Anxiety symptom severity, body mass index, and cigarette smoking had higher relevance for women, while housing stability and frequency of anxiety and depression had higher relevance for men. Results highlight the potential for machine learning algorithms to advance health equity research.

Life course insights into social relationship quality: a cross-national analysis of 22 countries

Research has demonstrated strong associations between social relationships and health and well-being, but considerably less is known about the upstream factors-specifically, the childhood antecedents-that contribute to the quality of one's social relationships in adulthood. We use data from the first wave of the Global Flourishing Study, a diverse, global sample of 202,898 individuals across 22 countries, to evaluate an array of social and economic factors, adverse events and experiences, health status, and sociodemographic characteristics from childhood as potential predictors of adult social relationship quality. Using multivariate regression analysis, random effects meta-analytic results indicated that during childhood, having higher subjective financial status, better self-rated health, frequent religious service attendance, good relationships with mother and father, and being female and born in an earlier birth cohort were associated with better social relationship quality in adulthood. In contrast, experiencing abuse and feeling like an outsider in one's family growing up were associated with lower social relationship quality. Country-specific analyses showed substantial between-country variations in these associations. Our findings provide an empirical foundation for further investigation into variability and mechanisms in associations between childhood factors and adult social relationship quality, and cultural differences in these patterns.

Extended Reality (XR) in Pediatric Acute and Chronic Pain: Systematic Review and Evidence Gap Map

BACKGROUND

The use of extended reality (XR), including virtual reality (VR) and augmented reality (AR), for treating pain has accelerated in the last 10 years. XR is an attractive biobehavioral intervention that may support management of pain or pain-related disability. Reviews of the literature pertaining to adults report promising results, particularly for acute procedural pain.

OBJECTIVE

This study aimed to (1) summarize the available evidence with respect to feasibility, safety, and effectiveness (pain intensity) of XR for pediatric acute and chronic pain; (2) summarize assessment tools used to measure study outcomes; and (3) identify gaps in evidence to guide future research efforts.

METHODS

This study is a systematic review of the literature. Multiple databases (CINAHL, Cochrane Central, Embase, MEDLINE, PsycINFO) were searched from inception until March 2023. Titles, abstracts, and full-text articles were reviewed by 2 team members to determine eligibility. Articles were included if the (1) participants were aged 0 to 18 years; (2) study intervention was VR or AR; (3) study outcomes included safety, feasibility, acceptability, or effectiveness on the outcome of pain; and (4) study design was observational or interventional. Data were collected on bibliographic information; study characteristics; XR characteristics; outcome domains; outcome measures; and study findings pertaining to safety, feasibility, and effectiveness.

RESULTS

We included 90 articles in the review. All included studies used VR, and 93% (84/90) studied VR in the context of acute pain. Of the 90 studies, 74 studies were randomized trials, and 15 studies were observational. Safety was assessed in 23 studies of acute pain, with 13 studies reporting no adverse events and 10 studies reporting events of low concern. Feasibility was assessed in 27 studies. Of the 84 studies of acute pain, 62% (52/84) reported a positive effect on pain intensity, 21% (18/84) reported no effect, and 13% (11/84) reported mixed effects. All 6 studies of chronic pain reported a positive effect on pain intensity. An evidence gap map was used to illuminate gaps in specific research areas stratified by subtypes of pain. Risk of bias assessment revealed 67 studies had a moderate risk of bias, 17 studies had a high risk, and 5 studies were deemed to be low risk.

CONCLUSIONS

The current body of literature around XR for pediatric pain is focused on acute pain with promising results of safety and effectiveness on pain intensity. The literature pertaining to chronic pain lags behind, limiting our ability to draw conclusions. The risk of bias in studies is problematic in this field, with the inherent challenge of blinding participants and researchers to the intervention. Future research should aim to measure effectiveness beyond pain intensity with a consistent approach to measuring key outcome domains and measures. Current efforts are underway to establish expert consensus on best research practices in this field.

TRIAL REGISTRATION

Prospero CRD42022307153; https://www.crd.york.ac.uk/PROSPERO/view/CRD42022307153.

Methods to discriminate between nociceptive, neuropathic and nociplastic in children & adolescents: A systematic review of psychometric properties and feasibility

The aim of this systematic review was to identify and critically analyse the tools available for categorising pain as nociceptive, neuropathic and nociplastic pain in children and adolescents. Studies were included if they (i) included children and adolescents with a mean age of 0-24 years old, (ii) examined assessment tools that categorise pain as nociceptive, neuropathic or nociplastic, and (iii) examined the psychometric properties of the tools. Sensitive searches were conducted in five online databases in March 2024. Eligible studies were assessed for risk of bias and quality by two authors using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria. The search yielded 26 studies for 11 tools. No assessment tool had evidence for all nine recommended psychometric properties. Quantitative Sensory Testing, a tool used to identify signs and symptoms of nociplastic and neuropathic pain, was the most studied tool and had moderate evidence for construct validity, criterion validity and reliability. Three self-reported questionnaires, the Self-reported Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), Central Sensitisation Inventory (CSI) and PainDETECT, had moderate evidence for construct validity and show promise as preliminary tools to identify possible neuropathic or nociplastic pain. However, they had low specificity when used in isolation. All assessment methods would benefit from further psychometric evaluation and validation in children and adolescents. PERSPECTIVE: This systematic review highlights the limited validation of pain assessment tools for children and adolescents. While Quantitative Sensory Testing and self-reported questionnaires show promise in identifying pain mechanisms, their applicability remains uncertain. Further psychometric validation is crucial to improve pain assessment and guide personalized treatment in young populations.

Lived and care experiences of young people with chronic musculoskeletal pain and mental health conditions: a systematic review with qualitative evidence synthesis

ABSTRACT

Chronic musculoskeletal pain (CMP) and coexisting mental health conditions impact young people; however, little is known about their lived and care experiences. In a prospectively registered systematic review with qualitative evidence synthesis (PROSPERO: CRD42022369914), we explored the following: (1) lived physical, psychological, and social experiences; and (2) care experiences/preferences of young people living with CMP and mental health conditions. Inclusion criteria: studies using qualitative methods; participants aged 16 to 24 years with CMP and coexisting mental health condition(s); phenomenon explored included lived and/or care experiences. Seven databases were searched (inception to 19-May-2024), study quality was assessed, data were extracted and analysed thematically, and GRADE-CERQual was used to assess confidence in findings. Twenty-two studies (23 reports) were included (>239 participants, 82% women). Lived experiences yielded 4 themes (9 findings): 2-way relationship between CMP and mental health (2 findings, low to moderate confidence); psychosocial implications of CMP (3 findings, very low-moderate confidence); uncertainty about future (2 findings, low-moderate confidence); coping with CMP and mental health conditions (2 findings, low-moderate confidence). Care experiences/preferences yielded 3 themes (8 findings): navigating healthcare systems (2 findings, moderate confidence); receiving appropriate care (3 findings, very low-moderate confidence); point-of-care experiences and care preferences (3 findings, very low-moderate confidence). Chronic musculoskeletal pain and mental health conditions are interconnected, significantly impacting young people's lives, identities, and socialisation, yet services for CMP and mental health are often inadequate and poorly integrated. The mechanisms and interplay of CMP and mental health require deeper exploration, including how young people may be better supported with personalised, holistic, developmentally and/or life-stage-appropriate integrated care.

Measuring and Contextualizing School Refusal in Pediatric Chronic Pain: Establishing the Psychometric Properties of the SChool REfusal EvaluatioN Measure for Youth With Chronic Pain

OBJECTIVE

School refusal is a longstanding difficulty for youth with chronic pain. Yet, research is hindered by a lack of adequate measurement tools to assess and describe the complex interpersonal and system-level factors contributing to school refusal. This study investigates the utility of the SChool REfusal EvaluatioN (SCREEN) measure and its psychometric properties in a sample of youth with chronic pain.

MATERIALS AND METHODS

Youth undergoing multidisciplinary evaluation at outpatient pain clinics completed self and parent-report questionnaires. Descriptive data examined school refusal. Internal consistency and construct validity were tested. Multiple regressions examined the parent and child factors related to school refusal.

RESULTS

In all, 698 youth with chronic pain participated. Two-thirds reported symptoms suggesting at-risk or clinically significant symptoms of school refusal. Cronbach alpha scores were in the acceptable to good range on the SCREEN. Convergent validity for the interpersonal discomfort subscale of the SCREEN was established. The child's fear of pain, stress, peer relationships, and parent protective behaviors significantly correlated with SCREEN total scores. Participants enrolled in fully in-person school during the study period reported significantly higher scores on the interpersonal discomfort scale than those enrolled in remote learning.

DISCUSSION

Our results provide evidence that youth with chronic pain experience significant challenges with school functioning and offer some support for the reliability and validity of the SCREEN in a sample of youth with chronic pain, a population for which few appropriate measures of school functioning have been established. The SCREEN measure may aid in assessing school refusal, with good clinical potential to quantify risk and identify modifiable factors.

Risk factors associated with the development and persistence of pain in adolescents: an international Delphi study

Introduction

Despite significant advancements in research on paediatric pain, a consensus on the primary risk factors (RFs) for the development and persistence of pain in this population has not yet been reached.

Objectives

This study aims to establish a consensus among experts on the most significant RFs for the onset and persistence of pain in adolescents.

Methods

A modified international e-Delphi study with 4 rounds was conducted. An international and multidisciplinary panel of experts in paediatric pain and/or pain RFs was recruited. The experts were provided with 2 lists of potential RFs (1 for the onset, 1 for the persistence of pain) and were asked to rate the importance of each RF on a 5-point Likert scale. In each round, experts were asked to reconsider their answers in light of other experts' evaluations and comments.

Results

A total of 43 experts participated in the study (33 completed all rounds). Forty-six RFs (out of 74) reached consensus for pain onset, and 4 were considered very important. Regarding the persistence of pain, consensus was reached on 56 out of 88 RFs. Eleven of these were found to be very important.

Conclusion

This study generated consensus among experts on the importance of several RFs for the development and persistence of pain in adolescents. This consensus will be valuable in informing the design of future longitudinal studies, as well as treatment and preventive programs.

Mapping the research landscape of mHealth and technology in pediatric chronic illness: a bibliometric study

Introduction

The presence of a chronic disease during adolescence has been linked to an increased risk of developing psychosocial problems and a greater likelihood of experiencing difficulties during the transition to adulthood. In this regard, research has been conducted on the development of applications or programs based on new technologies to address the potential complications associated with self-management and coping with chronic diseases in adolescents.

Method

The objective of the present study was to conduct a bibliometric analysis of the existing literature on the use of new technologies to enhance self-management and coping with chronic diseases during adolescence. This four-staged bibliometric analysis was conducted using the following software programs: HisCite, Bibexcel, Pajek, and VOSviewer. The programs were utilized for the extraction of data and the subsequent construction of graphs, which facilitate the visualization of existing networks between disparate authors, institutions, and terms.

Results

The screening results shortlisted a total of 157 articles from an initial 207. The further analysis of these records indicated that the United States was the most prominent nation in terms of scientific output in the domain of digital applications designed to enhance self-management and coping in chronic diseases during adolescence.

Discussion

The digital intervention in this specific population is primarily associated with the development of the mHealth app, along with the physical and psychological consequences that illness can entail. This research can serve as a reference for future bibliometric studies or scientific investigations in this field.

The role of fatigue in adolescents' chronic pain: A study on facets of fatigue in young patients with a chronic pain disorder

Fatigue has been proposed as a potential factor influencing the perception of pain, which could be pertinent for enhancing chronic pain treatment. Exploring the relationship between pain and fatigue during a 3-week inpatient interdisciplinary multimodal pain therapy program, we evaluated children and adolescents (11-18 years) who reported significant chronic pain. Assessment tools included the Multidimensional Fatigue Inventory and other clinical questionnaires. The participants had higher fatigue scores than healthy subjects, general fatigue was found to be associated with the perception of pain in a random-effects model. The connection between fatigue and pain in adolescents with chronic pain suggests that the degree of fatigue and the changes in fatigue were associated with the intensity of their pain. The participants' (N = 94) dimensions of fatigue and the intensity of their pain were reduced. We discuss implications for fatigue-reducing treatments in chronic pain management to reduce pain and augment pain management skills.

The Moderating Role of Ethnicity on Depressive and Anxiety Symptoms and Pain Catastrophizing in Hispanic/Latinx and Non-Hispanic/Latinx White Youth With Chronic Pain

OBJECTIVES

Chronic pain (CP) significantly impacts emotional and physical well-being and overall quality of life across diverse populations in the United States (US). Notably, under-represented minoritized (URM) groups, such as Hispanic/Latinx (H/L) youth, may experience disproportionate effects due to health disparities and lack of access to quality health care. However, this remains understudied. This study aimed to examine the association between CP and its related psychosocial factors-depressive and anxiety symptoms, and pain catastrophizing-in H/L youth, as compared with Non-Hispanic White (NHW) youth.

METHODS

The current study sample included 58 self-identifying H/L and 58 NHW youth seeking CP treatment at a large Northeastern tertiary pain clinic, ages 12 to 18 years old, (M=15.49, SD=1.71), of which 88% identified as biologically female. Participant samples for each group were age and-sex-matched.

RESULTS

Significant associations were found between anxiety and depressive symptoms and pain catastrophizing for youth in both groups. Ethnicity significantly moderated the associations between pain catastrophizing and depressive symptoms and between anxiety and depressive symptoms, with NHW youth with pain exhibiting stronger relations between these constructs when compared with H/L youth with pain.

DISCUSSION

Our results suggested that for NHW youth with CP, greater tendencies toward catastrophizing and experiences of anxiety may more strongly contribute to depressive symptoms, when compared with their Hispanic/Latinx youth counterparts. Further investigation of pain-coping mechanisms among H/L youth and other youth from historically marginalized populations (e.g., racial/ethnic minoritized groups) will help advance clinical understanding of sociocultural variability in links between pain-related psychosocial outcomes in the CP experience.

Treatment expectations and pain-related outcomes in clinical trials of digital cognitive-behavioral therapy for youth with chronic pain

Treatment expectations (TE) are predictive of patient outcomes in clinical practice and suggested to moderate treatment responses in chronic pain clinical trials. However, evidence is mainly derived from studies conducted with adult populations with musculoskeletal pain, primarily focused on pharmacological treatments and a few alternative intervention modalities (e.g., acupuncture). We examined the role of pretreatment TE in youth participating in two randomized controlled trials of digital cognitive-behavioral therapy (CBT) for chronic pain-the WebMAP2 Trial of youth with chronic primary pain (n = 273) and the iCC-SCD Trial of youth with sickle cell pain (n = 111). Specifically, we tested: 1) whether controlling for TE enhanced the detection of treatment efficacy, 2) the main effect of TE in predicting pain-related outcomes over time (regardless of treatment assignment), and 3) the effect of TE in moderating treatment efficacy (digital CBT vs education control). Findings indicated that adjusting for pretreatment TE did not enhance the ability to detect treatment efficacy. In the WebMAP2 Trial, higher pretreatment TE were associated with greater reductions in anxiety and lower CBT efficacy (relative to education control) in improving depressive and anxiety symptoms. In the iCC-SCD Trial, higher pretreatment TE were associated with greater improvement in mobility and enhanced CBT efficacy (relative to education control) for improving mobility. Overall, higher pretreatment TE were associated with better functioning over time, though the specific domains of improvement and the moderating effects on treatment efficacy somewhat differed between youth with primary and sickle cell-related chronic pain. PERSPECTIVE: Incorporating TE into clinical assessments and ensuring consistent collection, reporting, and analysis in clinical trials are crucial for identifying potential heterogeneous treatment responses. Standardizing TE measures for youth with chronic pain and considering population characteristics are important for understanding TE's role in treatment responses.

Pain Predicts Cannabis Initiation Among Emerging Adults: Results from the Population Assessment of Tobacco and Health (PATH) Study

Pain is highly prevalent among emerging adults (18-25 years old), and rates of cannabis use are increasing among this population. Research indicates pain is a unique risk factor and motivator for substance use. However, evidence for pain-cannabis use relations among emerging adults is largely cross-sectional, and the only prospective evidence focuses on the frequency, quantity, and consequences of cannabis use, not initiation. Accordingly, this is the first study to examine pain as a prospective predictor of cannabis initiation among emerging adults. Data were drawn from five annual waves of the Population Assessment of Tobacco and Health Study. Emerging adults who denied cannabis use at baseline (n = 4,185) were included in the analysis. At baseline, a tenth of emerging adults reported moderate/severe pain (≥4/10). Adjusted Cox regression analysis revealed that emerging adults with moderate/severe baseline pain were more likely to initiate cannabis use, and did so earlier over the subsequent 4 years, than those with no/low baseline pain. These findings provide initial evidence for pain as a risk factor for cannabis initiation during emerging adulthood. Future research is needed to identify mechanisms by which pain motivates cannabis initiation and to examine the utility of pain-targeted content in cannabis use prevention and intervention efforts among emerging adults.

Coping in youth living with chronic pain: A systematic review of qualitative evidence

Background

Chronic pain is progressively receiving attention as a universal public health priority. It is anticipated that there will be an increase in the prevalence of chronic pain in the coming years, particularly among youth. Chronic pain can be stressful and have a significant impact on young people and their family.

Aims

The aim of this systematic review was to synthesize the best available qualitative evidence on the coping experiences of youth living with chronic pain and to note whether there were any differences in their coping experiences.

Methods

A multi-database search was conducted including child development and adolescent studies. CINAHL, MEDLINE, PsycINFO, Embase, and Scopus were searched for eligible English-language articles from inception to December 2023. Out of 1625 article titles and abstracts screened for eligibility, 280 articles underwent full-text screening, with 20 ultimately meeting all inclusion criteria. We conducted a thematic analysis of data extracted from the 20 reviewed articles.

Results

We arrived at two synthesized findings. A Different Way of Being considers the experience of being a youth with chronic pain. Learning to Get By looks at the coping strategies youth use to manage their chronic pain and involved youth using self-directed strategies, as well as relying on external supports.

Conclusions

It is apparent from these synthesized findings that youths' lives have been significantly impacted by chronic pain. Findings from this study can be used to support the care and well-being of youth living with chronic pain.

Romancing With Pain: A Survey Study of Young Adults With Chronic Pain

BACKGROUND

Developing and maintaining romantic relationships is a hallmark of entry to adulthood. Studies suggest that young people with chronic pain often experience social challenges engaging in romantic intimacy, but these studies are limited as they (1) combined participants who were and were not in romantic relationships and (2) focused solely on heterosexual romantic relationships. It is unknown how young adults with chronic pain, inclusive of diverse genders and sexual orientations, perceive themselves on romantic relationship factors.

PURPOSE

To determine how pain-related factors are associated with romantic relationship factors when young adults with chronic pain are actively in a romantic relationship.

DESIGN

An online cross-sectional survey using validated questionnaires assessed chronic pain characteristics, romantic relationship factors, social well-being, and demographics. A social media campaign recruited 72 young adults (18-25 years) who were in a romantic relationship regardless of sexual orientation or gender identification.

RESULTS

Pain characteristics, not demographics, explained 23.6% of the variance in romantic relationship anxiety, suggesting that pain contributed to concerns about an individual needing their partner's approval and distress when their partner is unresponsive to their needs. Pain characteristics did not impact participants' present relationship satisfaction, but negatively impacted loneliness. Interestingly, loneliness was negatively associated with romantic relationship factors.

CONCLUSIONS

Nurses and members of the interprofessional team should reassure young adults with chronic pain that pain is not necessarily a limiting factor in romantic relationship satisfaction. Additionally, clinical staff should also assess loneliness as romantic relationships alone are insufficient in decreasing loneliness within this population.

Impact of BMI and Work Environment Circumstances on Prevalence and Severity of Chronic Pain among Nurses

PURPOSE

The objective of this study was to explore the relationship between workplace conditions, demographic characteristics, and physical attributes with the prevalence and severity of chronic pain among nurses. The goal was to gain insights into the factors contributing to chronic pain within the nursing profession.

METHODS

A cross-sectional descriptive-analytic study was conducted among 415 nurses in Turkey using purposive convenience sampling. Data collection instruments included the Graded Chronic Pain Scale, a body diagram, a pain exacerbator/alleviator inquiry, and a socio-demographic form. Data were analyzed using SPSS 25.

RESULTS

The majority of participants were female nurses (87.7%) with a mean age of 34.62 ± 9.32 and a body mass index (BMI) of 24.51 ± 4.32. Nearly half reported irregular exercise habits (49.9%), and 36.1% indicated high levels of work-related stress. A significant proportion exhibited moderate levels of work-related anxiety (39%), smoked (40%), and consumed alcohol (37.1%). Chronic pain was experienced by 40.9% on most days, with the head and lumbar regions being the most affected (45.5% and 44.1%, respectively). The study identified a significant association between BMI and pain frequency (p = .043) and severity (p < .014). Furthermore, pain localization and management strategies varied between male and female nurses.

DISCUSSION

The study's results underscore the substantial impact of chronic pain on nurses' quality of life, activity levels, and work attendance. Notably, the study provides results that support the relationship between BMI and chronic pain. The study revealed gender-specific differences in pain localization and management strategies among nurses, highlighting the importance of gender-tailored interventions in chronic pain management among nurses.

CONCLUSION

Addressing the interplay between BMI, work-related factors, and chronic pain is vital for nurses' well-being and a conducive work environment, potentially reducing financial costs associated with medical leave and absenteeism.

Adolescents' Use of Music for Pain Management

To investigate the experiences of adolescents with chronic pain who participated in an intensive interdisciplinary pain treatment program, this secondary study analyzes the themes that emerged regarding the spontaneous utilization of music in coping strategies for chronic pain. During research interviews focused on coping skills and treatment engagement, participants spontaneously reported using music as an effective coping strategy for managing pain. A deductive thematic analysis revealed key themes related to their usage, including using music as a distractor, motivator and in other ways as coping strategies. Since participants indicated that music is essential to their experiences of coping with pain, incorporating these strategies could improve the effectiveness of treatment protocols. To this end, further investigation is necessary to assess the impact of music on adolescents with chronic pain, focusing on its role in enhancing interdisciplinary treatment.

Adolescent predictors of substance use in young adulthood among individuals with childhood-onset chronic pain: A follow-up study

BACKGROUND

Adolescent chronic pain is a substantial public health problem, and pain symptoms often persist into adulthood. Young adults with chronic pain are at elevated risk for more frequent tobacco, alcohol and cannabis use, and cross-sectional research highlights the importance of psychosocial vulnerability factors. Limited research has examined how adolescent predictors, including mental health symptoms, pain, sleep and family functioning, impact later, young adult substance use.

METHODS

A prospective cohort of 229 young adults (77.3% female; Mage = 21.0, SD = 1.6) with childhood-onset chronic pain completed measurements in adolescence and a follow-up assessment in young adulthood of past 3-month substance use frequency.

RESULTS

Adolescent sleep quality and male sex were associated with more frequent tobacco use; adolescent depression was associated with more frequent alcohol use, and adolescent pain severity was associated with less frequent, and male sex was associated with more frequent cannabis use.

CONCLUSIONS

Adolescent predictors of young adult substance use among youth with childhood-onset chronic pain represent important factors that may inform assessment, prevention and treatment of substance use in this population. Identifying and testing psychological interventions that target these vulnerability factors may reduce overall substance use risk in young adulthood.

SIGNIFICANCE

This prospective observational study of young adults with childhood-onset chronic pain identified adolescent depression and sleep quality as vulnerability factors associated with substance use. Given the increasing risk for substance use during adolescence and young adulthood, these findings highlight the potential importance of early intervention to reduce substance use among young adults with childhood-onset chronic pain.

Experiences of Gender-Diverse Youth Living With Chronic Pain

BACKGROUND

Although sex differences in pain are well documented, little is known regarding the relationship between gender and pain. Gender-diverse youth experience unique pain risk factors, including minority stress exposure, but are underrepresented in research.

OBJECTIVE

Elicit experiences of gender-diverse youth who live with chronic pain.

METHODS

Semistructured interviews were conducted with youth virtually using Zoom. Youth were recruited from a Canadian tertiary care pediatric hospital, community-based clinics, and the general population. Interviews were recorded, transcribed, and analyzed with a patient partner using reflexive thematic analysis, integrating relevant existing theoretical and empirical models for understanding gender and pain, identity development, minority stress, and intersectionality.

RESULTS

The final sample included 19 youth who represented a variety of gender identities and pain conditions and reported accessing a range of types and levels of care. Three themes were identified through qualitative analysis: (1) the fight to legitimize both their pain and gender, (2) the tension between affirming gender and managing pain and the role of gender euphoria as a buffer against pain, and (3) the role of intersecting (eg, neurodiversity and race) identities in understanding gender-diverse youths' pain experiences.

CONCLUSIONS

In a diverse sample of gender-diverse youth who live with chronic pain, experiences of invalidation and difficulty managing pain were experienced in the context of unique stressors and sources of joy in living as a gender-diverse individual. These results point to the need for more intersectional and affirming pain research and integration of findings into clinical practice.

Mapping the Gaps: A Scoping Review of Virtual Care Solutions for Caregivers of Children with Chronic Illnesses

Background/Objectives: Caregivers of children with chronic illnesses, including chronic pain, experience high levels of distress, which impacts their own mental and physical health as well as child outcomes. Virtual care solutions offer opportunities to provide accessible support, yet most overlook caregivers' needs. We conducted a scoping review to create an interactive Evidence and Gap Map (EGM) of virtual care solutions across a stepped care continuum (i.e., from self-directed to specialized care) for caregivers of youth with chronic illnesses. Methods: The review methodology was co-designed with four caregivers. Data sources were the peer-reviewed scientific literature and a call for innovations. Records were independently coded and assessed for quality. Results: Overall, 73 studies were included. Most virtual care solutions targeted caregivers of children with cancer, neurological disorders, and complex chronic illnesses. Over half were noted at lower levels of stepped care (i.e., self-guided apps and websites), with psychological strategies being predominant (84%). However, very few addressed caregivers' physical health (15%) or provided family counseling (19%) or practical support (1%). Significant gaps were noted in interventions for managing caregiver chronic pain, despite its high prevalence and impact on child outcomes. Conclusions: Evidence and Gap Maps are innovative visual tools for knowledge synthesis, facilitating rapid, evidence-informed decision-making for patients, families, health professionals, and policymakers. This EGM highlighted high-quality virtual care solutions ready for immediate scaling and identified critical evidence gaps requiring prioritization. To address the complexities of pediatric chronic illnesses, including chronic pain, virtual care initiatives must prioritize family-centered, accessible, and equitable approaches. Engaging caregivers as partners is critical to ensure interventions align with their needs and priorities.

Deep proteomics and network pharmacology reveal sex- and age-shared neuropathic pain signatures in mouse dorsal root ganglia

Our understanding of how sex and age influence chronic pain at the molecular level is still limited with wide-reaching consequences for adolescent patients. Here, we leveraged deep proteome profiling of mouse dorsal root ganglia (DRG) from adolescent (4-week-old) and adult (12-week-old) male and female mice to investigate the establishment of neuropathic pain in the spared nerve injury (SNI)-model in parallel. We quantified over 12,000 proteins, including notable ion channels involved in pain, highlighting the sensitivity of our approach. Differential expression revealed sex- and age-dependent proteome changes upon nerve injury. In contrast to most previous studies, our comprehensive dataset enabled us to determine differentially expressed proteins (DEPs), which were shared between male and female mice of both age groups. Among these, the vast majority (94 %) were also expressed and, in part, altered in human DRG of neuropathic pain patients, indicating evolutionary conservation. Proteome signatures represented numerous targets of FDA-approved drugs comprising both (i) known pain therapeutics (e.g. Pregabalin and opioids) and, importantly, (ii) compounds with high potential for future re-purposing, e.g. Ptprc-modulators and Epoetins. Protein network and multidimensional analysis uncovered distinct hubs of sex- and age-shared biological pathways impacted by neuropathic pain, such as neuronal activity and synaptic function, DNA-damage, and neuroimmune interactions. Taken together, our results capture the complexity of nerve injury-associated DRG alterations in mice at the network level, moving beyond single-candidate studies. Consequently, we provide an innovative resource of the molecular landscape of neuropathic pain, enabling novel opportunities for translational pain research and network-based drug discovery.

Social Skills and Creativity as Elements That Enhance Resilience in Adolescence

Resilience plays a crucial role in overcoming the adversities and challenges faced by young people during adolescence. Current research focuses on understanding the factors that contribute to the development of resilience at this stage, with the goal of promoting the well-being and mental health of young people. In this descriptive cross-sectional study, we examined the relationship between social skills, creativity and resilience in a sample of 743 students aged 14 to 19 years from different educational centers in the province of Almería (Spain). We used the Social Skills Questionnaire (CHASO), the Turtle Creativity Questionnaire and the reduced resilience scale CDRISC-10 to collect data. Data analysis was performed using correlation analysis, Student's t-test for differences according to sex, analysis of variance to test for differences according to resilience groups, multiple regression analysis for predictors of resilience and simple mediation analysis. The results showed a positive and significant relationship between social skills, creativity, and resilience. The differences found suggest that being male and having a higher level of resilience increases the likelihood of having higher social skills and resilience. Social skills and creativity predicted resilience and social skills mediated the relationship between creativity and social skills. These findings highlight the importance of strengthening social skills and promoting creativity to enhance resilience in adolescents, which may have practical implications for the design of intervention and support programs.

The association between anxiety and depression symptoms and pain and function in adolescents and young adults with chronic pain: A meta-analysis

OBJECTIVE

Chronic pain in adolescents and young adults (AYAs) is associated with adverse functional and psychological outcomes; however, inconsistent findings across studies necessitate a comprehensive synthesis. This meta-analysis aimed to quantify associations between anxiety, depression, and pain/functional outcomes, and explore study and sample moderators, such as age, sex, pain duration, recruitment setting, and measurement tools.

METHODS

We searched MEDLINE, PsycINFO, CENTRAL, and Embase through May 2024. included 57 studies (N = 12,603) of AYAs aged 12-25 years with chronic pain. Risk of bias and GRADE assessments were conducted. Pearson r correlations were meta-analyzed using a random-effects model.

RESULTS

Small associations were found between anxiety, depression, and heightened pain intensity (r = 0.20, 0.24). Moderate-to-large associations were observed between anxiety, depression, and disability (r = 0.32, 0.34), pain interference (r = 0.47, 0.51), pain catastrophizing (both r = 0.50), and poorer quality of life (r = -0.56, -0.61). Anxiety had stronger correlations with pain intensity and catastrophizing in samples with more males. Anxiety measure moderated the anxiety-pain intensity relationship. Depression had stronger correlations with pain intensity for shorter pain duration, and catastrophizing and pain interference for longer pain durations. The depression-catastrophizing association was stronger in older samples.

CONCLUSION

Anxiety and depression significantly impact the chronic pain experience in AYAs, with stronger effects on functional outcomes and quality of life than pain intensity. Tailored interventions that consider age, sex, and pain duration may enhance treatment outcomes in this population.

Influence of pain neuroscience education and exercises for the management of neck pain: A meta-analysis of randomized controlled trials

BACKGROUND

It is elusive to combine pain neuroscience education with exercises to treat neck pain, and this meta-analysis aims to study the efficacy of pain neuroscience education plus exercises for the treatment of neck pain.

METHODS

Several databases including PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systemically searched from inception to August 2023, and we included the randomized controlled trials (RCTs) assessing the effect of pain neuroscience education plus exercises on the relief of neck pain.

RESULTS

We total included 4 eligible RCTs and 246 patients with neck pain in this meta-analysis. Compared with exercise intervention for neck pain, pain neuroscience education plus exercise was associated with remarkably decreased VAS after treatment (MD = -1.12; 95% CI = -1.51 to -0.73; P < .00001), VAS after 3 months (MD = -1.24; 95% CI = -2.26 to -0.22; P = .02), functional disability index (MD = -1.22; 95% CI = -1.46 to -0.97; P < .00001) and pain catastrophizing scale (MD = -4.25; 95% CI = -5.50 to -3.00; P < .00001).

CONCLUSIONS

Pain neuroscience education plus exercises is effective for the relief of neck pain.

Who develops chronic pain after an acute lower limb injury? A longitudinal study of children and adolescents

ABSTRACT

Prevention of chronic pain is a major challenge in this area of clinical practice. To do this, we must be able to understand who is most at risk of developing chronic pain after an injury. In this study, we aimed to identify risk factors of chronic pain onset, disability, and pain interference after a lower limb musculoskeletal injury in children and adolescents between 8 to 16 years of age. We assessed biopsychosocial factors including age, sex, pubertal status, anxiety, depression, fear of pain, pain worry, adverse life events, and sleep in children. We also assessed risk factors in parents including parent anxiety, depression, parent pain catastrophising, and protective behaviours. Logistic and hierarchical linear regressions identified risk factors assessed immediately postinjury for outcomes assessed at 3 months postinjury. Fourteen percent (17/118 children) reported chronic pain 3 months after injury. There were significant between-group differences in children with and without chronic pain at baseline. Children with chronic pain reported higher pain intensity, disability, pain interference, child depression, fear of pain, and catastrophic thinking about their pain. Regressions showed child depression and fear of pain at baseline independently predicted chronic pain onset at 3 months, parent protectiveness predicted child pain interference at 3 months, and child depression, poor sleep, parent anxiety and pain catastrophising predicted disability. Most children recover after a lower limb injury, but a minority develop chronic pain predicted by important psychosocial risk factors, which could be addressed to prevent the onset of treatment-resistant chronic pain and disability.

Anxiety and Depression in Youth With Chronic Pain: A Systematic Review and Meta-Analysis

Importance

For youth with chronic pain, anxiety and depression are reported as consequences of experiencing pain and maintaining factors of ongoing pain and disability. However, prevalence estimates of anxiety and depression remain unclear.

Objective

To report the prevalence of clinical anxiety and depression for youth with chronic pain and compare symptoms of anxiety and depression between youth with and without chronic pain.

Data Sources

MEDLINE, PsycINFO, CENTRAL, and Embase from inception to April 30, 2023.

Study Selection

Included studies that reported prevalence data or symptom scores for anxiety and/or depression in individuals younger than 25 years (mean, ≤18 years) with chronic pain and were published in English.

Data Extraction and Synthesis

From 9648 nonduplicate records, 801 full-text articles were screened. Screening and data extraction occurred in duplicate. Prevalence was determined using event rate calculations. Between-group symptom differences were calculated using Hedges g. Analyses were conducted using the random-effects model. Reporting bias and Grading of Recommendation, Assessment, Development, and Evaluation assessments were conducted.

Main Outcomes and Measures

Prevalence of anxiety and depression (based on diagnosis and clinical cutoff scores) and differences in anxiety and depression symptoms. Moderators of prevalence and symptom differences were analyzed when data allowed.

Results

A total of 79 studies were included with a total sample of 22 956 youth (n = 12 614 with chronic pain). Most youth were female (mean, 74%), with an age range of 4 to 24 (mean [SD], 13.7 [2.10]) years. The prevalence estimate of anxiety diagnoses was 34.6% (95% CI, 24.0%-47.0%) and the portion that exceeded clinical cutoff scores was 23.9% (95% CI, 18.3%-30.6%). The prevalence of depression diagnoses was 12.2% (95% CI, 7.8%-18.7%) and the portion that exceeded clinical cutoff scores was 23.5% (95% CI, 18.7%-29.2%). Youth with chronic pain had greater symptoms of anxiety (g = 0.61; 95% CI, 0.46-0.77) and depression (g = 0.74; 95% CI, 0.63-0.85) compared with controls. Sex, age, pain location, and recruitment sample may moderate anxiety and depression. Considerable heterogeneity was reported for all outcomes. Studies had a low reporting bias, and outcomes were moderate to high quality.

Conclusions and Relevance

The findings of this meta-analysis suggest that 1 in 3 youth with chronic pain meet criteria for anxiety disorder, and 1 in 8 meet criteria for a depressive disorder. This represents a major clinical comorbidity. Moving forward, screening, prevention, and treatment of mental health should be important health care priorities for youth with chronic pain.

Probing white matter microstructure in youth with chronic pain and its relation to catastrophizing using neurite orientation dispersion and density imaging

ABSTRACT

Chronic pain is common in young people and can have a major life impact. Despite the burden of chronic pain, mechanisms underlying chronic pain development and persistence are still poorly understood. Specifically, white matter (WM) connectivity has remained largely unexplored in pediatric chronic pain. Using diffusion-weighted imaging, this study examined WM microstructure in adolescents (age M = 15.8 years, SD = 2.8 years) with chronic pain (n = 44) compared with healthy controls (n = 24). Neurite orientation dispersion and density imaging modeling was applied, and voxel-based whole-white-matter analyses were used to obtain an overview of potential alterations in youth with chronic pain and tract-specific profile analyses to evaluate microstructural profiles of tracts of interest more closely. Our main findings are that (1) youth with chronic pain showed widespread elevated orientation dispersion compared with controls in several tracts, indicative of less coherence; (2) signs of neurite density tract-profile alterations were observed in several tracts of interest, with mainly higher density levels in patients; and (3) several WM microstructural alterations were associated with pain catastrophizing in the patient group. Implicated tracts include both those connecting cortical and limbic structures (uncinate fasciculus, cingulum, anterior thalamic radiation), which were associated with pain catastrophizing, as well as sensorimotor tracts (corticospinal tract). By identifying alterations in the biologically informative WM microstructural metrics orientation dispersion and neurite density, our findings provide important and novel mechanistic insights for understanding the pathophysiology underlying chronic pain. Taken together, the data support alterations in fiber organization as a meaningful characteristic, contributing process to the chronic pain state.

Helping Educators Learn Pediatric Pain Assessment and Intervention Needs Program (HELP PAIN): Program Development with Community Partners

BACKGROUND/OBJECTIVES

This paper details the development of the Helping Educators Learn Pediatric Pain Assessment and Intervention Needs (HELP PAIN) program.

METHODS

HELP PAIN is an 8 h live training program for school providers (e.g., school nurses and social workers) to use evidence-based nonpharmacologic pediatric pain management tools. The program's scope reflected the reach of the participating intermediary community organizations, resulting in focused training in rural northwest Michigan due to the Health Department of Northwest Michigan's service in that region and statewide reach due to the broad representation of members from the Michigan Association of School Nurses.

RESULTS

We describe the development of the HELP PAIN program, drawing on evidence-based nonpharmacologic (e.g., cognitive behavioral and mindfulness meditation) strategies for pediatric pain management.

CONCLUSIONS

In partnership with the key community organizations and community partners, we developed, interactively refined, and delivered this training program.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Factors Affecting Health Care Utilization Associations Among Young Adolescents With Persistent or Recurrent Pain

BACKGROUND

It is unclear how family factors affect health care utilization among youth with persistent or recurrent pain, despite potential relevance to interventions targeting treatment barriers.

OBJECTIVE

We aimed to examine health care utilization among young adolescents with persistent or recurrent pain and family factor influences toward higher health care utilization.

METHODS

We analyzed longitudinal data from the Adolescent Brain Cognitive Development Study and coded pain as none, infrequent (present 1-2 years), or persistent/recurrent pain (present 3-4 years). Higher health care utilization was coded as nonroutine or emergency department visit at ≥2 years. Parent-reported education, pain status, family income, and insurance status were recorded. Logistic regression examined the contributions of the child's pain and family factors toward higher health care utilization.

RESULTS

Among 5960 youth, 1908 (32%) had persistent/recurrent pain and 2199 (37%) had infrequent pain. Youth with persistent/recurrent pain were more likely to have higher health care utilization compared to those without pain (adjusted odds ratio [OR]: 2.39) or those with infrequent pain (OR: 1.79). Higher health care utilization was associated with parents' pain (adjusted OR: 1.22) and higher education (adjusted OR: 1.44), and family income below the poverty line (adjusted OR: 1.26), controlling for child characteristics and pain status.

CONCLUSION

Findings show how youths' persistent/recurrent pain, parental, and family socioeconomic factors affect health care utilization among young adolescents, emphasizing a need for family-centered care and economic policies.

Credibility, readability and content analysis of treatment recommendations for adolescents with nonspecific back pain published on consumer websites

BACKGROUND

Parents may seek out health information online when their adolescent has nonspecific back pain to better understand treatment options. Such information directed towards consumers has not been previously analysed.

METHODS

A descriptive cross-sectional content analysis was performed to describe the treatments recommended on consumer websites for nonspecific back pain in adolescents. The credibility and readability of the websites were also assessed. Systematic Google searches were completed in five countries, and relevant content from eligible web pages was analysed. An a priori codebook with 34 treatment-related codes was developed. Nine additional codes were inductively created during analysis. Credibility was assessed using the JAMA benchmark. Readability was assessed via the Flesch Kincaid Grade Level.

RESULTS

Of 245 web pages, 48 were deemed eligible and analysed. Of 43 treatment codes, 37 were present in at least one web page. The five most frequently identified codes were See the doctor/get a diagnosis (found on 85% of web pages), Ergonomics/posture/biomechanics (52%), Reassurance (48%), Physiotherapy (48%) and Non-prescription pharmaceuticals/supplements (46%). Only 21% of the web pages met all four JAMA benchmark criteria, and 15% cited at least one recent or high-quality source. The median Flesch Kincaid Grade Level score was 9.0 (range 3.5-12.9).

CONCLUSIONS

Parents of adolescents with nonspecific back pain may find that treatment recommendations published online are numerous and varied, with visits to the doctor encouraged. The credibility scores of these web pages are generally low, while the median reading level may be too high for the general population.

SIGNIFICANCE STATEMENT

This analysis reveals that public-facing websites with recommendations for treating adolescent nonspecific back pain do not cite the most recent, high-quality research. Although web pages correctly encourage physical activity and exercise over surgery and prescription medications, they do not reflect the psychologically informed or interdisciplinary care emphasized in recently published treatment recommendations. Clinicians must be aware that caregivers of their adolescent patients with nonspecific back pain may be exposed to online messages that encourage them to keep seeking a diagnosis.

The Effectiveness of Pain Science Education on Caregiver and Children's Knowledge, Beliefs, Attitudes, and Behaviors-A Systematic Review and Meta-Analysis

Pain science education (PSE) can be used as part of treatment and prevention for chronic pain in children. We assessed the effectiveness of PSE on knowledge, beliefs, attitudes, and behaviors in children and the people that care for children. We set a minimum criterion for education to address pain biology knowledge. We included studies aimed at both treatment and prevention of chronic pain. We conducted searches using 5 databases. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool. Data were pooled using a random-effects meta-analysis or assessed using a narrative synthesis. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation. We screened 14,505 records and included 7 studies involving 351 caregivers and 1,285 children. Four studies were included in meta-analyses. We found low-certainty evidence that PSE has a large beneficial effect on caregiver knowledge and beliefs compared with alternative education (standardized mean difference = 1.14 [95% confidence interval: .88-1.42]; I2 = 0%). We found no difference in functional disability in children with chronic pain after PSE (Functional Disability Inventory score mean difference = .73 [95% confidence interval: -.81 to 2.27; I = 0%]). Narrative syntheses showed low-certainty evidence for improved knowledge and beliefs in children with preventative and treatment effects. Overall, we found few studies, and along with high risk of bias, this significantly contributed to the low certainty of findings. The effect of learning pain science for both preventative and treatment effects in children, carers, and the child/carer dyad remains mostly unknown. This review was prospectively registered with The international Prospective register of systematic reviews (CRD42022344382) on July 22, 2022. PERSPECTIVE: This review examines the effect of PSE on pain-related knowledge, beliefs, attitudes, and behaviors in children and the people that care for children (0-18). The findings contribute to knowledge about pain treatments and health promotion for caregivers and their children with and without chronic pain.

Early childhood risk factors for later onset of pediatric chronic pain: a multi-method longitudinal study

BACKGROUND

Pediatric chronic pain (i.e., pain lasting ≥ 3 months) is prevalent, disabling, and costly. It spikes in adolescence, interrupts psychosocial development and functioning, and often co-occurs with mental health problems. Chronic pain often begins spontaneously without prior injuries and/or other disorders. Prospective longitudinal cohort studies following children from early childhood, prior to chronic pain onset, are needed to examine contributing factors, such as early pain experiences and mental health. Using data from a longitudinal community pregnancy cohort (All Our Families; AOF), the present study examined the associations between early developmental risk factors, including early childhood pain experiences and mental health symptoms, and the onset of pediatric chronic pain at ages 8 and 11 years.

METHODS

Available longitudinal AOF data from child age 4 months, as well as 1, 2, 3, 5, 8, and 11 years, were used. Mothers reported their child's pain experiences (e.g., hospitalizations, vaccinations, gut problems) at each timepoint from 4 months to 8 years, child chronic pain at age 8, and child mental health symptoms at ages 5 and 8 years. Children reported their chronic pain frequency and interference at age 11. Adaptive least absolute shrinkage and selection operator (LASSO) regressions were used to select predictor variables. Complete case analyses were complemented by multiple imputation using chained equation (MICE) models.

RESULTS

Gut problems, emergency room visits, frequent pain complaints, and headaches at age 5 or earlier, as well as female sex, were associated with increased risk of maternal reported child chronic pain at age 8. Maternal reported chronic pain at age 8 was associated with higher levels of child-reported pain frequency and pain interferences at age 11. Boys self-reported lower levels of pain interference at age 11.

CONCLUSIONS

Some, but not all, painful experiences (e.g., gut problems, ER visits, pain complaints) in early life contribute to pediatric chronic pain onset and should be considered for screening and early intervention.

A systematic review of the prevalence of chronic postsurgical pain in children

Two prior reviews highlight the scarcity and conflicting nature of available data on chronic postsurgical pain in children, reporting a wide prevalence range of 3.2% to 64% (at ≥3 months). This updated systematic review aimed to consolidate information on the prevalence of pediatric chronic postsurgical pain. A thorough literature search of full English-text publications from April 2014 to August 2021 was conducted using Ovid MEDLINE, PubMed, and Cochrane Database of Systematic Reviews, with search terms: postoperative pain, child, preschool, pediatrics, adolescent, chronic pain. Seventeen relevant studies were identified. Most assessed chronicity once greater than 3 months duration postoperatively (82%), were predominantly prospective (71%) and conducted in inpatient settings (88%). The surgeries examined included orthopedic (scoliosis and limb), urological, laparotomy, inguinal, and cardiothoracic procedures, involving numbers ranging from 36 to 750, totaling 3137 participants/2792 completers. The studies had wide variations in median age at surgery (6 days to 16 years), the percentage of female participants (unspecified or 12.5% to 90%), and follow-up duration (2.5 months to 9 years). Various pain, functional, psychosocial, and health-related quality of life outcomes were documented. Chronic postsurgical pain prevalence varied widely from 2% to 100%. Despite increased data, challenges persist due to heterogeneity in definitions, patient demographics, mixed versus single surgical populations, diverse perioperative analgesic interventions, follow-up durations and reported outcomes. Interpretation is further complicated by limited information on impact, long-term analgesia and healthcare utilization, and relatively small sample sizes, hindering the assessment of reported associations. In some cases, preoperative pain and deformity may not have been addressed by surgery and persisting pain postoperatively may then be inappropriately termed chronic postsurgical pain. Larger-scale, procedure-specific data to better assess current prevalence, impact, and whether modifiable factors link to negative long-term outcomes, would be more useful and allow targeted perioperative interventions for at-risk pediatric surgical patients.

Barriers and facilitators to transition from pediatric to adult healthcare for immigrant youth with chronic health conditions

PURPOSE

The objective of this study was to investigate the experience of first- and second- generation immigrant youth living with chronic health conditions in Canada, their parents or caregivers, and healthcare and service providers who care for immigrant youth, regarding the transition from pediatric to adult healthcare.

DESIGN AND METHODS

We conducted semi-structured individual interviews and focus groups. Youth were 1st or 2nd generation immigrants, aged 16-25, with pediatric-onset chronic health conditions. Parents or caregivers had raised youth children as described. Providers delivered healthcare or other services to immigrant populations. Thematic analysis was conducted of all transcripts.

RESULTS

Twenty youth, 14 parents/caregivers and five service providers participated. Most participants described healthcare transition as very difficult to navigate. Two major themes emerged across participant narratives: 1. Barriers to transition: lack of family experience in Canada, language, discrimination, financial strain, stigma, and long wait times. Some of these barriers are specific to newcomer families, but others are generalizable to the Canadian population. 2. Facilitators of transition: youth independence, youth acting as cultural bridges within their families, and cross-sector support between healthcare, education, social work and settlement services.

CONCLUSIONS

Immigrant youth and their families face a broad range of barriers to healthcare transition. The collaborative nature of cross-sector support effectively addressed some of the barriers faced by newcomer families.

PRACTICE IMPLICATIONS

Clinicians should provide immigrant youth and their families with accessible information about the health condition and how to navigate the adult healthcare system prior to transition, particularly when language barriers exist.

Brain Function and Pain Interference After Pediatric Intensive Interdisciplinary Pain Treatment

OBJECTIVES

Intensive interdisciplinary pain treatments (IIPTs) are programs that aim to improve functioning in youth with severe chronic pain. Little is known about how the brain changes after IIPT; however, decreased brain responses to emotional stimuli have been identified previously in pediatric chronic pain relative to healthy controls. We examined whether IIPT increased brain responses to emotional stimuli, and whether this change was associated with a reduction in pain interference.

PATIENTS AND METHODS

Twenty youths with chronic pain aged 14 to 18 years were scanned using functional magnetic resonance imaging, pre and post-IIPT. During the functional magnetic resonance imaging, patients were presented with emotional stimuli (ie, faces expressing happiness/fear), neutral expressions, and control (ie, scrambled) images. Patients completed a measure of pain interference pre and post-IIPT. Paired t tests were used to examine differences in brain activation in response to emotional versus neutral stimuli, pre to post-IIPT. Data from significant brain clusters were entered into linear mixed models to examine the relationships between brain activation and impairment pre and post-IIPT.

RESULTS

Patients demonstrated a decrease in middle frontal gyrus (MFG) activation in response to emotional stimuli (happy + fear) relative to scrambled images, between pre and post-IIPT ( P < 0.05). Lower MFG activation was associated with lower pain interference, pre and post-IIPT ( P < 0.05).

CONCLUSION

Contrary to our hypothesis, IIPT was associated with a reduction in MFG activation to emotional stimuli, and this change was associated with reduced pain interference. The MFG is a highly interconnected brain area involved in both pain chronification and antinociception. With further validation of these results, the MFG may represent an important biomarker for evaluating patient treatment response and target for future pain interventions.

Internet-Delivered Psychological Pain-Management for Young Adults With Chronic Pain: An Investigation of Clinical Trial Data

Young adults report chronic pain at rates of around 12% but lack access to clinical services. There is interest in learning how this emerging adult population engages with and responds to treatment. Using data from young adults aged 18 to 30 years (Mage = 25.8, SD = 3.2), taken from 4 previous randomised controlled trials, the current study investigated the feasibility, acceptability, and efficacy of an internet-delivered psychological pain-management intervention for young adults with chronic pain. We compared young adults in a treatment group (n = 104) with 1) a young-adult wait-list control group (n = 48), and 2) a treatment group reflecting the average-aged participant from the previous trials (39-63 years, n = 561). Feasibility was determined through treatment engagement, adherence and completion, and acceptability through a treatment satisfaction measure. Clinical outcomes were disability, pain intensity, anxiety, and depression; assessed at pre-treatment, post-treatment, and 3-month follow-up. Generalised estimation equation analyses were undertaken, using multiple imputations to account for missing data. Young adults had high engagement and acceptability ratings, though 34% did not complete the intervention. The treatment group significant improved across all outcomes, compared with control, with improvements maintained at follow-up. Post-treatment improvements were equivalent for young-adult and average-aged adult treatment groups, with no significant differences in feasibility or acceptability outcomes. Findings indicate young adults can engage with and show improvements following a psychological pain-management intervention designed for all adults with chronic pain. Future research is encouraged to examine outcomes related to role functioning of young adults, and moderators of treatment acceptability and efficacy for this population. PERSPECTIVE: Secondary analysis of data from 4 RCTs found an Internet-delivered psychological pain-management intervention acceptable and clinically efficacious for improving disability, anxiety, depression and pain intensity in young adults (18-30) with chronic pain.

A Systemic Review of the Psychosocial Aspects of Chronic Pain in Youth With Sickle Cell Disease

OBJECTIVES

The psychosocial aspects of chronic pain among youth with sickle cell are poorly described and may be better understood within a biopsychosocial model of chronic pain as applied to youth living with sickle cell disease.

DESIGN

A systematic literature review was performed to synthesize the psychosocial factors contributing to chronic pain in this population. Criteria for study inclusion were primary quantitative research studies focused on psychosocial aspects of chronic pain among youth with sickle cell disease.

DATA SOURCES

PubMed, CINAHL, PsychINFO, and Scopus were searched for relevant articles.

REVIEW/ANALYSIS METHODS

Articles selected for full-text review were appraised for quality using the Joanna Briggs Institute Quality Appraisal Tools. Thirteen articles were included.

RESULTS

Depression, anxiety, pain catastrophizing, pain coping, executive functioning, and functional impairment were prevalent in youth living with sickle cell disease and chronic pain. Research gaps included the influence of stigma, injustice, peer interactions, and school and work on chronic pain.

CONCLUSIONS

The biopsychosocial model of chronic sickle cell disease-related pain for youth was developed and modified based on the results of this systematic review to remind clinicians of the various factors to consider in clinical practice and spur additional research in this field.

Explaining the Components of Resilience in Patients with Chronic Pain: A Qualitative Content Analysis

Background

Resilience is a psychological trait and a protective factor that plays a vital role in coping with Chronic Pain (CP). Despite its importance, research has yet to fully clarify the concept and components of resilience in patients with CP. Accordingly, the present study aims to explain the components of resilience in patients with CP.

Materials and Methods

The current qualitative study used a conventional content analysis methodology. The research population included all patients with CP who were referred to clinics affiliated with Shiraz University of Medical Sciences (south of Iran) from August 2021 to August 2022. Participants were selected using the purposive sampling method. In-depth semi-structured interviews were conducted with 20 participants to collect information. Data analysis was conducted using MAXQDA 2020 software in conjunction with data collection efforts.

Results

Generally, in the current study, 30 sub-sub-categories, 11 sub-categories, and five main categories were extracted as components of resilience in patients with CP. The main categories of resilience against CP included the following: 1. emotional self-regulation, 2. psychological flexibility, 3. self-care, 4. appeal to religion-spirituality, and 5. internal resources and individual competencies.

Conclusions

The present study highlights the different physical, mental, and religious-spiritual strategies that may contribute to resilience against pain. The resilience components identified in this study provide a foundation for healthcare professionals, particularly nurses, to design and implement diverse pain management strategies that enhance adjustment to CP conditions.

Cost-of-illness and Economic Evaluation of Interventions in Children and Adolescents With Chronic Pain: A Systematic Review

OBJECTIVES

Chronic pain in children and adolescents (CPCA) is widespread with an increasing prevalence. It is associated with a decreased quality of life and an increased parental work loss. Accordingly, CPCA may pose a substantial economic burden for patients, health care payers, and society. Therefore, this systematic review aimed to synthesize (1) the results of existing cost-of-illness studies (COIs) for CPCA and (2) the evidence of economic evaluations (EEs) of interventions for CPCA.

METHODS

The systematic literature search was conducted in EMBASE, MEDLINE, PsycINFO, NHS EED, and HTA Database until February 2023. Title, abstract, and full-text screening were conducted by 2 researchers. Original articles reporting costs related to CPCA published in English or German were included. Study characteristics, cost components, and costs were extracted. The quality of studies was assessed using standardized tools. All costs were adjusted to 2020 purchasing power parity US dollars (PPP-USD).

RESULTS

Fifteen COIs and 10 EEs were included. The mean annual direct costs of CPCA ranged from PPP-USD 603 to PPP-USD 16,271, with outpatient services accounting for the largest share. The mean annual indirect costs ranged from PPP-USD 92 to PPP-USD 12,721. All EEs reported a decrease in overall costs in treated patients.

DISCUSSION

The methodology across studies was heterogeneous limiting the comparability. However, it is concluded that CPCA is associated with high overall costs, which were reduced in all EEs. From a health-economic perspective, efforts should address the prevention and early detection of CPCA followed by specialized pain treatment.

Opioid use disorder in pediatric populations: considerations for perioperative pain management and precision opioid analgesia

INTRODUCTION

Opioids are commonly used for perioperative analgesia, yet children still suffer high rates of severe post-surgical pain and opioid-related adverse effects. Persistent and severe acute surgical pain greatly increases the child's chances of chronic surgical pain, long-term opioid use, and opioid use disorder.

AREAS COVERED

Enhanced recovery after surgery (ERAS) protocols are often inadequate in treating a child's severe surgical pain. Research suggests that 'older' and longer-acting opioids such as methadone are providing better methods to treat acute post-surgical pain. Studies indicate that lower repetitive methadone doses can decrease the incidence of chronic persistent surgical pain (CPSP). Ongoing research explores genetic components influencing severe surgical pain, inadequate opioid analgesia, and opioid use disorder. This new genetic research coupled with better utilization of opioids in the perioperative setting provides hope in personalizing surgical pain management, reducing pain, opioid use, adverse effects, and helping the fight against the opioid pandemic.

EXPERT OPINION

The opioid and analgesic pharmacogenomics approach can proactively 'tailor' a perioperative analgesic plan to each patient based on underlying polygenic risks. This transition from population-based knowledge of pain medicine to individual patient knowledge can transform acute pain medicine and greatly reduce the opioid epidemic's socioeconomic, personal, and psychological strains globally.

Patient-Reported Wait Times and the Impact of Living with Chronic Pain on their Quality of Life: A Waiting Room Survey in Chronic Pain Clinics in Ontario, Manitoba, and Quebec

Background

Wait times at Canadian multidisciplinary pain clinics have been reported as excessive for nearly 2 decades.

Aims

The aim of this study was to gain insight into the patient experience of waiting for chronic pain specialty care.

Methods

A cross-sectional survey of new patients waiting for an appointment was conducted in six multidisciplinary pain clinics, including one pediatric clinic, in Ontario, Quebec, and Manitoba between February 2020 and October 2022. Participants were asked about the length of time they waited for their appointment since being referred, their quality of life, health care professionals seen while waiting, and an open-ended question, "Is there anything else you'd like to tell us?"

Results

Among the 493 adult and 100 pediatric respondents, 53% of adults and 82% of children reported wait times under 6 months, whereas 22% of adults and 4% of children waited longer than a year. Between 52% and 63% of adults and 29% to 48% of children reported being affected by chronic pain "quite a bit" or "extremely" on measures of quality of life. The most visited health care professionals while waiting for a pain clinic appointment were family doctors/nurse practitioners for adults and physiotherapists for children. Qualitative analysis of open-ended question responses revealed eight themes: system navigation issues, administrative issues, decreased quality of life, distress, self-advocacy, coping strategies, communication, and distrust.

Conclusions

Our findings provide real-time regional snapshots into the impact of long wait times experienced by Canadians living with chronic pain. There is an urgent need to better support patients during the waiting period. Expanding technologies such as electronic consultation hold great promise.

Understanding the impacts of chronic pain on autistic adolescents and effective pain management: a reflexive thematic analysis adolescent-maternal dyadic study

OBJECTIVE

Sensory elements are core features in chronic pain and autism, yet knowledge of the pain experience in autistic adolescents is limited. Little is known regarding how autistic adolescents experience chronic pain, manage their pain and perceive psychological treatment for their chronic pain.

METHODS

Ten autistic adolescents (6 female, 3 male, and 1 self-identified as agender) with chronic pain and their mothers (n = 10) participated in semistructured interviews concerning their perceptions of living with chronic pain. Participants were recruited from U.K. pain management services. According to preference, interviews were conducted individually (n = 10) or dyadically (n = 10 participants across 5 dyads). Data were analyzed using inductive reflexive thematic analysis.

RESULTS

Two themes were generated. Theme 1, "overstimulated and striving for control" described how adolescents' experience of heightened sensitivity enhanced adolescents' levels of anxiety and subsequent pain, illustrating a reciprocal relationship between anxiety, pain, and sensory elements. Theme 2, "not everyone fits the mold" captured how autistic adolescents positioned themselves as distinct from others due to the unique nature of being autistic and living with pain. This sense of difference negatively impacted adolescents' ability to engage with and benefit from the standard treatment for chronic pain.

CONCLUSIONS

Findings suggest that autistic adolescents living with pain experience pain and face barriers to effective pain treatment. Our results identify the need for educational resources to facilitate clinicians to better understand the experience of autistic adolescents living with pain. In turn, such understanding may improve treatment and outcomes in this population.

The Health Care Transition Needs of Adolescents and Emerging Adults with Chronic Pain: A Narrative Review

The aim of this narrative review was to provide an overview of what is known about the health care transition process in pediatric chronic pain, barriers to successful transition of care, and the roles that pediatric psychologists and other health care providers can play in the transition process. Searches were run in in Ovid, PsycINFO, Academic Search Complete, and PubMed. Eight relevant articles were identified. There are no published protocols, guidelines, or assessment measures specific to the health care transition in pediatric chronic pain. Patients report many barriers to the transition process, including difficulty attaining reliable medical information, establishing care with new providers, financial concerns, and adapting to the increased personal responsibility for their medical care. Additional research is needed to develop and test protocols to facilitate transition of care. Protocols should emphasize structured, face-to-face interactions and include high levels of coordination between pediatric and adult care teams.

Utilization of an Educational Liaison for Coordinated Care Between the Medical Home and School-Based Professionals for Students with Chronic Pain

BACKGROUND

Pediatric programs focused on treating chronic pain often do not include an educational liaison (EL) to coordinate services between the patient's medical home and school. As chronic pain in youth can have deleterious effects on school functioning, collaboration between the medical home and the school system are needed to assure these students receive appropriate accommodations.

CONTRIBUTIONS TO THEORY

This manuscript describes a model of coordinated care for students with chronic pain that includes a systemic strategy for collaborative care across settings. Specifically, the role of an EL is described in the context of advocating for the patient to receive appropriate educational accommodations.

CONCLUSIONS

This paper provides a guide for caregivers and professionals to assure appropriate access to support services across settings. Recommendations are included for school accommodations and services to improve academic functioning and outcomes for students with chronic pain.

Exploring Referral and Service Utilization Patterns Within an Outpatient Interdisciplinary Pediatric Chronic Pain Program

Purpose

We examine referral sources and clinical characteristics for youth presenting to an outpatient interdisciplinary pediatric chronic pain program.

Patients and Methods

Referral data were extracted from the electronic health record. PROMIS Pediatric Anxiety and Pain Interference Scales were administered at an initial evaluation visit.

Results

The program received 1488 referrals between 2016 and 2019, representing 1338 patients, with increasing volume of referrals over time. Referrals were primarily from orthopedics (19.6%), physical medicine and rehabilitation (18.8%), neurology (14.4%), and rheumatology (12.6%). Patients referred were primarily female (75.4%), White (80.1%), English-speaking (98.4%) adolescents (median=15.0 years). Of those referred, 732 (54.7%) attended an interdisciplinary evaluation (ie, with ≥2 disciplines). Adolescent anxiety was within the expected range by self-report (N=327, MT-score=55.67) and parent proxy-report (N=354, MT-score=57.70). Pain interference was moderately elevated by self-report (N=323, MT-score=61.52) and parent proxy-report (N=356, MT-score=64.02). There were no differences between patients referred who attended versus did not attend an interdisciplinary evaluation based on age, sex, ethnicity, or language. A smaller than expected proportion of referred Black patients (44%, P=0.02) and patients referred from orthopedics (40%) or pulmonology (11%) attended an evaluation, whereas a larger than expected proportion of those referred from physical medicine and rehabilitation (78%) were evaluated (P<0.001).

Conclusion

Results highlight the demand for outpatient interdisciplinary pediatric chronic pain treatment. Findings can inform decisions related to staffing and service design for pediatric hospitals that aim to establish or grow outpatient pediatric chronic pain programs.

Recommendations for Patient-Reported Outcomes Measurement Information System pediatric measures in youth with chronic pain: a COnsensus-based Standards for the selection of health Measurement INstruments systematic review of measurement properties

ABSTRACT

The Patient-Reported Outcome Measurement Information System (PROMIS) pediatric measures assess physical, emotional, and social health among children and adolescents. However, their measurement properties have not been systematically examined in youth with chronic pain. A systematic review applying the COnsensus based Standards for the selection of health Measurement INstruments (COSMIN) methodology was conducted to evaluate self-reported PROMIS pediatric measures in youth with chronic pain, assessing 8 measurement properties across all versions (item bank, short form, and computer adaptive testing) from 63 studies covering 25 measures. Moderate or high-quality evidence was most available for content validity, structural validity, internal consistency (measurement precision), and construct validity. Four short-form PROMIS pediatric measures-mobility, anxiety, depressive symptoms, and physical stress experiences-achieved recommendation for the use in chronic pain clinical trials; 7 approached recommendation and 14, including the commonly used PROMIS Pediatric Pain Interference Scale, would be recommended with further evidence. Recommendations were also provided for the use of each measure in observational studies. Overall, based on the existing evidence, a total of 11 self-reported PROMIS pediatric short-form measures, including pain intensity, pain behavior, mobility, sleep disturbance, sleep-related impairment, anxiety, depressive symptoms, psychological stress experiences, physical stress experiences, family relationships, and positive effect, are recommended or approaching recommendation for use in youth ages 8 to 19 years with chronic pain. Research is needed to further establish test-retest reliability, measurement errors, cross-cultural validity, and responsiveness. Future work should expand the evaluation of PROMIS pediatric measures in subpopulations of youth with chronic pain, particularly young children and those with neurodevelopmental disabilities.

And what about today? Burden and support needs of adolescent childhood cancer survivors in long-term follow-up care-A qualitative content analysis

PURPOSE

Childhood cancer affects approximately 2000 children annually in Germany, and there is an increasing number of long-term childhood cancer survivors. Due to developmental tasks, adolescent survivors in long-term follow-up (LTFU) care may face specific challenges and perceive different burden due to their disease. The current study explored (a) the impact of cancer and burden regarding survivorship and (b) supportive needs of adolescent childhood cancer survivors in LTFU care.

METHODS

Semistructured qualitative interviews were conducted with 18 adolescent childhood cancer survivors in LTFU care aged 14-18 years (average age 16.4 years). Interviews were transcribed verbatim and analysed using content analysis.

RESULTS

Based on the exploratory research questions, two key categories were generated: (1) The impact and burden on survivors' lives during LTFU care and (2) support needs of adolescent childhood cancer survivors in LTFU care. The four subcategories that emerged regarding the impact and burden on survivors' lives during LTFU care were (1) physical consequences, (2) cognitive impairments, (3) difficulties in social interactions, and (4) psychosocial burden. Additionally, two subcategories, (1) practical and (2) emotional support needs of adolescent childhood cancer survivors were identified.

CONCLUSIONS

Our results indicate that childhood cancer influences adolescent survivors' life in a negative way even many years after the end of treatment. Furthermore, parents seem to play a crucial role in the survivorship experience of childhood cancer survivors, as they remain keep responsible for most cancer-related concerns even during LTFU care, causing adolescents to persist in the child role. A family systemic approach to care is suggested to facilitate development-specific tasks and to enable adolescents to become autonomous adults. Still, the question remains as to who in the health care system could take over the family systemic tasks.