Courtney W. Hess

All Publications

• Extended Reality (XR) in Pediatric Acute and Chronic Pain: Systematic Review and Evidence Gap Map. JMIR pediatrics and parenting Hess, C. W., Rosenbloom, B. N., Mesaroli, G., Lopez, C., Ngo, N., Cohen, E., Ouellette, C., Gold, J. I., Logan, D., Simons, L. E., Stinson, J. N. 2025; 8: e63854

  Abstract

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

  View details for DOI 10.2196/63854

  View details for PubMedID 40194270

• Navigating Burnout in Pediatric Chronic Pain Teams: Insights from Provider Experiences Guardino, K., Gaydos, E., McDonnell, A., Escobar, M., Simons, L., Hess, C. OXFORD UNIV PRESS INC. 2025: 117

  View details for Web of Science ID 001434801700244

• Reaching experts for enhanced referral (REFER) to pain psychology: a modified Delphi approach with multidisciplinary paediatric pain providers at a specialised center in the USA. BMJ paediatrics open Schemer, L., Harrison, L. E., Hess, C. W., Neville, A. J., Jehl, N., Ma, R. S., Glombiewski, J. A., Simons, L. E. 2024; 8 (1)

  Abstract

  To minimise the referral gap to pain psychology, the purpose of this study was to describe clinician-perceived patient suitability for pain psychology referral, develop a referral plan and outline essential elements of a referral conversation via a modified Delphi approach with multidisciplinary paediatric pain providers.We employed a three-round modified Delphi approach consulting multidisciplinary paediatric pain providers (n=18) including physicians, psychologists, physical therapists, occupational therapists and nurse practitioners (PT, OT, NP). Based on the responses to an online survey (Round 1), initial statements regarding the pain psychology referral process were developed. These statements were revised in three separate panels (MD panel, PSY panel, PT, OT, NP panel; Round 2). A priori consensus criteria were verified for each statement within and between groups using anonymous responses to a concluding online survey (Round 3).Approximately one-third of the statements (35%) reached consensus across all panels. For example, paediatric pain providers agreed that referrals should be communicated verbally, along with written materials, and that pain should be explained early from a biopsychosocial perspective. Paediatric pain providers also suggested minimising barriers through a flexible, stepped-care approach that adapts the delivery of pain psychology beyond traditional models. However, most statements reached consensus in only one or two panels (52%), indicating a lack of consensus across disciplines. The data suggest that it was comparatively easier to reach an overall consensus on statements formulating an ideal referral process to pain psychology (50%) than on statements characterising patient suitability (13%).Paediatric pain providers developed an actionable plan for pain psychology referrals. This plan could bridge referral gaps and improve access to pain psychology treatment. Given the low provider consensus on patient suitability, further research is warranted to understand pain psychology referral decision-making, including differing perceptions of patient suitability across disciplines.

  View details for DOI 10.1136/bmjpo-2024-003020

  View details for PubMedID 39725452

• Navigating virtual realities: identifying barriers and facilitators to implementing VR-enhanced PT for youth with chronic pain. Journal of pediatric psychology Jehl, N. M., Hess, C. W., Choate, E. S., Nguyen, H. T., Yang, Y., Simons, L. E. 2024

  Abstract

  Virtual reality (VR) can enhance engagement in outpatient physical therapy (PT) through distraction and gamification of movement. This study assessed barriers and facilitators to VR-enhanced PT.Data were collected during a feasibility trial of VR-enhanced PT for youth with chronic musculoskeletal pain. Semistructured and informal interviews were conducted with youth participants, their caregivers, and collaborating physical therapists. To analyze transcriptions, content analysis was employed in multiple rounds. Barriers and facilitators to VR implementation were coded using a deductive approach, then an inductive approach was used to identify emergent themes within each deductive code category.We completed interviews with youth participants (n = 9), caregivers (n = 7), and clinician stakeholders (n = 5). Coded barriers included: (1) participant identity and self-narrative inconsistent with the intervention, (2) system-level, structural constraints of healthcare, (3) lack of guidance and leadership from clinicians around VR use, (4) research burnout, (5) expectation violation and disappointment, and (6) missing the optimal treatment window. Coded facilitators included: (1) viewing VR as a bridge to achieving treatment goals, (2) having access to resources, (3) sustained positive experience and immersion in the game, (4) alignment between identity and the intervention, and (5) champion-level collaborations.This study highlights the importance of considering the VR technology, person using the VR, and the context in which VR is being implemented to optimize uptake and acceptability. Adopting an implementation science lens to the field of VR for chronic pain will enhance the applicability and scale of impact.

  View details for DOI 10.1093/jpepsy/jsae056

  View details for PubMedID 39110918

• Examining where to go: pediatric psychology trainees' perception of their graduate training in culture and diversity. Journal of pediatric psychology Hess, C. W., Rea, K. E., Wruble, L. P., Yee, S. T., Bejarano, C. M., Williford, D. N., Gibler, R. C., Eshtehardi, S. S., Fisher, R. S., Morgan, C. H. 2024

  Abstract

  Culture and diversity-related training is critical to the development of competent pediatric psychologists. Evaluation of training efforts have been conducted at the program level, yet evaluation of trainee experiences in culture and diversity-related training remains unassessed. This trainee-led study was the first formal assessment of pediatric psychology trainee experiences of culture and diversity-related training and the impact of training on their own cultural humility.Study overview and a survey link was distributed across 2 listservs associated with the American Psychological Association (Division 53, Division 54) and sent directly to directors of graduate, internship, and fellowship training programs with a request to share with trainees. Surveys assessing integration of cultural training and trainee cultural humility were completed. Trainees also provided qualitative feedback regarding their multicultural training and development.Pediatric psychology trainees (N = 90) reported inconsistent integration of culture and diversity topics into their training. Of the 34 training areas assessed, 10 were perceived as thoroughly integrated into formal training by at least half of the respondents. Trainees often sought independent cultural training outside of their programs, and no relationship was detected between perceived integration of cultural training and trainee cultural competence.Results indicate room for improvement regarding integration of cultural training and a need to better understand driving forces behind trainees independently seeking training outside of their formal training programs. Moreover, understanding the aspects of training that are most contributory to trainee development is needed given that no relationship between training and development emerged in the current study.

  View details for DOI 10.1093/jpepsy/jsae049

  View details for PubMedID 38872285

• Understanding Treatment Trajectories of Patients with Functional Neurological Disorder in Intensive Interdisciplinary Pain Treatment: A Case Series Brabson, L., Ma, R., Harrison, L. E., Hess, C. W., Webb, W., Majmundar, S., Wagner, J., Williams, S. E., Griffin, A. OXFORD UNIV PRESS INC. 2024: 75

  View details for Web of Science ID 001271423400153

• Making the teamwork dream work: Assessing burnout within integrated pain care teams Hess, C. W., Simons, L. OXFORD UNIV PRESS INC. 2024: 150

  View details for Web of Science ID 001271423400306

• The Role Of Threat Learning In The Relationship Between Adverse Childhood Experiences And Chronic Pain In Adolescents Gaydos, E., Hess, C. W., Biggs, E., Simons, L. OXFORD UNIV PRESS INC. 2024: 148

  View details for Web of Science ID 001271423400302

• Application of PainDETECT in pediatric chronic pain: how well does it identify neuropathic pain and its characteristics? Pain reports Hess, C. W., Van Orden, A. R., Mesaroli, G., Stinson, J. N., Borsook, D., Simons, L. E. 2023; 8 (6): e1109

  Abstract

  Neuropathic pain (NP) arises from nerve damage or disease, and when not defined, it can impair function and quality of life. Early detection allows for interventions that can enhance outcomes. Diagnosis of NP can be difficult if not properly evaluated. PainDETECT is a NP screening tool developed and successfully used in adults.We evaluated the validity of painDETECT in a pediatric population.Adolescents and young adults (10-19 years old) completed painDETECT and quantitative sensory testing (QST), which assessed mechanical allodynia and hyperalgesia, common symptoms of NP. Pain diagnoses, including neuropathic pain (n = 10), were collected through documentation in the medical chart. Descriptive statistics were used to examine age, gender, pain diagnoses, and painDETECT scores. Kruskal-Wallis H tests were conducted to examine differences in QST results across painDETECT categorizations.Youth with chronic pain (N = 110, Mage = 15.08 ± 2.4 years, Nfemale = 88) and peers without pain (N = 55, Mage = 15.84 ± 3.9 years, Nfemale = 39) completed the painDETECT. The painDETECT scores for youth with pain (M = 12.7 ± 6.76) were significantly higher than those for peers without pain (M = 2.05 ± 2.41). PainDETECT demonstrated 80% sensitivity and 33% specificity in a pediatric population. Individuals who screened positively on the PainDETECT had significantly higher mechanical allodynia (M = 0.640 ± 0.994) compared with those who screened negatively (M = 0.186 ± 0.499; P = 0.016).PainDETECT demonstrated the ability to screen for NP, and QST mechanical allodynia results were consistent with a positive NP screen. Results of the study offer preliminary support for the ongoing assessment of the painDETECT as a brief, inexpensive, and simple-to-use screening tool for pediatric patients with primary pain complaints.

  View details for DOI 10.1097/PR9.0000000000001109

  View details for PubMedID 38033717

  View details for PubMedCentralID PMC10686590

• Implementation of Concussion Management Policies in High Schools: The Critical Role of School Nurses. The Journal of school nursing : the official publication of the National Association of School Nurses Hess, C. W., Howland, J., Hackman, H., Campbell, J. K., Vannoy, S., Hayden, L. 2023: 10598405231160249

  Abstract

  Evidence-based practices in concussion management (CM) have been codified into legislation. However, legislation is varied, and implementation is narrowly evaluated. School nurses hold a unique position to assess the implementation of health policies. The implementation of concussion management policies across Massachusetts high schools was evaluated by the school nurse. A cross-sectional survey was sent to school nurses (N=304), and responses (n=201; 68.1% response rate) were tallied whereby higher scores indicated more practices being implemented. One open-text question was included to encourage nurses to provide context regarding implementation in their school. Descriptive statistics and thematic analysis were used to assess current implementation and nursing perspectives. Findings indicate that the degree of implementation varies, and some nurses reported difficulty with mobilizing clinical uptake of concussion management practices in their schools. Further implementation research is needed, and school nurses are an important stakeholder to include when assessing the clinical uptake of concussion management policies in schools.

  View details for DOI 10.1177/10598405231160249

  View details for PubMedID 36916285

• Enhancing Exposure Treatment for Youths With Chronic Pain: Co-design and Qualitative Approach. Journal of participatory medicine Schemer, L., Hess, C. W., Van Orden, A. R., Birnie, K. A., Harrison, L. E., Glombiewski, J. A., Simons, L. E. 2023; 15: e41292

  Abstract

  Increasing the access to and improving the impact of pain treatments is of utmost importance, especially among youths with chronic pain. The engagement of patients as research partners (in contrast to research participants) provides valuable expertise to collaboratively improve treatment delivery.This study looked at a multidisciplinary exposure treatment for youths with chronic pain through the lens of patients and caregivers with the aim to explore and validate treatment change processes, prioritize and develop ideas for improvement, and identify particularly helpful treatment elements.Qualitative exit interviews were conducted with patients and caregivers at their discharge from 2 clinical trials (ClinicalTrials.gov NCT01974791 and NCT03699007). Six independent co-design meetings were held with patients and caregivers as research partners to establish a consensus within and between groups. The results were validated in a wrap-up meeting.Patients and caregivers described that exposure treatment helped them better process pain-related emotions, feel empowered, and improve their relationship with each other. The research partners developed and agreed upon 12 ideas for improvement. Major recommendations include that pain exposure treatment should be disseminated more not only among patients and caregivers but also among primary care providers and the general public to facilitate an early referral for treatment. Exposure treatment should allow flexibility in terms of duration, frequency, and delivery mode. The research partners prioritized 13 helpful treatment elements. Most of the research partners agreed that future exposure treatments should continue to empower patients to choose meaningful exposure activities, break long-term goals into smaller steps, and discuss realistic expectations at discharge.The results of this study have the potential to contribute to the refinement of pain treatments more broadly. At their core, they suggest that pain treatments should be disseminated more, flexible, and transparent.

  View details for DOI 10.2196/41292

  View details for PubMedID 36892929

• Virtual Reality-Augmented Physiotherapy for Chronic Pain in Youth: Protocol for a Randomized Controlled Trial Enhanced With a Single-Case Experimental Design. JMIR research protocols Simons, L. E., Hess, C. W., Choate, E. S., Van Orden, A. R., Tremblay-McGaw, A. G., Menendez, M., Boothroyd, D. B., Parvathinathan, G., Griffin, A., Caruso, T. J., Stinson, J., Weisman, A., Liu, T., Koeppen, K. 2022; 11 (12): e40705

  Abstract

  BACKGROUND: Chronic musculoskeletal (MSK) pain is a prominent health concern, resulting in pain-related disability, loss of functioning, and high health care costs. Physiotherapy rehabilitation is a gold-standard treatment for improving functioning in youth with chronic MSK pain. However, increasing physical activity can feel unattainable for many adolescents because of pain-related fear and movement avoidance. Virtual reality (VR) offers an immersive experience that can interrupt the fear-avoidance cycle and improve engagement in physiotherapy. Despite promising initial findings, data are limited and often lack the rigor required to establish VR as an evidence-based treatment for MSK pain.OBJECTIVE: This trial evaluates physiorehabilitation with VR in adolescents with MSK pain. This protocol outlines the rationale, design, and implementation of a randomized controlled trial enhanced with a single-case experimental design.METHODS: This study is a 2-group randomized controlled trial assessing the use of physiorehabilitation with VR in adolescents with MSK pain. The authors will collaborate with physical therapists to integrate VR into their standard clinical care. For participants enrolled in standard physiotherapy, there will be no VR integrated into their physical therapy program. Primary outcomes include physical function and engagement in VR. Secondary outcomes include pain-related fear and treatment adherence. Moreover, we will obtain clinician perspectives regarding the feasibility of integrating the intervention into the flow of clinical practice.RESULTS: The pilot study implementing physiorehabilitation with VR demonstrated that high engagement and use of physiorehabilitation with VR were associated with improvements in pain, fear, avoidance, and function. Coupled with qualitative feedback from patients, families, and clinicians, the pilot study results provide support for this trial to evaluate physiorehabilitation with VR for youth with chronic MSK pain. Analysis of results from the main clinical trial will begin as recruitment progresses, and results are expected in early 2024.CONCLUSIONS: Significant breakthroughs for treating MSK pain require mechanistically informed innovative approaches. Physiorehabilitation with VR provides exposure to progressive challenges, real-time feedback, and reinforcement for movement and can include activities that are difficult to achieve in the real world. It has the added benefit of sustaining patient motivation and adherence while enabling clinicians to use objective benchmarks to influence progression. These findings will inform the decision of whether to proceed with a hybrid effectiveness-dissemination trial of physiorehabilitation with VR, serving as the basis for potential large-scale implementation of physiorehabilitation with VR.TRIAL REGISTRATION: ClinicalTrials.gov NCT04636177; https://clinicaltrials.gov/ct2/show/NCT04636177.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40705.

  View details for DOI 10.2196/40705

  View details for PubMedID 36508251

• Targeting Pain Science Education in Youth with Chronic Pain: What are the Sticking Points for Youth and Their Parents? The Clinical journal of pain Pate, J. W., Harrison, L. E., Hess, C. W., Moseley, G. L., Rush, G., Heathcote, L. C., Simons, L. E. 2022

  Abstract

  An important part of providing pain science education is to first assess baseline knowledge and beliefs about pain, thereby identifying misconceptions and establishing individually-tailored learning objectives. The Concept of Pain Inventory (COPI) was developed to support this need. This study aimed to characterize concept of pain in care-seeking youth and their parents, to examine its clinical and demographic correlates, and to identify conceptual gaps.Following an initial interdisciplinary evaluation, a cohort of 127 youth aged 8-18 years, and their parents, completed a series of questionnaires.Parents had slightly higher COPI scores than youth did, reflecting parents' greater alignment with contemporary pain science. The moderate positive association with older age among youth (r=.32) suggests that the COPI is sensitive to cognitive development and/or life experiences. Youth and parent COPI responses were weakly associated (r=0.24), highlighting the importance of targeting concept of pain in both groups. For both parents and youth, 'Learning about pain can help you feel less pain' was the least endorsed concept. This conceptual 'gap' is a key point of intervention, that could potentially lead to greater engagement with multidisciplinary pain treatment.The COPI appears useful for identifying conceptual gaps or 'sticking points'; this may be an important step to pre-emptively address misconceptions about pain via pain science education. Future research should determine the utility of the COPI in assessing and treating youth seeking care for pain. The COPI may be a useful tool for tailoring pain science education to youth and their parents.

  View details for DOI 10.1097/AJP.0000000000001088

  View details for PubMedID 36453624

• Looking inward to improve pediatric chronic pain outcomes: a call for team science research. Pain Hess, C. W., Rosen, M. A., Simons, L. E. 2022

  View details for DOI 10.1097/j.pain.0000000000002836

  View details for PubMedID 36637136

• Application of painDETECT in Pediatric Chronic Pain: How Well Does It Identify Neuropathic Pain and Its Characteristics? Van Orden, A., Hess, C. W., Mesaroli, G., Stinson, J., Borsook, D., Simons, L. E. CHURCHILL LIVINGSTONE. 2022: 51

  View details for Web of Science ID 000792497000192

• Lived Experiences of an Elite Performance Management Team Through Injury Rehabilitation: An Interpretative Phenomenological Analysis JOURNAL OF SPORT REHABILITATION Hess, C. W., Meyer, B. B. 2022; 31 (2): 199-210

  Abstract

  Injury is a common and challenging experience for many athletes, and return-to-sport outcomes have been persistently poor despite advancements in research and practice. To ameliorate this challenge and to bridge a gap that exists in the sport injury literature between theoretical conceptualization and intervention design, research is needed to explore team-based approaches to professional practice. The current study aimed to begin this work through exploration of a single performance management team (PMT) through 2 injury and rehabilitation cases leading into and across the 2014 Olympic Winter Games.Qualitative, interpretative phenomenological analysis.Interviews were conducted with the 5 members of the PMT (coach, physiotherapist, sport psychology consultant, case manager, and athlete) involved in both injury cases. Lower-order and higher order themes were identified and interpreted through the extent literature.Results indicate that 3 higher order themes interacted to impact the lived experiences of the PMT members across the 2 injury cases. Participants described the sociocultural context that surrounded the team, the individual struggles they faced, and the functioning of the team as the primary contributors to their lived experiences as well as observed rehabilitation outcomes.Findings of this study mirror previous research in team science within the general health care domain, and prompt ongoing exploration of how to improve the experiences for PMT members as well as rehabilitation and return-to-sport outcomes for athletes.

  View details for DOI 10.1123/jsr.2021-0072

  View details for Web of Science ID 000791037300010

  View details for PubMedID 34784584

• Evidence-based practice: a comparison of International Clinical Practice Guidelines and current research on physical activity for mild to moderate depression TRANSLATIONAL BEHAVIORAL MEDICINE Hess, C., Karter, J., Cosgrove, L., Hayden, L. 2019; 9 (4): 703-710

  Abstract

  In 2016, the U.S. Preventive Services Task Force recommended routine depression screening for individuals aged 13 and above. Questionnaire-based screening will likely increase treatment in patients with milder symptoms. Although professional groups who develop clinical practice guidelines recognize the importance of considering the risks and benefits of interventions, no official mandate exists for a stepped-care approach. Physical activity warrants increased consideration in guidelines, given the optimal risk/benefit profile and the increasing evidence of efficacy for the treatment and prevention of depression. The aim of the current study was to evaluate clinical practice guidelines for the treatment of major depressive disorder, specifically the recommendation of physical activity and adherence to a stepped-care approach. Authors searched three databases to identify treatment guidelines for depression. Guidelines were reviewed on the following domains regarding recommendation of physical activity: (a) front-line intervention, (b) explicit but not front-line recommendation, (c) inexplicit recommendation, (d) no mention, (e) adherence to a stepped-care approach, and (f) presentation of empirical support for their recommendation. Seventeen guidelines met inclusion criteria. Four guidelines recommended physical activity as a front-line intervention, two did not mention physical activity, eleven made some mention of physical activity, seven presented evidence to support their recommendation, and seven employed a stepped-care approach. The majority of guidelines did not use a stepped-care approach and varied greatly in their inclusion of physical activity as a recommended intervention for mild to moderate depression. Implications for practice, research, and policy are discussed.

  View details for DOI 10.1093/tbm/iby092

  View details for Web of Science ID 000492967600014

  View details for PubMedID 30321410