Publications by authors named "Tonya M Palermo"

233 Publications

Prescription Opioid Misuse and Sports-Related Concussion Among High School Students in the United States.

J Head Trauma Rehabil 2021 Sep-Oct 01;36(5):338-344

Department of Anesthesiology and Pain Medicine, Center for Child Health, Behaviors, and Development, Seattle Children's Hospital, Seattle, Washington; and University of Washington School of Medicine, Seattle.

Study Objective: Concussion is highly prevalent in adolescents and associated with a higher risk of substance use. With the rising use of opioids among adolescents, one form of substance use of concern is the misuse of prescription opioids. This study aimed to examine the association between a history of sports-related concussion in the past year and current prescription opioid misuse among high school students in the United States.

Setting: Secondary data analysis from the 2019 Youth Risk Behavior Survey.

Participants: Nationally representative sample of high school students (n = 7314).

Design: Cross-sectional study.

Main Measures: Participants were asked whether they experienced any concussions related to sports or being physically active during the past 12 months and whether they had any prescription opioid misuse within the past 30 days.

Results: Among this cohort, 14.0% reported sustaining a concussion in the past 12 months and 6% reported current prescription opioid misuse. The prevalence of prescription opioid misuse was higher among those with a history of concussion (9.9%) than among those without concussion (5.5%, P = .002). Controlling for covariates (sex, race/ethnicity, other substance use, depressive symptoms), the odds of prescription opioid misuse was 1.5 times higher for adolescents with concussion than those without (adjusted odds ratios [aOR] = 1.5; 95% CI, 1.0-2.3; P = .029).

Conclusion: Concussion was associated with prescription opioid misuse among the US youth, even after accounting for depressive symptoms and other substance use. Longitudinal studies are needed to test causal relationships and understand biobehavioral mechanisms that underlie associations between concussion and opioid misuse in adolescents.
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http://dx.doi.org/10.1097/HTR.0000000000000706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8428243PMC
January 2022

A digital health peri-operative cognitive-behavioral intervention to prevent transition from acute to chronic postsurgical pain in adolescents undergoing spinal fusion (SurgeryPal): study protocol for a multisite randomized controlled trial.

Trials 2021 Jul 30;22(1):506. Epub 2021 Jul 30.

Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.

Background: Spinal fusion surgery is associated with severe acute postsurgical pain and high rates of chronic postsurgical pain in adolescents. Psychological distress, sleep disturbance, and low pain self-efficacy predict higher acute pain and likelihood of developing chronic postsurgical pain. Interventions targeting baseline psychosocial risk factors have potential to interrupt a negative trajectory of continued pain and poor health-related quality of life (HRQL) over time but have not yet been developed and evaluated. This randomized controlled trial will test effectiveness of a digital peri-operative cognitive-behavioral intervention (SurgeryPal) vs. education-control delivered to adolescents and their parents to improve acute and chronic pain and health outcomes in adolescents undergoing spine surgery.

Methods: Adolescents 12-18 years of age undergoing spinal fusion for idiopathic conditions, and their parent, will be recruited from pediatric centers across the USA, for a target complete sample of 400 dyads. Adolescents will be randomized into 4 study arms using a factorial design to SurgeryPal or education control during 2 phases of treatment: (1) pre-operative phase (one-month before surgery) and (2) post-operative phase (1 month after surgery). Acute pain severity and interference (primary acute outcomes) and opioid use will be assessed daily for 14 days following hospital discharge. Chronic pain severity and interference (primary acute outcomes), as well as HRQL, parent and adolescent distress, sleep quality, and opioid use/misuse (secondary outcomes), will be assessed at 3 months and 6 months post-surgery.

Discussion: Demonstration of effectiveness and understanding optimal timing of perioperative intervention will enable implementation of this scalable psychosocial intervention into perioperative care. Ultimately, the goal is to improve pain outcomes and reduce reliance on opioids in adolescents after spine surgery.

Trial Registration: NCT04637802 ClinicalTrials.gov. Registered on November 20, 2020.
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http://dx.doi.org/10.1186/s13063-021-05421-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8325315PMC
July 2021

Improving the Quality of Pilot/Feasibility Trials Reporting in Pediatric Psychology.

J Pediatr Psychol 2021 07;46(6):645-649

Department of Anesthesiology & Pain Medicine, Seattle Children's Research Institute, University of Washington, USA.

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http://dx.doi.org/10.1093/jpepsy/jsab056DOI Listing
July 2021

Does Quantitative Sensory Testing Improve Prediction of Chronic Pain Trajectories? A Longitudinal Study of Youth With Functional Abdominal Pain Participating in a Randomized Controlled Trial of Cognitive Behavioral Treatment.

Clin J Pain 2021 09;37(9):648-656

Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN.

Objectives: Youth with functional abdominal pain (FAP) experience significant pain-related distress and functional impairment. Although quantitative sensory testing protocols have identified alterations in pain modulatory systems that distinguish youth with FAP from healthy controls, the extent to which evoked pain responses predict subsequent trajectories of pain symptoms and disability over and above established psychosocial risk factors is unclear.

Methods: The present study included 183 adolescents with FAP who were enrolled in a randomized controlled trial comparing an 8-week, internet-delivered program of cognitive behavior therapy (n=90) or pain education (n=93). Participants completed a quantitative sensory testing protocol before the intervention and were followed for 12-month posttreatment.

Results: Whereas adolescents with FAP who exhibited stronger baseline conditioned pain modulation (CPM) reported decreases in pain-related interference over follow-up (b=-0.858, SE=0.396, P=0.032), those with weaker CPM exhibited high, relatively stable levels of pain-related interference over time (b=-0.642, SE=0.400, P=0.110). CPM status predicted changes in pain-related interference after controlling for the effects of treatment condition and psychosocial risk factors. Static measures of pain sensitivity (ie, pain threshold, pain tolerance) and temporal summation of second pain were not associated with changes in measures of abdominal pain, gastrointestinal symptom severity, or pain-related interference over follow-up.

Discussion: The present findings contribute to a growing literature on the predictive utility of quantitative sensory testing indices and suggest that CPM may complement existing psychosocial risk measures in determining individualized pain-related risk profiles.
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http://dx.doi.org/10.1097/AJP.0000000000000956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373792PMC
September 2021

Painful chronic pancreatitis - new approaches for evaluation and management.

Curr Opin Gastroenterol 2021 09;37(5):504-511

Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.

Purpose Of Review: Management of abdominal pain in patients with chronic pancreatitis is often suboptimal. We review recent data on the epidemiology and new approaches for managing pain in chronic pancreatitis.

Recent Findings: Chronic pancreatitis duration does not appear to affect the pain experience. Pain pattern in chronic pancreatitis patients frequently changes and is not related to traditional patient and disease-related factors. Psychologic comorbidities, i.e. anxiety and depression, are frequent in patients with chronic pancreatitis, and are associated with more severe pain and pain interference. Adjunctive treatments, such as cognitive behavioral therapy, may positively influence pain management in chronic pancreatitis. Total pancreatectomy with islet autotransplantation (TPIAT) is an increasingly adopted treatment option in painful chronic pancreatitis. Ongoing multicenter studies will help define optimal candidates, predictors of successful pain remission and diabetes outcomes after TPIAT. Pancreatic quantitative sensory testing, a promising technique to interrogate nociception and sensory response, holds promise to identify patients with central sensitization. Initial studies show feasibility to stratify patients into defined pain profiles, and future studies will explore if these can help in prognostication of pain therapy.

Summary: Several lines of investigations currently under evaluation are likely to have a positive impact on the management of pain in chronic pancreatitis.
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http://dx.doi.org/10.1097/MOG.0000000000000769DOI Listing
September 2021

Internet Cognitive-Behavioral Therapy for Painful Chronic Pancreatitis: A Pilot Feasibility Randomized Controlled Trial.

Clin Transl Gastroenterol 2021 Jun 18;12(6):e00373. Epub 2021 Jun 18.

Division of Gastroenterology & Hepatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Introduction: Severe abdominal pain is a cardinal symptom of chronic pancreatitis (CP) associated with a high economic and societal burden. In other chronic pain conditions, cognitive-behavioral therapy (CBT) has demonstrated efficacy in improving patient outcomes (e.g., pain-related disability and depression). However, CBT has not yet been evaluated in adult patients with painful CP. We aimed to (i) evaluate the feasibility and acceptability of an adapted Internet CBT program for CP and (ii) generate pilot data regarding the effects of treatment on patient pain outcomes.

Methods: Thirty adults (mean age = 49.8 years, SD = 12.5; 80% women) with suspected or definite CP were randomized to Internet CBT (Pancreatitis Pain Course) versus control. The Pancreatitis Pain Course has 5 CBT lessons (e.g., thought challenging, relaxation, and activity pacing) delivered over 8 weeks. Pain interference, pain intensity, and quality of life were assessed at pretreatment, posttreatment, and the 3-month follow-up. Qualitative interviews were conducted at posttreatment with a subset of participants.

Results: Eighty percent of participants rated the program as highly acceptable; 64.3% completed all 5 lessons. Qualitative data revealed positive perceptions of program features, relevancy, and skills. Patients randomized to Internet CBT demonstrated moderate to large effects in reducing pain intensity and pain interference from baseline to 3 months. The proportion of treatment responders (>30% improvement) was significantly greater in the Internet-CBT group than in the control group (50% vs 13%, Fisher exact t test P = 0.04).

Discussion: In this first trial of CBT pain self-management in CP, feasibility, acceptability, and preliminary efficacy for reducing pain and disability were demonstrated. Future definitive trials of CBT are needed.
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http://dx.doi.org/10.14309/ctg.0000000000000373DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216675PMC
June 2021

Pilot Study of Telehealth Delivered Rehabilitative Exercise for Youth With Concussion: The Mobile Subthreshold Exercise Program (MSTEP).

Front Pediatr 2021 28;9:645814. Epub 2021 May 28.

Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States.

Concussion is common, and up to 30% of youth develop persistent symptoms. Preliminary data suggests treatment with rehabilitative exercise is beneficial, but most programs require frequent in-person visits, which is challenging for youth in rural areas, and has been made more difficult for all youth during the COVID-19 pandemic. We have adapted an exercise intervention to be delivered via telehealth using Zoom and personal fitness devices, which could ensure access to this type of treatment. The goal of this study was to assess feasibility and acceptability of a telehealth delivered exercise intervention for concussion, the Mobile Subthreshold Exercise Program (MSTEP), and collect pilot data regarding efficacy. All youth received the 6-week MSTEP intervention which included wearing a Fitbit and setting exercise heartrate and duration goals weekly over Zoom with the research assistant. Youth completed standardized measures of concussive symptoms (Health Behavior Inventory, HBI), fear-avoidance (Fear of Pain Questionnaire, FOPQ) and health-related quality of life (Pediatric Quality of life Assessment, PedsQL), as well as a structured qualitative exit interview. We examined change in measures over time using mixed effects modeling, controlling for age, sex, prior concussion and duration of symptoms. We coded qualitative interviews using Thematic analysis. We recruited 19 subjects, 79% female with average age 14.3 (SD 2.2) and mean duration of symptoms 75.6 days (SD 33.7). Participants wore the Fitbit on 80% of days, and completed 94% of surveys and 96% of Zoom calls. Concussive symptoms (HBI) decreased significantly over the 6 week intervention (-10.6, 95%CI: -16.0 to -5.1) as did fear-avoidance (-21.6, 95%CI: -29.8 to -13.5). PedsQL improved significantly during the same time period (+15.1, 95%CI: 8.6-21.6). Approximately three-quarters (76%) of youth rated their care as "excellent." Participants appreciated the structure of the guided exercise program and the support of the RA. They also enjoyed being able to track their progress with the Fitbit. This study provides evidence for the feasibility and acceptability of a telehealth delivered rehabilitative exercise intervention for youth with concussion. Further research utilizing a randomized controlled trial is needed to assess efficacy. https://clinicaltrials.gov, identifier: NCT03691363. https://clinicaltrials.gov/ct2/show/NCT03691363.
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http://dx.doi.org/10.3389/fped.2021.645814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193501PMC
May 2021

Longitudinal study of early adaptation to the coronavirus disease pandemic among youth with chronic pain and their parents: effects of direct exposures and economic stress.

Pain 2021 07;162(7):2132-2144

Center for Child Health, Behavior and Development, Seattle Children's Research Institute Seattle, WA, United States.

Abstract: The novel coronavirus disease (COVID-19) has caused prolonged disruptions in daily life for many communities. Little is known about the impact of the COVID-19 pandemic on the health and well-being of youth with chronic pain and their families. We conducted a longitudinal, mixed-methods study to characterize early adaptation to the COVID-19 pandemic among 250 families of youth (ages 12-21 years) diagnosed with chronic headache (64%) or other chronic pain conditions (36%) and to determine whether direct exposures to COVID-19 and secondary economic stress modified symptom trajectories. Youth and parents reported on pain interference, anxiety, depression, and insomnia symptoms at 4 waves of data collection from April 2020 to July 2020. We also collected qualitative data on the impact of the pandemic on the youth's pain problem. Nearly half of our sample (49.6%) experienced direct exposures to COVID-19. Secondary economic stress was also common, affecting 44.4% of families. Symptom trajectories for pain, insomnia, depression, and anxiety remained stable or improved for most participants, indicating adaptive adjustment. However, overall symptom burden was high with persistent and clinically elevated depression, anxiety, and insomnia symptoms common among youth and parents. Direct exposures to COVID-19 did not modify symptom trajectories. However, youth pain interference and parent insomnia worsened in families who experienced secondary economic stress. Qualitative data revealed perceived benefits and harms from school closures on the youth's pain problem. Our findings of high symptom burden suggest that pediatric pain clinicians should offer distance assessment and treatment (eg, through telemedicine) to avoid pandemic-related disruptions in pain care.
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http://dx.doi.org/10.1097/j.pain.0000000000002290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8205975PMC
July 2021

Associations between insufficient sleep and prescription opioid misuse among high school students in the United States.

J Clin Sleep Med 2021 May 21. Epub 2021 May 21.

Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington.

Study Objectives: The aim of this study was to estimate the association between insufficient sleep and prescription opioid misuse among US high school students.

Methods: Participants were 6,884 high school students who self- reported on sleep duration and prescription opioid misuse in the 2019 Youth Risk Behavior Survey (YRBS). Sleep duration was categorized by YRBS according to the American Academy of Sleep Medicine guidelines as follows: Recommended sleep duration (8-9 hours) vs. Insufficient sleep (<8 hours). Participants also reported whether they had any prescription opioid misuse during their lifetime and whether they had prescription opioid misuse within the past 30 days.

Results: Most (79.4%) participants reported sleeping less than 8 hours per night. Among all youth, 12.9% reported lifetime prescription opioid misuse and 6.2% reported current prescription opioid misuse. Prevalence of both lifetime and current opioid medication misuse was higher among those also reporting insufficient sleep as compared to those reporting recommended sleep duration (14.3% vs 7.7%, p<0.0001 for lifetime misuse and 6.6% vs 4.3%, p=0.0091 for current misuse). In multivariate models, insufficient sleep was associated with an increased odds of lifetime prescription opioid misuse (adjusted odds ratios = 1.4, 95% confidence interval: 1.1-1.2; p = 0.006), however we did not find an association between sleep duration and current prescription opioid misuse in multivariate analysis.

Conclusions: Sleep duration is associated with lifetime opioid misuse among US youth. Longitudinal studies are needed to test whether causal relationships exist, and to understand biobehavioral mechanisms that underlie associations between sleep deficiency and opioid misuse in adolescents.
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http://dx.doi.org/10.5664/jcsm.9418DOI Listing
May 2021

Multisite Pain Is Highly Prevalent in Children with Functional Abdominal Pain Disorders and Is Associated with Increased Morbidity.

J Pediatr 2021 Sep 30;236:131-136. Epub 2021 Apr 30.

Department of Pediatrics, Baylor College of Medicine, Houston, TX; Children's Nutrition Research Center, United States Department of Agriculture, Houston, TX.

Objectives: To characterize the types of multisite pain experienced by children with functional abdominal pain disorders (FAPDs) and to examine differences in psychosocial distress, functional disability, and health-related quality of life in children with multisite pain vs abdominal pain alone.

Study Design: Cross-sectional study of children ages 7-17 years (n = 406) with pediatric Rome III FAPDs recruited from both primary and tertiary care between January 2009 and June 2018. Subjects completed 14-day pain and stool diaries, as well as validated questionnaires assessing abdominal and nonabdominal pain symptoms, anxiety, depression, functional disability, and health-related quality of life.

Results: In total, 295 (73%) children endorsed at least 1 co-occurring nonabdominal pain, thus, were categorized as having multisite pain with the following symptoms: 172 (42%) headaches, 143 (35%) chest pain, 134 (33%) muscle soreness, 110 (27%) back pain, 94 (23%) joint pain, and 87 (21%) extremity (arms and legs) pain. In addition, 200 children (49%) endorsed 2 or more nonabdominal pain symptoms. Participants with (vs without) multisite pain had significantly higher abdominal pain frequency (P < .001) and severity (P = .03), anxiety (P < .001), and depression (P < .001). Similarly, children with multisite pain (vs without) had significantly worse functional disability (P < .001) and health-related quality of life scores (P < .001). Increasing number of multisite pain sites (P < .001) was associated with increased functional disability when controlling for demographic and other clinical factors.

Conclusions: In children with FAPDs, nonabdominal multisite pain is highly prevalent and is associated with increased psychosocial distress, abdominal pain frequency and severity, functional disability, and lower health-related quality of life.
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http://dx.doi.org/10.1016/j.jpeds.2021.04.059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8403143PMC
September 2021

The Role of Sleep in the Transition from Acute to Chronic Musculoskeletal Pain in Youth-A Narrative Review.

Children (Basel) 2021 Mar 20;8(3). Epub 2021 Mar 20.

Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA 98105, USA.

Musculoskeletal pain is common in the general pediatric population and is a challenge to youth, their parents, and society. The majority of children experiencing musculoskeletal pain will recover; however, a small subgroup of youth develops chronic pain. There is limited understanding of the factors that affect the transition from acute to chronic pain in youth. This review introduces sleep deficiency in the acute to chronic pain transition, exploring the potential mediational or mechanistic role and pathways of sleep in this process, including the interaction with sensory, psychological, and social components of pain and highlighting new avenues for treatment. Biological mechanisms include the increased production of inflammatory mediators and the effect on the hypothalamus-pituitary-adrenal (HPA) axis and on the dopaminergic signaling. Psychological and social components include the effect of sleep on the emotional-affective and behavioral components of pain, the negative impact on daily and social activities and coping strategies and on the reward system, increased pain catastrophizing, fear of pain, pain-related anxiety, hypervigilance, and social isolation. Future longitudinal studies are needed to elucidate these mechanistic pathways of the effect of sleep on the transition from acute to chronic pain, which may lead to the development of new treatment targets to prevent this transition.
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http://dx.doi.org/10.3390/children8030241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8003935PMC
March 2021

Core outcome set for pediatric chronic pain clinical trials: results from a Delphi poll and consensus meeting.

Pain 2021 Oct;162(10):2539-2547

Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, United States.

Appropriate outcome measures and high-quality intervention trials are critical to advancing care for children with chronic pain. Our aim was to update a core outcome set for pediatric chronic pain interventions. The first phase involved collecting providers', patients', and parents' perspectives about treatment of pediatric chronic pain to understand clinically meaningful outcomes to be routinely measured. The second phase was to reach consensus of mandatory and optional outcome domains following the OMERACT framework. A modified Delphi study with 2 rounds was conducted including 3 stakeholder groups: children with chronic pain (n = 93), their parents (n = 90), and health care providers who treat youth with chronic pain (n = 52). Quantitative and qualitative data from round 1 of the Delphi study were summarized to identify important outcomes, which were condensed to a list of 10 outcome domains. Round 2 surveys were analyzed to determine the importance of the 10 domains and their relative ranking in each stakeholder group. A virtual consensus conference was held with the steering committee to reach consensus on a set of recommended outcome domains for pediatric chronic pain clinical trials. It was determined, by unanimous vote, that pain severity, pain interference with daily living, overall well-being, and adverse events, including death, would be considered mandatory domains to be assessed in all trials of any type of intervention. Emotional functioning, physical functioning, and sleep were important but optional domains. Last, the research agenda identifies several important emerging areas, including biomarkers. Future work includes selecting appropriate validated measures to assess each outcome domain.
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http://dx.doi.org/10.1097/j.pain.0000000000002241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442740PMC
October 2021

Age differences in cognitive-affective processes in adults with chronic pain.

Eur J Pain 2021 05 24;25(5):1041-1052. Epub 2021 Jan 24.

Center for Child Health, Behavior & Development, Seattle Children's Research Institute, Seattle, WA, USA.

Background: Chronic pain is associated with significant physical and psychological impairments across the adult lifespan. However, there is a relative gap in knowledge on individual differences that predict pain-related functioning. The current study highlights one important source of individual variation: age.

Methods: We used cross-sectional data from a large treatment-seeking cohort of 2,905 adults (M age = 46.6 [13.1]; 71.8% women) presenting to a tertiary pain centre in the United Kingdom to determine age differences in cognitive-affective processes (catastrophizing, acceptance, self-efficacy), including their differential patterns and effects on disability and depression.

Results: Older adults (ages 65-75) were found to experience higher pain acceptance and pain self-efficacy compared to both middle-aged (ages 40-64) and young adult (ages 18-39) age groups. Older adults also experienced lower levels of catasophizing compared to middle-age adults. Testing age as a moderator, we found that the relationships of pain self-efficacy and acceptance with depression as well as the relationship between pain self-efficacy and disability were comparatively weakest among older adults and strongest among young adults. Similarly, the relationship between pain catastrophizing and depression was relatively stronger for young and middle-aged adults compared to older adults.

Conclusions: Age-related differences in psychological mechanisms that influence pain-related functioning present unique challenges and opportunities for scientists and clinicians to improve our understanding and treatment of pain across the lifespan. Additional work is needed to refine our knowledge of age-related differences in cognitive-affective, biopsychosocial dimensions of chronic pain and to develop and test the efficacy of age-tailored interventions.

Significance: Our cross-sectional analysis of 2,905 treatment-seeking adults with chronic pain presenting to a tertiary care center in the United Kingdom revealed distinct age differences in cognitive-affective linked to disability and depression. This study contributes to the limited knowledge on age-related variance in psychological mechanisms underlying adjustment to chronic pain. Promising avenues for future research include refining our understanding of age-related differences in cognitive-affective, biopsychosocial dimensions of chronic pain and elucidating the most salient treatment targets among different age groups.
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http://dx.doi.org/10.1002/ejp.1725DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8055045PMC
May 2021

A Conceptual Model of Biopsychosocial Mechanisms of Transition from Acute to Chronic Postsurgical Pain in Children and Adolescents.

J Pain Res 2020 24;13:3071-3080. Epub 2020 Nov 24.

Weill Cornell Medicine, New York, NY, USA.

Acute and chronic pain are highly prevalent and impactful consequences of surgery across the lifespan, yet a comprehensive conceptual model encompassing biopsychosocial factors underlying acute to chronic pain transition is lacking, particularly in youth. Building on prior chronic postsurgical pain models, we propose a new conceptual model of biopsychosocial mechanisms of transition from acute to chronic postsurgical pain. This review aims to summarize existing research examining key factors underlying acute to chronic postsurgical pain transition in order to guide prevention and intervention efforts aimed at addressing this health issue in children. As pain transitions from acute nociceptive pain to chronic pain, changes in the peripheral and central nervous system contribute to the chronification of pain after surgery. These changes include alterations in sensory pain processing and psychosocial processes (psychological, behavioral, and social components), which promote the development of chronic pain. Patient-related premorbid factors (eg, demographic factors, genetic profile, and medical factors such as premorbid pain) may further modulate these changes. Factors related to acute injury and recovery (eg, surgical and treatment factors), as well as biological response to surgery (eg, epigenetic, inflammatory, and endocrine factors), may also influence this process. Overall, longitudinal studies examining temporal pathways of biopsychosocial processes including both risk and resiliency factors will be essential to identify the mechanisms involved in the transition from acute to chronic pain. Research is also needed to unravel connections between the acute pain experience, opioid exposure, and sensory pain processing during acute to chronic pain transition. Furthermore, future studies should include larger and more diverse samples to more fully explore risk factors in a broader range of pediatric surgeries. The use of conceptual models to guide intervention approaches targeting mechanisms of transition from acute to chronic pain will significantly advance this field and improve outcomes for children and adolescents undergoing surgery.
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http://dx.doi.org/10.2147/JPR.S239320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7699440PMC
November 2020

Topical Review: Examining Multidomain Pain Resilience in Late Adolescents and Young Adults.

J Pediatr Psychol 2021 03;46(3):280-285

Department of Community Dentistry and Behavioral Science, University of Florida.

Objective: Upwards of 14% of late adolescents and young adults (AYAs) experience chronic pain; however, limited research has focused on factors specifically influencing late AYAs as they transition to adulthood. In this topical review, we propose a conceptual model of multidomain pain resilience (MDPR) in late AYAs with chronic pain that extends existing pain resilience literature, including the Ecological Resilience-Risk Model for Pediatric Chronic Pain.

Method: A conceptual framework for MDPR in late AYAs was developed from the existing literature on resilience in young people with chronic pain. Gaps in knowledge specific to late AYAs are identified, and relevant research examining MDPR in adults with pain are summarized to inform applications of this concept to youth as they transition to adulthood.

Results: Few studies have explored resilience factors in pediatric pain. Of note, these endeavors have largely neglected late adolescence and young adulthood, despite unique considerations germane to this crucial developmental period. Existing research has also focused exclusively on assessing resilience as a unitary, rather than a multidimensional construct. Although limited, MDPR has been examined in midlife and older adults with chronic pain, highlighting the need to expand prior models of pain resilience and extend these principles to emerging adulthood.

Conclusions: Understanding MDPR in late AYAs with chronic pain may provide insights regarding measurable and modifiable resilience factors (e.g., adaptive and personal resources) that promote healthy pain-related outcomes (e.g., reduced pain and enhanced physical functioning) and optimize prevention and/or treatment strategies for this group.
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http://dx.doi.org/10.1093/jpepsy/jsaa108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977437PMC
March 2021

Pain prevention and management must begin in childhood: the key role of psychological interventions.

Authors:
Tonya M Palermo

Pain 2020 09;161 Suppl 1:S114-S121

Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle Children's Research Institute, Seattle, WA, United States.

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http://dx.doi.org/10.1097/j.pain.0000000000001862DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566813PMC
September 2020

eHealth and mHealth Psychosocial Interventions for Youths With Chronic Illnesses: Systematic Review.

JMIR Pediatr Parent 2020 Nov 10;3(2):e22329. Epub 2020 Nov 10.

Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, United States.

Background: An estimated 12.8% of children and adolescents experience chronic health conditions that lead to poor quality of life, adjustment and coping issues, and concurrent mental health problems. Digital health deployment of psychosocial interventions to support youth with chronic illness has become increasingly popular with the advent of the technological advances in the digital age.

Objective: Our objectives were to systematically review published efficacy studies of eHealth and mHealth (mobile health) psychosocial interventions for youths with chronic illnesses and review intervention theory and treatment components.

Methods: PubMed, Embase, Web of Science, PsycInfo, and Cochrane Database of Systematic Reviews were searched for studies published from 2008 to 2019 of eHealth and mHealth psychosocial interventions designed for children and adolescents with chronic illnesses in which efficacy outcomes were reported. We excluded studies of interventions for caregivers, healthy youth, disease and medication management, and telehealth interventions that function solely as a platform to connect patients to providers via phone, text, or videoconference.

Results: We screened 2551 articles and 133 relevant full-text articles. Sixteen efficacy studies with psychosocial and health outcomes representing 12 unique interventions met the inclusion criteria. Of the included studies, 12 were randomized controlled trials and 4 were prospective cohort studies with no comparison group. Most interventions were based in cognitive behavioral theory and designed as eHealth interventions; only 2 were designed as mHealth interventions. All but 2 interventions provided access to support staff via text, phone, email, or discussion forums. The significant heterogeneity in intervention content, intervention structure, medical diagnoses, and outcomes precluded meta-analysis. For example, measurement time points ranged from immediately postcompletion of the mHealth program to 18 months later, and we identified 39 unique outcomes of interest. The majority of included studies (11/16, 69%) reported significant changes in measured health and/or psychosocial posttreatment outcomes, with small to large effect sizes.

Conclusions: Although the available literature on the efficacy of eHealth and mHealth psychosocial interventions for youth with chronic illnesses is limited, preliminary research suggests some evidence of positive treatment responses. Future studies should continue to evaluate whether digital health platforms may be a viable alternative model of delivery to traditional face-to-face approaches.
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http://dx.doi.org/10.2196/22329DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7685926PMC
November 2020

Associations between adolescent sleep deficiency and prescription opioid misuse in adulthood.

Sleep 2021 03;44(3)

Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA.

Study Objectives: The main aim of this study was to estimate the association between sleep deficiency in adolescence and subsequent prescription opioid misuse in adulthood using United States nationally representative longitudinal data.

Methods: Self-reported data captured in the National Longitudinal Study of Adolescent to Adult Health at baseline (Wave 1; mean age = 16 years) and 12 year follow-up (Wave 4; mean age = 29 years). Participants (n = 12,213) reported on four measures of sleep during adolescence (Wave 1) and on lifetime prescription opioid misuse during adulthood (Wave 4). Associations between adolescent sleep and adult opioid misuse were estimated using multivariate logistic regression analysis controlling for sociodemographics, chronic pain, mental health, childhood adverse events, and a history of substance use.

Results: During adolescence, 59.2% of participants reported sleep deficiency. Prospectively, adolescents reporting not getting enough sleep, chronic unrestful sleep, and insomnia were associated with an increased risk for prescription opioid misuse (adjusted odds ratios [OR] = 1.2, p < 0.005 for all three variables). Short sleep duration was not associated with opioid misuse.

Conclusion: This is the first study to longitudinally link sleep deficiency as an independent risk factor for the development of prescription opioid misuse. Sleep deficiency could be a driver of the opioid crisis affecting young people in the United States. Future studies should determine whether early and targeted sleep interventions may decrease risk for opioid misuse in high-risk patients prescribed opioids for pain.
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http://dx.doi.org/10.1093/sleep/zsaa201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953216PMC
March 2021

Subgroups of Pediatric Patients With Functional Abdominal Pain: Replication, Parental Characteristics, and Health Service Use.

Clin J Pain 2020 12;36(12):897-906

Pediatrics, Vanderbilt University Medical Center.

Objectives: Prior work in a cohort of youth with functional abdominal pain (FAP) identified patient subgroups (High Pain Dysfunctional, High Pain Adaptive, Low Pain Adaptive) that predicted differences in the course of FAP from childhood into young adulthood. We aimed to replicate these subgroups in a new sample of adolescents with FAP using the original classification algorithm and to extend subgroup characteristics to include parental characteristics and health service use.

Methods: Adolescents (n=278; ages 11 to 17 y, 66% females) presenting to a gastroenterology clinic for abdominal pain, and their parents (92% mothers) completed self-report measures; adolescents also completed a 7-day pain diary.

Results: The replicated patient subgroups exhibited distress and impairment similar to subgroups in the original sample. Moreover, in novel findings, the High Pain Dysfunctional subgroup differed from other subgroups by the predominance of mother-daughter dyads jointly characterized by high levels of anxiety, depressive symptoms, pain behavior, and pain catastrophizing. The High Pain Dysfunctional subgroup used more health care services than Low Pain Adaptive but did not differ from High Pain Adaptive.

Discussion: Findings replicate and extend the original FAP classification and suggest that the subgroups have unique patient and parent features that may reflect distinct illness mechanisms requiring different treatments.
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http://dx.doi.org/10.1097/AJP.0000000000000882DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666007PMC
December 2020

Psychology's role in addressing the dual crises of chronic pain and opioid-related harms: Introduction to the special issue.

Am Psychol 2020 09;75(6):741-747

Pain Management Collaboratory Coordinating Center, Yale University.

Chronic pain is considered a public health crisis due to its high prevalence, impact, costs, and disparities in pain prevalence and treatment. In parallel, drug overdose, particularly due to opioids, has become an epidemic in the United States, prompting a public health crisis concerning harms associated with both prescribed opioid therapy for chronic pain and illicit opioid use. The purpose of this special issue is to highlight state-of-the-art psychological research that addresses the combined issues of chronic pain and harms associated with opioids. Articles included in this special issue focus on 2 related areas. The 1st set of innovative articles focuses on risk factors for chronic pain, characterization of patterns of opioid use and misuse, assessment of opioid risk, and identification of moderating factors in populations ranging from adolescents to older adults. The 2nd set of articles includes exemplary research on psychological approaches for management of chronic pain and opioid risk mitigation; integration of psychological approaches in patient-centered, evidence-based, multimodal and interdisciplinary plans of pain care; and treatment of co-occurring chronic pain and opioid use disorder. Last, the issue includes a guest editorial highlighting psychological research and the participation of psychologists in the National Institutes of Health's Helping to End Addiction Long-Term (HEAL) initiative. In this introduction, the guest editors highlight the objectives in this special issue are to stimulate additional research to develop psychological approaches to reduce opioid misuse behaviors, to help educate providers on opioid prescribing that is equitable and minimizes risk of harms, and to address co-occurring chronic pain and opioid use disorder in vulnerable populations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/amp0000711DOI Listing
September 2020

Abdominal Pain After Pediatric Inflammatory Bowel Disease Diagnosis: Results From the ImproveCareNow Network.

J Pediatr Gastroenterol Nutr 2020 12;71(6):749-754

Center for Child Health, Behavior and Development, Seattle Children's Research Institute.

Objectives: Although abdominal pain is a hallmark symptom of pediatric inflammatory bowel disease (IBD), limited research has examined pain during the first year after diagnosis. The purpose of the present study is to examine prevalence, predictors, and impact of abdominal pain during the 12 months after pediatric IBD diagnosis using data from the ImproveCareNow (ICN) Network.

Patients And Methods: Participants consisted of 13,875 youth (age 8-18 years, 44% female, 81% Caucasian) with IBD (65% Crohn's disease; 27% ulcerative colitis, 8% indeterminate colitis) enrolled in the ICN Network with data from clinic visits during the first year after diagnosis (1-22 visits; mean = 3.7). Multivariable mixed effects logistic regression models were conducted to analyze the presence versus the absence of abdominal pain, activity limitations, and decrements in well-being.

Results: The percentage of youth reporting abdominal pain decreased significantly during the first year after diagnosis and yet a sizeable group reported continued pain at 12 months (55.9% at diagnosis; 34.0% at 12 months). Multivariable analyses revealed that greater time since diagnosis (odds ratio [OR] = 0.98, P < 0.001), higher disease severity (OR = 11.84, P < 0.001), presence of psychosocial risk factors (OR = 2.33, P = 0.036), and female sex (OR = 1.90, P < 0.010) were significant correlates of continuing abdominal pain. Abdominal pain was significantly associated with decrements in well-being (OR = 5.11, P < 0.001) as well as limitations in activity (OR = 9.31, P < 0.001), over and above the influence of disease severity.

Conclusions: Abdominal pain is prevalent and impactful, even when controlling for disease activity, during the first year after pediatric IBD diagnosis. Results from the present study can inform screening and tailored pain management intervention efforts in pediatric IBD.
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http://dx.doi.org/10.1097/MPG.0000000000002933DOI Listing
December 2020

Adverse childhood experiences and chronic pain among children and adolescents in the United States.

Pain Rep 2020 Sep-Oct;5(5):e839. Epub 2020 Aug 13.

Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA.

Objective: To evaluate the association between adverse childhood experiences (ACEs) and chronic pain during childhood and adolescence.

Methods: Cross-sectional analysis of the 2016-2017 National Survey of Children's Health, including 48,567 child participants of 6 to 17 years of age. Parents of children reported on 9 ACEs. Chronic pain was defined as parents reporting that their children had Multivariate logistic regression analysis adjusted for sociodemographic and health-related factors.

Results: In this nationally representative sample, 49.8% of children were exposed to one or more ACEs during their lifetime. Children with exposure to 1 or more ACEs had higher rates of chronic pain (8.7%) as compared to those with no reported ACEs (4.8%). In multivariate analysis, children with ACEs had increased odds for chronic pain (adjusted odds ratio [aOR]: 1.6, 95% confidence interval [CI]: 1.3-2.2, for 0 vs 1 ACE and aOR: 2.7, 95% CI: 2.1-3.4 for 0 vs 4+ ACEs). The strongest associations of individually measured ACEs with chronic pain included financial instability (aOR: 1.9, 95% CI: 1.6-2.2), living with a mentally ill adult (aOR: 1.8, 95% CI: 1.5-2.2), and having experienced discrimination based on race (aOR: 1.7, 95% CI: 1.3-2.2).

Conclusions: Children and adolescents with ACEs had increased risk for chronic pain, and this association increased in a dose-dependent fashion.
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http://dx.doi.org/10.1097/PR9.0000000000000839DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431222PMC
August 2020

Assessing Digital Health Implementation for a Pediatric Chronic Pain Intervention: Comparing the RE-AIM and BIT Frameworks Against Real-World Trial Data and Recommendations for Future Studies.

J Med Internet Res 2020 09 1;22(9):e19898. Epub 2020 Sep 1.

Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States.

Background: Digital health interventions have demonstrated efficacy for several conditions including for pediatric chronic pain. However, the process of making interventions available to end users in an efficient and sustained way is challenging and remains a new area of research. To advance this field, comprehensive frameworks have been created.

Objective: The aim of this study is to compare the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) and Behavior Interventions using Technology (BIT) frameworks with data collected from the web-based management of adolescent pain (WebMAP Mobile; WMM) randomized controlled trial (RCT).

Methods: We conducted a hybrid effectiveness-implementation cluster RCT with a stepped wedge design in which the intervention was sequentially implemented in 8 clinics, following a usual care period. Participants were 143 youths (mean age 14.5 years, SD 1.9; 117/143, 81.8% female) with chronic pain, from which 73 were randomized to receive the active intervention. Implementation outcomes were assessed using the RE-AIM and BIT frameworks.

Results: According to the RE-AIM framework, the WMM showed excellent reach, recruiting a sample 19% larger than the size originally planned and consenting 79.0% (143/181) of eligible referred adolescents. Effectiveness was limited, with only global impression of change showing significantly greater improvements in the treatment group; however, greater treatment engagement was associated with greater reductions in pain and disability. Adoption was excellent (all the invited clinics participated and referred patients). Implementation was acceptable, showing good user engagement and moderate adherence and positive attitudes of providers. Costs were similar to planned, with a 7% increase in funds needed to make the WMM publicly available. Maintenance was evidenced by 56 new patients downloading the app during the maintenance period and by all clinics agreeing to continue making referrals and all, but one, making new referrals. According to the BIT, 82% (60/73) of adolescents considered the treatment acceptable. In terms of adoption, 93% (68/73) downloaded the app, and all of them used it after their first log-in. In terms of appropriateness at the user level, 2 participants were unable to download the app. Perceptions of the appearance, navigation, and theme were positive. Providers perceived the WMM as a good fit for their clinic, beneficial, helpful, and resource efficient. In terms of feasibility, no technical issues were reported. In terms of fidelity, 40% (29/73) completed the treatment. Implementation costs were 7% above the budget. With regard to penetration, 56 new users accessed the app during the maintenance period. In terms of sustainability, 88% (7/8) of clinics continued recommending the WMM after the end of the study.

Conclusions: For the first time, a real-world digital health intervention was used as a proof of concept to test all the domains in the RE-AIM and BIT frameworks, allowing for comparisons.

International Registered Report Identifier (irrid): RR2-10.1016/j.cct.2018.10.003.
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http://dx.doi.org/10.2196/19898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492980PMC
September 2020

Longitudinal Impact of Parent Factors in Adolescents With Migraine and Tension-Type Headache.

Headache 2020 Sep 27;60(8):1722-1733. Epub 2020 Aug 27.

Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA.

Objective: To examine longitudinal associations between parent factors (parent headache frequency and disability, protective parenting behaviors, parent catastrophizing) with adolescent headache-related disability and headache frequency over 6 months.

Background: Theoretical models propose bidirectional, longitudinal relationships between parent factors and adolescent headache. Few studies have examined this using prospective study designs.

Design And Methods: Participants were a cohort of 239 youth ages 11-17 years with recurrent migraine (with and without aura; chronic migraine) or tension-type headache (episodic and chronic) and their parents recruited from a pediatric neurology clinic and the community who completed assessments at baseline and 6-month follow-up.

Results: After controlling for demographic and clinical covariates, we found that every point increase in baseline protective parenting behavior corresponded with a 2.19-point increase in adolescent headache frequency at follow-up (P = .026, 95% CI [0.27, 4.10]). Similarly, every point increase in baseline parent catastrophizing corresponded with a 0.93-point increase in adolescent headache-related disability (P = .029, 95% CI [0.09, 1.77]) and a .13-point increase in adolescent headache frequency (P = .042, 95% CI [0.01, 0.25]) at follow-up. We also found support for the reverse association, where every point increase in baseline adolescent headache-related disability predicted a 0.03-point increase in parent catastrophizing (P = .016, 95% CI [0.01, 0.05]) and a 0.02-point increase in protective parenting behavior (P = .009, 95% CI [0.01, 0.03]) at follow-up. The remaining bidirectional, longitudinal associations tested between parent factors and adolescent headache were not statistically significant.

Conclusion: Findings suggest that family-based psychological interventions targeting modifiable adolescent and parent factors may lead to improvements in adolescent headache-related disability and reductions in adolescent headache frequency.
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http://dx.doi.org/10.1111/head.13939DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719069PMC
September 2020

Understanding the Psychosocial and Parenting Needs of Mothers with Irritable Bowel Syndrome with Young Children.

Children (Basel) 2020 Aug 7;7(8). Epub 2020 Aug 7.

Center for Child Health, Behavior and Development, Seattle Children's Research Institute, PO Box 5371, M/S CW8-6, Suite 400, Seattle, WA 98145, USA.

Women of childbearing age experience the highest prevalence of irritable bowel syndrome (IBS), yet little is known about their psychosocial and parenting needs, which may influence their children's experience of future gastrointestinal or pain-related conditions. The aims of this study were to conduct qualitative interviews to understand the psychosocial and parenting needs of mothers with IBS who have young school-age children, and to assess mothers' potential interest in and acceptability of a preventive parenting intervention program. Ten mothers with IBS who have young (age 5-10), healthy children were interviewed. Interviews were coded with thematic analysis and three themes were identified: (1) Guilt about how IBS impacts children, (2) Worry that children will develop IBS, and (3) Already on high alert for children's health. All mothers expressed interest in an Internet-based preventive intervention and identified tools and strategies they would want included. Results demonstrate that mothers experience guilt about how IBS has impacted their children in their daily lives, concern that they need to pay attention to children's early signs and symptoms that could indicate gastrointestinal problems, and worry about children developing IBS in the future-suggesting that a preventive intervention may address important concerns for this population.
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http://dx.doi.org/10.3390/children7080093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7463880PMC
August 2020

Baseline Characteristics of a Dyadic Cohort of Mothers With Chronic Pain and Their Children.

Clin J Pain 2020 10;36(10):782-792

Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.

Objectives: A growing body of research has demonstrated a robust link between parental chronic pain and child pain and psychological function. Although the association between parent and child pain is strong, there are limited data to understand environmental and behavioral processes that account for the association and how this develops over time. This longitudinal cohort study was designed to understand the potential mechanisms that confer risk or resilience for chronic pain among child offspring of mothers with chronic pain.

Methods: The current paper presents baseline data on the cohort to describe the pain and psychosocial characteristics of mothers with chronic pain and their 8- to 12-year-old children. A total of 400 mothers with chronic pain and their children were enrolled into the longitudinal study and completed measures of pain, physical, and psychosocial functioning.

Results: Mothers reported a range of pain and pain-related disability and were grouped into 4 pain grades (PGs) representing different pain and disability levels. Mothers in these groups differed on rates of widespread pain and opioid use. Maternal PGs also differed by physical function, fatigue, sleep disturbance, and psychological function. Most children in this sample reported pain and psychosocial symptoms in the nonclinical range, and child variables did not differ by maternal PG. Maternal disability and function were concurrently associated with child psychosocial function.

Discussion: While maternal PGs map broadly onto several dimensions of maternal functioning, they were not significantly related to child pain or function. Results may help identify potential protective factors in the intergenerational transmission of risk for chronic pain.
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http://dx.doi.org/10.1097/AJP.0000000000000864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7485271PMC
October 2020
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