Laura Simons

All Publications

• Emotional memory bias in adolescents with chronic pain: examining the relationship with neural, stress, and psychological factors. Pain Biggs, E. E., Timmers, I., Heathcote, L. C., Tremblay-McGaw, A. G., Noel, M., Borsook, D., Simons, L. E. 2024

  Abstract

  Memory biases for pain-related information may contribute to the development and maintenance of chronic pain; however, evidence for when (and for whom) these biases occur is mixed. Therefore, we examined neural, stress, and psychological factors that could influence memory bias, focusing on memories that motivate disabling behaviors: pain perception, conditioned responses to threat-and-safety cues, and responses to aversive nonnoxious stimuli. Two studies were conducted with adolescents with and without chronic pain. Data from 58 participants were included in study 1 (chronic pain n = 34, pain free n = 24, mean age = 16 years), and 39 participants were included in study 2 (chronic pain n = 26, pain free n = 13, mean age = 16 years). Both studies used a threat-safety learning paradigm with memory recall (≈1 month later). Participants completed structural and functional (resting-state) magnetic resonance imaging, salivary cortisol measurements, and self-report measures. Adolescents with pain and pain-free peers consistently recalled being more afraid of safety cues (CS-) and, during heightened stress at encoding (higher cortisol levels), also reported being more afraid of threat cues (CS+). However, no memory bias was present for the emotional response to an aversive stimulus (US; loud scream) or for the recall of pain intensity. Functional connectivity of the amygdala and hippocampus with memory circuits related to the degree of memory bias, but the specific connections varied between the studies, and we observed no relationship between memory bias and brain morphology. Our findings highlight the value of considering the interaction between implicit and explicit memory systems, contributing to a more comprehensive understanding of emotional memory biases in the context of chronic pain.

  View details for DOI 10.1097/j.pain.0000000000003382

  View details for PubMedID 39172857

• A randomized controlled trial of graded exposure treatment (GET living) for adolescents with chronic pain. Pain Simons, L. E., Harrison, L. E., Boothroyd, D. B., Parvathinathan, G., Van Orden, A. R., O'Brien, S. F., Schofield, D., Kraindler, J., Shrestha, R., Vlaeyen, J. W., Wicksell, R. K. 2023

  Abstract

  Graded exposure treatment (GET) is a theory-driven pain treatment that aims to improve functioning by exposing patients to activities previously feared and avoided. Combining key elements of GET with acceptance-based exposure, GET Living (GL) was developed for adolescents with chronic pain (GL). Based on robust treatment effects observed in our single-case experimental design pilot trial of GL (NCT01974791), we conducted a 2-arm randomized clinical trial comparing GL with multidisciplinary pain management (MPM) comprised of cognitive behavioral therapy and physical therapy for pain management (NCT03699007). A cohort of 68 youth with chronic musculoskeletal pain (M age 14.2 years; 81% female) were randomized to GL or MPM. Owing to COVID-19 restrictions, 54% of participants received zoom video delivered care. Assessments were collected at baseline, discharge, as well as at 3-month and 6-month follow-up. Primary outcomes were self-reported pain-related fear and avoidance. Secondary outcomes were child functional disability and parent protective responses to child pain. As hypothesized, GL improved in primary and secondary outcomes at 3-month follow-up. Contrary to our superiority hypothesis, there was no significant difference between GL and MPM. Patients reported both GL and MPM (in person and video) as credible and were highly satisfied with the treatment experience. Next steps will involve examining the single-case experimental design data embedded in this trial to facilitate an understanding of individual differences in treatment responses (eg, when effects occurred, what processes changed during treatment within the treatment arm). The current findings support GET Living and MPM for youth with chronic pain.

  View details for DOI 10.1097/j.pain.0000000000003010

  View details for PubMedID 37624900

• 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

• 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

• Signature for Pain Recovery IN Teens (SPRINT): protocol for a multisite prospective signature study in chronic musculoskeletal pain. BMJ open Simons, L., Moayedi, M., Coghill, R. C., Stinson, J., Angst, M. S., Aghaeepour, N., Gaudilliere, B., King, C. D., López-Solà, M., Hoeppli, M. E., Biggs, E., Ganio, E., Williams, S. E., Goldschneider, K. R., Campbell, F., Ruskin, D., Krane, E. J., Walker, S., Rush, G., Heirich, M. 2022; 12 (6): e061548

  Abstract

  Current treatments for chronic musculoskeletal (MSK) pain are suboptimal. Discovery of robust prognostic markers separating patients who recover from patients with persistent pain and disability is critical for developing patient-specific treatment strategies and conceiving novel approaches that benefit all patients. Given that chronic pain is a biopsychosocial process, this study aims to discover and validate a robust prognostic signature that measures across multiple dimensions in the same adolescent patient cohort with a computational analysis pipeline. This will facilitate risk stratification in adolescent patients with chronic MSK pain and more resourceful allocation of patients to costly and potentially burdensome multidisciplinary pain treatment approaches.Here we describe a multi-institutional effort to collect, curate and analyse a high dimensional data set including epidemiological, psychometric, quantitative sensory, brain imaging and biological information collected over the course of 12 months. The aim of this effort is to derive a multivariate model with strong prognostic power regarding the clinical course of adolescent MSK pain and function.The study complies with the National Institutes of Health policy on the use of a single internal review board (sIRB) for multisite research, with Cincinnati Children's Hospital Medical Center Review Board as the reviewing IRB. Stanford's IRB is a relying IRB within the sIRB. As foreign institutions, the University of Toronto and The Hospital for Sick Children (SickKids) are overseen by their respective ethics boards. All participants provide signed informed consent. We are committed to open-access publication, so that patients, clinicians and scientists have access to the study data and the signature(s) derived. After findings are published, we will upload a limited data set for sharing with other investigators on applicable repositories.NCT04285112.

  View details for DOI 10.1136/bmjopen-2022-061548

  View details for PubMedID 35676017

• Virtual Reality in Pain Rehabilitation for Youth With Chronic Pain: Pilot Feasibility Study. JMIR rehabilitation and assistive technologies Griffin, A., Wilson, L., Feinstein, A. B., Bortz, A., Heirich, M. S., Gilkerson, R., Wagner, J. F., Menendez, M., Caruso, T. J., Rodriguez, S., Naidu, S., Golianu, B., Simons, L. E. 2020; 7 (2): e22620

  Abstract

  BACKGROUND: In the field of pain, virtual reality (VR) technology has been increasingly common in the context of procedural pain management. As an interactive technology tool, VR has the potential to be extended beyond acute pain management to chronic pain rehabilitation with a focus on increasing engagement with painful or avoided movements.OBJECTIVE: We outline the development and initial implementation of a VR program in pain rehabilitation intervention to enhance function in youth with chronic pain.METHODS: We present the development, acceptability, feasibility, and utility of an innovative VR program (Fruity Feet) for pediatric pain rehabilitation to facilitate increased upper and lower extremity engagement. The development team was an interdisciplinary group of pediatric experts, including physical therapists, occupational therapists, pain psychologists, anesthesiologists, pain researchers, and a VR software developer. We used a 4-phase iterative development process that engaged clinicians, parents, and patients via interviews and standardized questionnaires.RESULTS: This study included 17 pediatric patients (13 female, 4 male) enrolled in an intensive interdisciplinary pain treatment (IIPT) program, with mean age of 13.24 (range 7-17) years, completing a total of 63 VR sessions. Overall reports of presence were high (mean 28.98; max 40; SD 4.02), suggestive of a high level of immersion. Among those with multisession data (n=8), reports of pain (P<.001), fear (P=.003), avoidance (P=.004), and functional limitations (P=.01) significantly decreased. Qualitative analysis revealed (1) a positive experience with VR (eg, enjoyed VR, would like to utilize the VR program again, felt VR was a helpful tool); (2) feeling distracted from pain while engaged in VR; (3) greater perceived mobility; and (4) fewer clinician-observed pain behaviors during VR. Movement data support the targeted impact of the Fruity Feet compared to other available VR programs.CONCLUSIONS: The iterative development process yielded a highly engaging and feasible VR program based on qualitative feedback, questionnaires, and movement data. We discuss next steps for the refinement, implementation, and assessment of impact of VR on chronic pain rehabilitation. VR holds great promise as a tool to facilitate therapeutic gains in chronic pain rehabilitation in a manner that is highly reinforcing and fun.

  View details for DOI 10.2196/22620

  View details for PubMedID 33226346

• The interaction between stress and chronic pain through the lens of threat learning. Neuroscience and biobehavioral reviews Timmers, I. n., Quaedflieg, C. W., Hsu, C. n., Heathcote, L. C., Rovnaghi, C. R., Simons, L. E. 2019

  Abstract

  Stress and pain are interleaved at multiple levels - interacting and influencing each other. Both are modulated by psychosocial factors including fears, beliefs, and goals, and are served by overlapping neural substrates. One major contributing factor in the development and maintenance of chronic pain is threat learning, with pain as an emotionally-salient threat - or stressor. Here, we argue that threat learning is a central mechanism and contributor, mediating the relationship between stress and chronic pain. We review the state of the art on (mal)adaptive learning in chronic pain, and on effects of stress and particularly cortisol on learning. We then provide a theoretical integration of how stress may affect chronic pain through its effect on threat learning. Prolonged stress, as may be experienced by patients with chronic pain, and its resulting changes in key brain networks modulating stress responses and threat learning, may further exacerbate these impairing effects on threat learning. We provide testable hypotheses and suggestions for how this integration may guide future research and clinical approaches in chronic pain.

  View details for DOI 10.1016/j.neubiorev.2019.10.007

  View details for PubMedID 31622630

• Avoid or engage? Outcomes of graded exposure in youth with chronic pain using a sequential replicated single-case randomized design. Pain Simons, L. n., Vlaeyen, J. W., Declercq, L. n., Smith, A. n., Beebe, J. n., Hogan, M. n., Li, E. n., Kronman, C. n., Mahmud, F. n., Corey, J. n., Sieberg, C. n., Ploski, C. n. 2019

  Abstract

  Pain-related fear is typically associated with avoidance behavior and pain-related disability in youth with chronic pain. Youth with elevated pain-related fear have attenuated treatment responses, thus targeted treatment is highly warranted. Evidence supporting graded in-vivo exposure treatment (GET) for adults with chronic pain is considerable, but just emerging for youth. The current investigation represents the first sequential replicated and randomized single-case experimental phase design with multiple measures evaluating GET for youth with chronic pain, entitled GET Living. A cohort 27 youth (81% female) with mixed chronic pain completed GET Living. For each participant, a no-treatment randomized baseline period was compared with GET Living and 3- and 6-month follow-ups. Daily changes in primary outcomes fear and avoidance and secondary outcomes pain catastrophizing, pain intensity, and pain acceptance were assessed using electronic diaries and subjected to descriptive and model-based inference analyses (MLM). Based on individual effect size calculations, a third of participants significantly improved by the end of treatment on fear, avoidance, and pain acceptance. By follow-up over 80% of participants had improved across all primary and secondary outcomes. MLM results to examine the series of replicated cases were generally consistent. Improvements during GET Living was superior to the no-treatment randomized baseline period for avoidance, pain acceptance, and pain intensity, whereas fear and pain catastrophizing did not improve. All five outcomes emerged as significantly improved at 3- and 6-month follow-up. The results of this replicated SCED support the effectiveness of graded exposure for youth with chronic pain and elevated pain-related fear avoidance.

  View details for DOI 10.1097/j.pain.0000000000001735

  View details for PubMedID 31693541

• Circles of engagement: Childhood pain and parent brain NEUROSCIENCE AND BIOBEHAVIORAL REVIEWS Simons, L. E., Goubert, L., Vervoort, T., Borsook, D. 2016; 68: 537-546

  Abstract

  Social interaction can have a profound effect on individual behavior, perhaps most salient in interactions between sick suffering children and their parents. Chronic pain is a difficult condition that can produce considerable changes in children's behaviors that can secondarily have profound effects on their parents. It may create a functionally disabling negative feedback loop. Research supports the notion of alterations in the brain of individuals who observe and empathize with loved ones in acute pain. However, neural activity in relation to empathic responses in the context of chronic pain has not been examined. Ongoing suffering with chronic pain in a child can result in child's brain circuit alterations. Moreover, prolonged suffering jointly experienced by the parent may putatively produce maladaptive changes in their neural networks and consequently in parental behaviors. Here we put forth the conceptual framework for 'Chronic pain contagion' (CPC). We review the underlying processes in CPC and discuss implications for devising and implementing treatments for children in chronic pain and their parents.

  View details for DOI 10.1016/j.neubiorev.2016.06.020

  View details for Web of Science ID 000383293500036

  View details for PubMedID 27320958

  View details for PubMedCentralID PMC5003639

• Pediatric Pain Screening Tool: rapid identification of risk in youth with pain complaints PAIN Simons, L. E., Smith, A., Ibagon, C., Coakley, R., Logan, D. E., Schechter, N., Borsook, D., Hill, J. C. 2015; 156 (8): 1511-1518

  Abstract

  Moderate to severe chronic pain is a problem for 1.7 million children, costing $19.5 billion dollars annually in the United States alone. Risk-stratified care is known to improve outcomes in adults with chronic pain. However, no tool exists to stratify youth who present with pain complaints to appropriate interventions. The Pediatric Pain Screening Tool (PPST) presented here assesses prognostic factors associated with adverse outcomes among youth and defines risk groups to inform efficient treatment decision making. Youth (n = 321, ages 8-18, 90.0% Caucasian, 74.8% female) presenting for multidisciplinary pain clinic evaluation at a tertiary care center participated. Of these, 195 (61.1%) participated at 4-month follow-up. Participants completed the 9-item PPST in addition to measures of functional disability, pain catastrophizing, fear of pain, anxiety, and depressive symptoms. Sensitivity and specificity for the PPST ranged from adequate to excellent, with regard to significant disability (78%, 68%) and high emotional distress (81%, 63%). Participants were classified into low- (11%), medium- (32%), and high- (57%) risk groups. Risk groups did not significantly differ by pain diagnosis, location, or duration. Only 2% to 7% of patients who met reference standard case status for disability and emotional distress at 4-month follow-up were classified as low risk at baseline, whereas 71% to 79% of patients who met reference standard case status at follow-up were classified as high risk at baseline. A 9-item screening tool identifying factors associated with adverse outcomes among youth who present with pain complaints seems valid and provides risk stratification that can potentially guide effective pain treatment recommendations in the clinic setting.

  View details for DOI 10.1097/j.pain.0000000000000199

  View details for Web of Science ID 000358815500018

  View details for PubMedID 25906349

  View details for PubMedCentralID PMC4504741

• Psychological processing in chronic pain: A neural systems approach NEUROSCIENCE AND BIOBEHAVIORAL REVIEWS Simons, L. E., Elman, I., Borsook, D. 2014; 39: 61-78

  Abstract

  Our understanding of chronic pain involves complex brain circuits that include sensory, emotional, cognitive and interoceptive processing. The feed-forward interactions between physical (e.g., trauma) and emotional pain and the consequences of altered psychological status on the expression of pain have made the evaluation and treatment of chronic pain a challenge in the clinic. By understanding the neural circuits involved in psychological processes, a mechanistic approach to the implementation of psychology-based treatments may be better understood. In this review we evaluate some of the principle processes that may be altered as a consequence of chronic pain in the context of localized and integrated neural networks. These changes are ongoing, vary in their magnitude, and their hierarchical manifestations, and may be temporally and sequentially altered by treatments, and all contribute to an overall pain phenotype. Furthermore, we link altered psychological processes to specific evidence-based treatments to put forth a model of pain neuroscience psychology.

  View details for DOI 10.1016/j.neubiorev.2013.12.006

  View details for Web of Science ID 000332752900004

  View details for PubMedID 24374383

  View details for PubMedCentralID PMC3944001

• Increasing presence via a more immersive VR system increases virtual reality analgesia and draws more attention into virtual reality in a randomized crossover study FRONTIERS IN VIRTUAL REALITY Hoffman, H. G., Seibel, C. C., Coron, L., Simons, L. E., Drever, S., Le May, S., Mason, K. P., Flor, H. 2024; 5

  View details for DOI 10.3389/frvir.2024.1452486

  View details for Web of Science ID 001315390800001

• 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

• Probing white matter microstructure in youth with chronic pain and its relation to catastrophizing using neurite orientation dispersion and density imaging. Pain Timmers, I., Biggs, E. E., Bruckert, L., Tremblay-McGaw, A. G., Zhang, H., Borsook, D., Simons, L. E. 2024

  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.

  View details for DOI 10.1097/j.pain.0000000000003269

  View details for PubMedID 38718105

• Sleep disturbances, altered brain microstructure and chronic headache in youth. Brain imaging and behavior Vandergaag, I. D., Nania, C., Timmers, I., Simons, L., Lebel, C., Rasic, N., Walker, A., Noel, M., Miller, J. V. 2024

  Abstract

  Chronic headache (persistent or recurrent headache for 3-months or longer) is highly prevalent among youth. While sleep disturbances have been associated with headache, their inter-relationship with brain connectivity remains unknown. This observational study examined whether self-report and actigraphy measures of sleep were associated with alterations to white matter tracts (i.e., uncinate fasciculus and cingulum) in youth with chronic headache versus healthy controls. Thirty youth aged 10-18 years with chronic headache and thirty controls underwent an MRI. Diffusion tensor images were obtained and mean fractional anisotropy values of the cingulum and uncinate were extracted. One-week prior to their MRI, youth wore an actigraph to obtain sleep duration, wake after sleep onset and sleep efficiency measures. Moreover, they completed questionnaires regarding their sleep quality and pain symptomatology. Linear regression was applied to examine the relationships between sleep (self-report and actigraphy), fractional anisotropy, and number of headache days per month. Self-report and actigraphy measures of sleep did not differ between patients and controls. However, poorer self-reported sleep quality was associated with lower fractional anisotropy values in the left uncinate (P = 0.05). Lower left uncinate fractional anisotropy was related to increased headache frequency (P = 0.002) in youth with chronic headache. Therefore, alterations to connectivity may be associated with the relationship between altered perceptions of sleep and headache chronicity.

  View details for DOI 10.1007/s11682-024-00876-9

  View details for PubMedID 38558207

  View details for PubMedCentralID 4371598

• 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

• The bodily threat monitoring scale: Development and preliminary validation in adult and childhood cancer survivors. Psycho-oncology Heathcote, L. C., Webster, S. N., Loecher, N., Spunt, S. L., Simon, P., Pradhan, P., Coutts-Bain, D., Sharpe, L., Tutelman, P. R., Simons, L. E. 2023

  Abstract

  Bodily threat monitoring is a core clinical feature of Fear of cancer recurrence (FCR) and is targeted in psycho-oncology treatments, yet no comprehensive self-report measure exists. The aim of this study was the theory-informed development and initial validation of the Bodily Threat Monitoring Scale (BTMS).Adult survivors of breast and gynaecological cancers (Study 1: N = 306, age = 37-81 years) and childhood cancer survivors (Study 2: N = 126, age = 10-25 years) completed the BTMS, designed to assess how individuals monitor for and interpret uncertain symptoms as indicating that something is wrong with their body. Participants completed measures to assess construct and criterion validity of the BTMS, and childhood cancer survivors (Study 2) completed the BTMS again 2 weeks later to assess test-retest reliability.The 19-item BTMS demonstrated excellent internal consistency across adult and childhood cancer samples (α = 0.90-0.96). Factor analyses indicated two subscales capturing 1. Monitoring of bodily sensations and 2. Threatening interpretations of bodily sensations. Two-week stability estimates were acceptable. For construct validity, the BTMS correlated with body vigilance and anxiety sensitivity. The BTMS also demonstrated criterion validity, yielding significant associations with FCR, intolerance of uncertainty, help-seeking behaviours, and quality of life. The BTMS was associated with FCR while controlling for body vigilance and anxiety sensitivity, indicating a unique contribution of this theory-informed measure.The BTMS shows evidence of sound psychometric properties and could be used to elucidate the role of bodily threat monitoring in the maintenance and management of FCR.

  View details for DOI 10.1002/pon.6236

  View details for PubMedID 37916988

• A single-item mood question adequately discriminates moderately severe to severe depression in individuals with persistent pain: preliminary validation. British journal of anaesthesia Mouatt, B., Leake, H. B., Stanton, T. R., Moseley, G. L., Simons, L. E., Braithwaite, F. A. 2023

  View details for DOI 10.1016/j.bja.2023.07.017

  View details for PubMedID 37587007

• Body mindsets are associated with pain and threat-related risk factors for pain in survivors of childhood cancer. The journal of pain Dowling, E. J., Simons, L. E., Crum, A. J., Spunt, S. L., Simon, P., Webster, S. N., Brown, M. R., Jhanji, S., Chilcot, J., Heathcote, L. C. 2023

  Abstract

  Pain is a common consequence of childhood cancer. While most research has examined biomedical predictors of post-cancer pain, biopsychosocial conceptualisations such as the Cancer Threat Interpretation (CTI) model hold promise for guiding comprehensive pain management strategies. Guided by the CTI model, this cross-sectional study evaluated correlates of post-cancer pain in childhood cancer survivors including threat-related risk factors (bodily threat monitoring, fear of cancer recurrence, help-seeking) and mindsets about the body. In the preceding three months, 21.8% of survivors reported chronic pain (>3 months) and 14.3% experienced pain most days. Greater bodily threat monitoring, more fear of cancer recurrence, and more help-seeking was associated with more pain. There was heterogeneity in the mindsets that survivors of childhood cancer hold about their bodies. Holding the mindset that the 'body is an adversary' was associated with more pain, greater bodily threat monitoring and more fear of cancer recurrence. Holding the mindset that the 'body is responsive' was associated with less bodily threat monitoring, while the mindset that the 'body is capable' was associated with greater help-seeking. A path model demonstrated a significant combined indirect effect of the 'body is an adversary' mindset on pain through bodily threat monitoring and fear of cancer recurrence. Overall, this study supported that a sub-group of childhood cancer survivors experience persistent and interfering pain and provided cross-sectional support for threat-related correlates for pain aligning with the CTI model. Body mindsets were associated with pain and threat-related correlates and may represent a novel target to support survivors with pain.

  View details for DOI 10.1016/j.jpain.2023.07.030

  View details for PubMedID 37549774

• Commentary: Peer Support Needs of Adolescents With Chronic Pain. Journal of pediatric psychology Choate, E. S., Neville, A. J., Simons, L. E. 2023

  View details for DOI 10.1093/jpepsy/jsad027

  View details for PubMedID 37155915

• "You don't accept he's completely ok": a reflexive thematic analysis of parents' roles in monitoring their child's health and symptoms after finishing childhood cancer treatment. Journal of cancer survivorship : research and practice Loecher, N., Jordan, A., Spunt, S. L., Simon, P., Simons, L. E., Dahl, G., Kosyluk, K., Heathcote, L. C. 2023

  Abstract

  OBJECTIVES/PURPOSE: Childhood cancer survival brings continued mental and physical health challenges both for the child and for the family. In this study, we investigated how parents viewed their roles in their child's health and symptom monitoring during the survivorship period.METHODS: Twenty-one parents of childhood cancer survivors (n=18 mothers; parent mage=49.78years, child mage=18.50years; range=12-25years), whose children were at least one year off-treatment (m=3.67years; SD=2.25; various diagnoses), completed semi-structured interviews. Interviews were recorded, transcribed, and analyzed using reflexive thematic analysis.RESULTS: Analyses generated three themes which reflect roles that parents may adopt in the context of monitoring symptoms in their childhood cancer survivor. "Vigilant Mama and Papa" (theme 1) described parents who expressed a strong sense of responsibility for protecting their child's health during survivorship resulting in careful monitoring of their child's symptoms and health. "Pragmatic Mamas and Papas" (theme 2) described parents who adopted an approach to symptom and health monitoring that emphasized moving past cancer and focusing on the future. Finally, "Encouraging Mamas and Papas" (theme 3) described parents who focused on educating and preparing their child to develop an autonomous approach to health and symptom self-monitoring as they transitioned to survivorship and adulthood.CONCLUSION: Parents take on varying roles in monitoring their child's symptoms and health after finishing childhood cancer treatment.IMPLICATIONS FOR CANCER SURVIVORS: Understanding the ways in which parents continue to be involved in their child's cancer journey helps researchers develop interventions to support dyadic coping in survivorship.

  View details for DOI 10.1007/s11764-023-01353-w

  View details for PubMedID 36821041

• International Survey of Pediatric Oncologists' Beliefs and Communication Practices Regarding Symptom Self-Monitoring by Childhood Cancer Survivors. JCO oncology practice Webster, S. N., Spunt, S. L., Cunningham, S. J., Wakefield, C. E., Smith, S. M., Alberts, N. M., Palesh, O., Simons, L. E., Heathcote, L. C. 2023: OP2200630

  Abstract

  Childhood cancer survivors report self-monitoring for and worrying about symptoms of disease recurrence and secondary cancers, although symptom-related worry is associated with poorer health-related quality of life. This survey captured pediatric oncologists' beliefs and communication practices regarding symptom self-monitoring for childhood cancer survivors.Using a closed-loop snowball sampling technique, pediatric oncologists completed an online survey regarding the importance of symptom self-monitoring for off-therapy patients, the degree to which symptom self-monitoring was perceived to cause stress and worry, and communication practices.196 pediatric oncologists (White [78%]; female [64%]; Mage = 47 years) from every continent except Antarctica participated. Oncologists believed it is important for off-therapy patients to self-monitor for symptoms of cancer recurrence (90%) and treatment late effects (94%), although some noted that recurrence (30%) and late effects (55%) are typically detected by routine surveillance before symptoms appear. Oncologists varied in their beliefs that off-therapy patients do (31%) or do not (31%) worry unnecessarily about symptoms of recurrence. Two thirds (62%) of oncologists reported often/always discussing with off-therapy patients which symptoms could indicate cancer recurrence, whereas fewer than half (43%) often/always discussed which symptoms were unlikely to indicate recurrence. Oncologists identified a need for education regarding how to communicate around symptom self-monitoring and the potential utility of a screening tool to identify those who worry excessively.Despite nearly universal belief that their off-therapy patients should self-monitor for symptoms of disease recurrence and late effects, a substantial proportion of pediatric oncologists do not counsel patients on symptom self-monitoring. Since nearly one-third believe that off-therapy patients worry unnecessarily about symptoms of recurrence, improving patient education regarding which symptoms are and are not medically concerning could decrease stress and improve health-related quality of life for pediatric cancer survivors.

  View details for DOI 10.1200/OP.22.00630

  View details for PubMedID 36800566

• Considering Precision and Utility When we Talk About Pain. Comment on Cohen et al. The journal of pain Moseley, G. L., Pearson, N., Reezigt, R., Madden, V. J., Hutchinson, M. R., Dunbar, M., Beetsma, A. J., Leake, H. B., Moore, P., Simons, L., Heathcote, L., Ryan, C., Berryman, C., Mardon, A. K., Wand, B. M. 2023; 24 (1): 178-181

  View details for DOI 10.1016/j.jpain.2022.05.010

  View details for PubMedID 36549800

• Considering Precision and Utility When we Talk About Pain. Comment on Cohen et al JOURNAL OF PAIN Moseley, G. L., Pearson, N., Reezigt, R., Madden, V. J., Hutchinson, M. R., Dunbar, M., Beetsma, A. J., Leake, H. B., Moore, P., Simons, L., Heathcote, L., Ryan, C., Berryman, C., Mardon, A. K., Wand, B. M. 2023; 24 (1): 178-181

  View details for Web of Science ID 000911083700001

• Innovative treatment formats, technologies, and clinician trainings that improve access to behavioral pain treatment for youth and adults. Frontiers in pain research (Lausanne, Switzerland) Darnall, B. D., Edwards, K. A., Courtney, R. E., Ziadni, M. S., Simons, L. E., Harrison, L. E. 2023; 4: 1223172

  Abstract

  Chronic pain is prevalent across the life span and associated with significant individual and societal costs. Behavioral interventions are recommended as the gold-standard, evidence-based interventions for chronic pain, but barriers, such as lack of pain-trained clinicians, poor insurance coverage, and high treatment burden, limit patients' ability to access evidenced-based pain education and treatment resources. Recent advances in technology offer new opportunities to leverage innovative digital formats to overcome these barriers and dramatically increase access to high-quality, evidenced-based pain treatments for youth and adults. This scoping review highlights new advances. First, we describe system-level barriers to the broad dissemination of behavioral pain treatment. Next, we review several promising new pediatric and adult pain education and treatment technology innovations to improve access and scalability of evidence-based behavioral pain treatments. Current challenges and future research and clinical recommendations are offered.

  View details for DOI 10.3389/fpain.2023.1223172

  View details for PubMedID 37547824

• Evidence of Chronic Complement Activation in Asymptomatic Pediatric Brain Injury Patients: A Pilot Study. Children (Basel, Switzerland) Holmes, S. A., Mar'i, J., Lemme, J., Maallo, A. M., Lebel, A., Simons, L., O'Brien, M. J., Zurakowski, D., Burnstein, R., Borsook, D. 2022; 10 (1)

  Abstract

  Physical insult from a mild Traumatic Brain Injury (mTBI) leads to changes in blood flow in the brain and measurable changes in white matter, suggesting a physiological basis for chronic symptom presentation. Post-traumatic headache (PTH) is frequently reported by persons after an mTBI that may persist beyond the acute period (>3 months). It remains unclear whether ongoing inflammation may contribute to the clinical trajectory of PTH. We recruited a cohort of pediatric subjects with PTH who had an acute or a persistent clinical trajectory, each around the 3-month post-injury time point, as well as a group of age and sex-matched healthy controls. We collected salivary markers of mRNA expression as well as brain imaging and psychological testing. The persistent PTH group showed the highest levels of psychological burden and pain symptom reporting. Our data suggest that the acute and persistent PTH cohort had elevated levels of complement factors relative to healthy controls. The greatest change in mRNA expression was found in the acute-PTH cohort wherein the complement cascade and markers of vascular health showed a prominent role for C1Q in PTH pathophysiology. These findings (1) underscore a prolonged engagement of what is normally a healthy response and (2) show that a persistent PTH symptom trajectory may parallel a poorly regulated inflammatory response.

  View details for DOI 10.3390/children10010045

  View details for PubMedID 36670596

• 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

• Altered anterior insula functional connectivity in adolescent and young women with endometriosis-associated pain: Pilot resting-state fMRI study. European journal of paediatric neurology : EJPN : official journal of the European Paediatric Neurology Society Szabo, E., Timmers, I., Borsook, D., Simons, L. E., Sieberg, C. B. 2022; 41: 80-90

  Abstract

  BACKGROUND: Endometriosis is the leading cause of chronic pelvic pain. Alterations in brain functional connectivity have been reported in adult women with endometriosis-associated pain (EAP), however, it is still unknown if similar patterns of changes exist in adolescents.METHODS: In this pilot study, resting-state fMRI scans were obtained from 11 adolescent and young women with EAP and 14 healthy female controls. Using a seed-to-voxel approach, we investigated functional connectivity between the anterior insula, medial prefrontal cortex, and the rest of the brain. Furthermore, we explored whether potential functional connectivity differences were correlated with clinical characteristics including disease duration, pain intensity, and different psychosocial factors (pain catastrophizing, fear of pain, functional disability, anxiety, and depression).RESULTS: Our findings revealed that patients with EAP demonstrated significantly decreased connectivity between the right anterior insula and two clusters: one in the right cerebellum, and one in the left middle frontal gyrus compared to controls. Additionally, functional connectivity between the right anterior insula and the right cerebellum was positively associated with pain intensity levels. In patients with EAP, brain changes were also correlated with state anxiety and fear of pain.CONCLUSIONS: Our results are relevant not only for understanding the brain characteristics underlying EAP at a younger age, but also in enhancing future pain treatment efforts by supporting the involvement of the central nervous system in endometriosis.

  View details for DOI 10.1016/j.ejpn.2022.10.004

  View details for PubMedID 36375399

• Agile development of a digital exposure treatment for youth with chronic musculoskeletal pain: protocol of a user-centred design approach and examination of feasibility and preliminary efficacy. BMJ open Harrison, L. E., Webster, S. N., Van Orden, A. R., Choate, E., Jehl, N., Stinson, J., Wicksell, R. K., Darnall, B. D., Simons, L. E. 2022; 12 (9): e065997

  Abstract

  INTRODUCTION: Chronic pain affects a significant number of children and impacts multiple domains including social, emotional and behavioural functioning, and negatively impacts family functioning. Roughly 5% of youth with chronic pain experience moderate to severe pain-related disability, with pain-related fear and avoidance of activities being identified as substantial barriers to treatment engagement. Evidence supports targeted psychological and physical interventions to address these barriers (eg, graded-exposure treatment), but accessibility to intervention is undermined by a shortage of services outside of urban areas, high treatment-related costs, and long provider waitlists; highlighting the need to develop digitally delivered behavioural intervention, using agile and iterative study designs that support rapid development and timely dissemination.METHODS AND ANALYSIS: This study seeks to develop an effective and scalable intervention for youth with chronic pain and their caregivers. This paper presents a user-centred protocol for the development and refinement of a digital exposure treatment for youth and caregivers, as well as the study design to examine feasibility and preliminary efficacy of the treatment using single-case experimental design (SCED). Assessments include daily diaries, completed from baseline and daily throughout the intervention (~6 weeks), and at 3-month follow-up, as well as self-report measures completed at baseline, end of intervention and 3-month follow-up. Primary outcomes include treatment satisfaction, treatment expectancy, adherence to daily dairies and functional disability. Secondary outcomes are pain-related fear and avoidance of activities, pain catastrophising and pain acceptance. We will present descriptive and model-based inference analyses, based on SCED reporting guidelines. We will calculate effect sizes for each individual on each outcome. We will examine mean treatment expectancy, credibility and satisfaction scores, and patient drop-out percentage.ETHICS AND DISSEMINATION: This study is approved by the Institutional Review Board at Stanford University (protocol #53323). Findings will be actively disseminated through peer-reviewed journals, conference presentations and social media.TRIAL REGISTRATION NUMBER: NCT05079984.

  View details for DOI 10.1136/bmjopen-2022-065997

  View details for PubMedID 36109029

• Microtemporal Relationships in the Fear Avoidance Model: An Ecological Momentary Assessment Study. The Clinical journal of pain Kichline, T., Cushing, C. C., Connelly, M., Black, W. R., Simons, L. E., Friesen, C., Schurman, J. V. 2022

  Abstract

  OBJECTIVES: Current literature in pediatric pain evaluates the Fear-Avoidance Model pathways at the trait (or macrotemporal) level, but it is unknown if these pathways also occur at the state (or microtemporal) level. Identifying microtemporal processes can improve our understanding of how the relationships within the Fear-Avoidance constructs vary when specific Fear-Avoidance variables wax and wane. We hypothesized that changes in FAM constructs would be associated with changes in the next variable in the sequence on a microtemporal level, including: (1) higher pain when there is more pain related fear, (2) higher pain-related fear when there is more avoidance, and (3) higher avoidance when there is more reported disability.METHODS: 71 pediatric patients with chronic abdominal pain (M=13.34y, SD=2.67y) reported pain severity, pain-related fear, and avoidance via ecological momentary assessments over 14 days.RESULTS: Our results indicated significant microtemporal relationships between Fear-Avoidance constructs for pain predicting pain related fear, pain-related fear predicting avoidance, and avoidance predicting disability.DISCUSSION: The current study suggests that the ways in which the FAM is related to various aspects of pain functioning differs on a state-level, which adds new clinical and research opportunities.

  View details for DOI 10.1097/AJP.0000000000001058

  View details for PubMedID 35866559

• Paediatric chronic pain as a catalyst for toxic stress. The Lancet. Child & adolescent health Nelson, S., Miller, J. V., Timmers, I., Simons, L. E., Meldrum, K., Noel, M. 2022

  View details for DOI 10.1016/S2352-4642(22)00187-0

  View details for PubMedID 35803291

• Rapid Transition to Virtual Assessment and Treatment in an Interdisciplinary Randomized Clinical Trial for Youth With Chronic Pain: Adaptations and Implications for Future Trials. The Clinical journal of pain Shear, D., Harrison, L. E., O'Brien, S., Khazendar, Z., Lyons, S., Morgan, J. J., Chan, S. K., Feinstein, A. B., Simons, L. E. 2022; 38 (7): 459-469

  Abstract

  COVID-19 abruptly halted in-person clinical care and research requiring a shift to virtual assessment and treatment. This unexpected transition of a 2-arm randomized controlled trial (RCT) examining interdisciplinary graded exposure treatment (GET Living) compared with multidisciplinary pain management for youth with chronic pain provided an opportunity to implement the first remotely delivered exposure treatment and remotely delivered biomechanical assessment for pediatric chronic pain. Here we describe these new approaches and provide lessons learned to inform future efforts in digital health care.A total of 68 youth (M=14.2 y; 80.9% female) were enrolled in the RCT (n=31 in-person, n=5 hybrid, n=32 virtual, n=9 withdrew). Of those withdrawn, n=3 withdrew due to COVID-19 related reasons. Some RCT elements required slight modification (eg, e-consent, actigraphy deployment, recruitment, and screening), while others were significantly altered (eg, session format and lab-based biomechanical assessment). Data from exit interviews were also examined to assess perspectives on the virtual format transition.Results showed an increased enrollment rate when virtual care was an option (70.7%) compared with in-person (44.3%). Equivalent rates of completion for daily assessment (in-person, 72.8%; virtual, 73.3) were also observed, and participants described enhanced experience when able to complete exercises and exposures in their home environment during session (vs. a rehabilitation gym) allowing for genuine in vivo exposures (eg, household chores, riding bicycles).Overall, our data demonstrate acceptability, feasibility, and equivalent patient engagement to virtual treatment. Novel methods implemented in this RCT can inform trial design and measures of clinical endpoints for future digital health interventions.

  View details for DOI 10.1097/AJP.0000000000001040

  View details for PubMedID 35686576

• 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

• Development, evaluation and implementation of a digital behavioural health treatment for chronic pain: study protocol of the multiphase DAHLIA project. BMJ open Bartels, S. L., Johnsson, S. I., Boersma, K., Flink, I., McCracken, L. M., Petersson, S., Christie, H. L., Feldman, I., Simons, L. E., Onghena, P., Vlaeyen, J. W., Wicksell, R. K. 2022; 12 (4): e059152

  Abstract

  INTRODUCTION: Chronic pain affects about 20%-40% of the population and is linked to mental health outcomes and impaired daily functioning. Pharmacological interventions are commonly insufficient for producing relief and recovery of functioning. Behavioural health treatment is key to generate lasting benefits across outcome domains. However, most people with chronic pain cannot easily access evidence-based behavioural interventions. The overall aim of the DAHLIA project is to develop, evaluate and implement a widely accessible digital behavioural health treatment to improve well-being in individuals with chronic pain.METHODS AND ANALYSIS: The project follows the four phases of the mHealth Agile Development and Evaluation Lifecycle: (1) development and pre-implementation surveillance using focus groups, stakeholder interviews and a business model; (2) iterative optimisation studies applying single case experimental design (SCED) method in 4-6 iterations with n=10 patients and their healthcare professionals per iteration; (3) a two-armed clinical randomised controlled trial enhanced with SCED (n=180 patients per arm) and (4) interview-based post-market surveillance. Data analyses include multilevel modelling, cost-utility and indicative analyses.In October 2021, inter-sectorial partners are engaged and funding is secured for four years. The treatment content is compiled and the first treatment prototype is in preparation. Clinical sites in three Swedish regions are informed and recruitment for phase 1 will start in autumn 2021. To facilitate long-term impact and accessibility, the treatment will be integrated into a Swedish health platform (www.1177.se), which is used on a national level as a hub for advice, information, guidance and e-services for health and healthcare.ETHICS AND DISSEMINATION: The study plan has been reviewed and approved by Swedish ethical review authorities. Findings will be actively disseminated through peer-reviewed journals, conference presentations, social media and outreach activities for the wider public.TRIAL REGISTRATION NUMBER: NCT05066087.

  View details for DOI 10.1136/bmjopen-2021-059152

  View details for PubMedID 35428645

• Smartphone-Based Ecological Momentary Assessment to Study "Scanxiety" among Adolescent and Young Adult Survivors of Childhood Cancer: A Feasibility Study. Psycho-oncology Heathcote, L. C., Cunningham, S. J., Webster, S. N., Tanna, V., Mattke, E., Loecher, N., Spunt, S. L., Simon, P., Dahl, G., Walentynowicz, M., Murnane, E., Tutelman, P. R., Schapira, L., Simons, L. E., Mueller, C. 2022

  Abstract

  OBJECTIVE: Scan-related anxiety ("scanxiety") refers to the fear, stress, and anxiety in anticipation of tests and scans in follow-up cancer care. This study assessed the feasibility of Ecological Momentary Assessment (EMA) for real-world, real-time capture of scanxiety using patients' personal smartphone.METHODS: Adolescent and Young Adult (AYA) survivors of childhood cancer were prompted to complete EMA surveys on a smartphone app three times per day for 11 days (33 surveys total) around their routine surveillance scans. Participants provided structured feedback on the EMA protocol.RESULTS: Thirty out of 46 contacted survivors (65%) enrolled, exceeding the preregistered feasibility cutoff of 55%. The survey completion rate (83%) greatly exceeded the preregistered feasibility cutoff of 65%. Participants generally found the smartphone app easy and enjoyable to use and reported low levels of distress from answering surveys. Participants reported significantly more daily fear of cancer recurrence (FCR) and negative affect in the days before compared to the days after surveillance scans, aligning with the expected trajectory of scanxiety. Participants who reported greater FCR and scanxiety using comprehensive measures at baseline also reported significantly more daily FCR around their surveillance scans, indicating validity of EMA items. Bodily threat monitoring was prospectively and concurrently associated with daily FCR, thus warranting further investigation as a risk factor for scanxiety.CONCLUSIONS: Findings indicate the feasibility, acceptability, and validity of EMA as a research tool to capture the dynamics and potential risk factors for scanxiety. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/pon.5935

  View details for PubMedID 35411626

• Amygdala functional connectivity mediates the association between catastrophizing and threat-safety learning in youth with chronic pain. Pain Timmers, I., Lopez-Sola, M., Heathcote, L. C., Heirich, M., Rush, G. Q., Shear, D., Borsook, D., Simons, L. E. 2022; 163 (4): 719-728

  Abstract

  ABSTRACT: There is a need to identify brain connectivity alterations predictive of transdiagnostic processes that may confer vulnerability for affective symptomology. Here, we tested whether amygdala resting-state functional connectivity (rsFC) mediated the relationship between catastrophizing (negative threat appraisals and predicting poorer functioning) and altered threat-safety discrimination learning (critical to flexibly adapt to new and changing environments) in adolescents with persistent pain. We examined amygdala rsFC in 46 youth with chronic pain and 29 healthy peers (age M = 15.8, SD = 2.9; 64 females) and its relationship with catastrophizing and threat-safety learning. We used a developmentally appropriate threat-safety learning paradigm and performed amygdala seed-based rsFC and whole-brain mediation analyses. Patients exhibited enhanced connectivity between the left amygdala and right supramarginal gyrus (SMG) (cluster-level P-FDR < 0.05), whereas right amygdala rsFC showed no group differences. Only in patients, elevated catastrophizing was associated with facilitated threat-safety learning (CS+>CS-; rp = 0.49, P = 0.001). Furthermore, in patients, elevated catastrophizing was associated with reduced left amygdala connectivity with SMG / parietal operculum, and increased left amygdala connectivity with hippocampus, dorsal striatum, paracingulate, and motor regions (P < 0.001). In addition, blunted left amygdala rsFC with right SMG/parietal operculum mediated the association between catastrophizing and threat-safety learning (P < 0.001). To conclude, rsFC between the left amygdala (a core emotion hub) and inferior parietal lobe (involved in appraisal and integration of bodily signals and attentional reorienting) explains associations between daily-life relevant catastrophizing and threat-safety learning. Findings provide a putative model for understanding pathophysiology involved in core psychological processes that cut across diagnoses, including disabling pain, and are relevant for their etiology.

  View details for DOI 10.1097/j.pain.0000000000002410

  View details for PubMedID 35302974

• Measuring Clinically Meaningful Change in Outcomes for Youth with Chronic Pain Following Graded Exposure Treatment. The Clinical journal of pain Harrison, L. E., Heathcote, L. C., Khazendar, Z., Richardson, P. A., Simons, L. E. 2022

  Abstract

  INTRODUCTION: Functional improvement is a critical outcome for individuals living with chronic pain. Graded exposure treatment has been associated with statistically significant improvements in functional outcomes for youth with chronic pain by targeting pain-related fear and avoidance.OBJECTIVE: The aim of the present study was to explore clinically meaningful change in outcomes in adolescents with chronic pain following participation in a graded exposure treatment (GET Living), and to then classify patients as treatment responders versus non-responders.METHODS: Participants included 27 youth (Mage=13.5) with chronic pain enrolled in a recently published single-arm randomized baseline trial of GET Living. Reliable change at the individual level was assessed using the Reliable Change Index (RCI). Adolescents were classified as treatment responders if they achieved a reliable change in outcomes across time points and also demonstrated a change in clinical severity range in the expected direction (i.e., from severe to moderate).RESULTS: Reliable and clinically significant improvements in pain-related fear and avoidance, functional disability, and school functioning were demonstrated at discharge, with improvements maintained at 3-month and 6-month follow up. Among core outcomes, 48% (n=13) of patients were classified as treatment responders in one or more outcomes at discharge, with this increasing to 76% (n=19) at 3-month follow-up.DISCUSSION: Examining reliable and clinically meaningful change (vs. statistical significance alone) provides a way to examine treatment response to an intervention and to enhance the interpretability of findings, helping to bridge the gap between clinical trials and clinical practice by providing guidelines for interpretation.

  View details for DOI 10.1097/AJP.0000000000001031

  View details for PubMedID 35276700

• Integrated Features for Optimizing Machine Learning Classifiers of Pediatric and Young Adults With a Post-Traumatic Headache From Healthy Controls. Frontiers in pain research (Lausanne, Switzerland) Holmes, S., Mar'i, J., Simons, L. E., Zurakowski, D., LeBel, A. A., O'Brien, M., Borsook, D. 2022; 3: 859881

  Abstract

  Post-traumatic headache (PTH) is a challenging clinical condition to identify and treat as it integrates multiple subjectively defined symptoms with underlying physiological processes. The precise mechanisms underlying PTH are unclear, and it remains to be understood how to integrate the patient experience with underlying biology when attempting to classify persons with PTH, particularly in the pediatric setting where patient self-report may be highly variable. The objective of this investigation was to evaluate the use of different machine learning (ML) classifiers to differentiate pediatric and young adult subjects with PTH from healthy controls using behavioral data from self-report questionnaires that reflect concussion symptoms, mental health, pain experience of the participants, and structural brain imaging from cortical and sub-cortical locations. Behavioral data, alongside brain imaging, survived data reduction methods and both contributed toward final models. Behavioral data that contributed towards the final model included both the child and parent perspective of the pain-experience. Brain imaging features produced two unique clusters that reflect regions that were previously found in mild traumatic brain injury (mTBI) and PTH. Affinity-based propagation analysis demonstrated that behavioral data remained independent relative to neuroimaging data that suggest there is a role for both behavioral and brain imaging data when attempting to classify children with PTH.

  View details for DOI 10.3389/fpain.2022.859881

  View details for PubMedID 35655747

• The Concept of Pain Inventory for Adults (COPI-Adult): Assessing Knowledge and Beliefs Regarding Pain Science Education. The Clinical journal of pain Pate, J. W., Simons, L. E., Rush, G., Hancock, M. J., Hush, J. M., Verhagen, A., Pacey, V. 2021

  Abstract

  OBJECTIVES: Assessing knowledge and beliefs regarding pain science can identify gaps and misconceptions. The Concept of Pain Inventory (COPI) was recently developed in children with the intent to guide targeted pain science education. We utilized the original COPI item pool to (1) develop a tool to assess an adult's concept of pain in a cohort who had not received pain science education, (2) evaluate its psychometric properties, (3) examine distribution of scores in a cohort of adults who had received pain science education, and (4) examine associations between scores and clinical variables.METHODS: A total cohort of 627 adults were recruited via social media for an online survey. Initial development was conducted on those who had not received prior pain science education (n=125), then the COPI-Adult tool was tested in those who had received prior pain science education (n=502).RESULTS: The resulting unidimensional 13-item COPI-Adult had acceptable internal consistency (alpha=0.78) and good test-retest reliability at 1 week (ICC(3,1)=0.84 (95%CI 0.71 to 0.91). Higher COPI-Adult scores reflect greater alignment with contemporary pain science. COPI-Adult scores were correlated with revised Neurophysiology of Pain Questionnaire (rNPQ) scores and inversely correlated with average and current pain intensity, and pain interference. Adults who reported having received pain science education had significantly higher mean COPI-Adult scores than those who had not, and this difference exceeded the smallest detectable change.DISCUSSION: The COPI-Adult is a brief questionnaire with promising psychometric properties to identify conceptual gaps or misconceptions to inform individualized pain science education.

  View details for DOI 10.1097/AJP.0000000000000990

  View details for PubMedID 34636751

• Establishment of an International Collaborative Network for N-of-1 Trials and Single-Case Designs. Contemporary clinical trials communications Nikles, J., Onghena, P., Vlaeyen, J. W., Wicksell, R. K., Simons, L. E., McGree, J. M., McDonald, S. 2021; 23: 100826

  Abstract

  In this article we briefly examine the unique features of Single-Case Designs (SCDs) (studies in a single participant), their history and current trends, and real-world clinical applications. The International Collaborative Network for N-of-1 Trials and Single-Case Designs (ICN) is a formal collaborative network for individuals with an interest in SCDs. The ICN was established in 2017 to support the SCD scientific community and provide opportunities for collaboration, a global communication channel, resource sharing and knowledge exchange. In May 2021, there were more than 420 members in 31 countries. A member survey was undertaken in 2019 to identify priorities for the ICN for the following few years. This article outlines the key priorities identified and the ICN's progress to date in these key areas including network activities (developing a communications strategy to increase awareness, collecting/sharing a comprehensive set of resources, guidelines and tips, and incorporating the consumer perspective) and scientific activities (writing position papers and guest editing special journal issues, exploring key stakeholder perspectives about SCDs, and working to streamline ethical approval processes for SCDs). The ICN provides a practical means to engage with this methodology through membership. We encourage clinicians, researchers, industry, and healthcare consumers to learn more about and conduct SCDs, and to join us in our mission of using SCDs to improve health outcomes for individuals and populations.

  View details for DOI 10.1016/j.conctc.2021.100826

  View details for PubMedID 34401597

• Pain and Intolerance of Uncertainty among Adolescent and Young Adult Cancer Survivors Tanna, V., Cunningham, S. J., Simon, P., Spunt, S. L., Schapira, L., Simons, L. E., Heathcote, L. C. CHURCHILL LIVINGSTONE. 2021: 611

  View details for Web of Science ID 000661623200140

• User-centered development of a digital exposure treatment for youth with chronic pain Khazendar, Z., Harrison, L., Wicksell, R., Simons, L. CHURCHILL LIVINGSTONE. 2021: 607

  View details for Web of Science ID 000661623200124

• The role of hippocampus and amygdala morphology in memory bias of learned fear in youth with chronic pain Perry, C., Heathcote, L., Thomas, K., Borsook, D., Simons, L., Timmers, I. CHURCHILL LIVINGSTONE. 2021: 604

  View details for Web of Science ID 000661623200114

• Memory bias for learned threat and safety cues in youth with chronic pain Thomas, K. C., Heathcote, L. C., Timmers, I., Perry, C. E., Noel, M., Simons, L. E. CHURCHILL LIVINGSTONE. 2021: 607

  View details for Web of Science ID 000661623200125

• Probing white matter microstructure in youth with chronic pain Timmers, I., Loecher, N., Coppieters, I., Borsook, D., Zhang, H., Simons, L. CHURCHILL LIVINGSTONE. 2021: 602

  View details for Web of Science ID 000661623200106

• Subclinical post-traumatic stress symptomology and brain structure in youth with chronic headaches. NeuroImage. Clinical Miller, J. V., Andre, Q., Timmers, I., Simons, L., Rasic, N., Lebel, C., Noel, M. 2021; 30: 102627

  Abstract

  BACKGROUND/AIMS: Post-traumatic stress symptoms (PTSS) and chronic pain often co-occur at high rates in youth. PTSS may alter brain structure thereby contributing to headache chronicity. This study examined whether PTSS and altered limbic circuitry were associated with headache frequency in youth.METHODS: Thirty youth aged 10-18years with chronic headaches and 30 age- and sex-matched controls underwent a 3T MRI scan. Volumes of the hippocampus and amygdala were obtained from T1-weighted images. Mean fractional anisotropy (FA, an index of white matter structure) axial and radial diffusivity values of the cingulum and uncinate fasciculus were extracted from diffusion-weighted images. Youth reported on their headaches daily, for one-month, and self-reported pubertal status, emotion regulation, adverse childhood experiences (ACEs) and PTSS using validated measures. Volumes of the hippocampus and amygdala and diffusivity values of the cingulum and uncinate were compared between patients and controls. Hierarchical linear regressions were used to examine the association between PTSS, subcortical volumes and/or diffusivity values and headache frequency.RESULTS: Mean FA values of the cingulum were higher in patients compared to controls (P=0.02, Cohen's d=0.69). Greater PTSS (P=0.04), smaller amygdala volumes (P=0.01) and lower FA of the cingulum (P=0.04) were associated with greater headache frequency, after accounting for age, puberty, pain duration, emotion regulation, and ACEs (Adjusted R2≥0.15). Headache frequency was associated with increases in radial diffusivity (P=0.002, Adjusted R2=0.59), as opposed to axial diffusivity (n.s.).CONCLUSIONS: PTSS, smaller amygdalar volume, and poorer cingulum structural connectivity were associated with headache frequency in youth, and may underlie headache chronicity.

  View details for DOI 10.1016/j.nicl.2021.102627

  View details for PubMedID 33812302

• Chronic Pain in Young Athletes: The Impact of Athletic Identity on Pain-related Distress and Functioning. The Clinical journal of pain Hsu, C., Loecher, N., Park, A. L., Simons, L. E. 2021; 37 (3): 219–25

  Abstract

  BACKGROUND: It is common for youth to engage in sport and unfortunately also common for chronic pain to emerge in childhood. The convergence of chronic pain and sports participation in youth has not been extensively studied.OBJECTIVE: The goal of this study was to examine the association between athletic identity (AI) and pain-related distress and functioning in youth with chronic pain.PARTICIPANTS: Our cohort consisted of 305 youth ages 8 to 21, 83.6% of whom reported being currently engaged or previously involved in sport. Correlation and regression analyses were completed to evaluate the relationship between AI and pain-related distress and functioning in our cohort of chronic pain patients.RESULTS: Children currently involved in sport had higher total AI and social AI, lower fear of pain, and lower functional disability. Greater negative affectivity-AI had the strongest relationship with pain-related distress, including pain catastrophizing, fear and avoidance of pain, and anxiety. Stronger social AI was associated with lower levels of depression and pain-related avoidance of activities. Functional disability was not significantly associated with AI, but was lowest in individuals currently involved in sport.CONCLUSION: Our study provides evidence that focusing on continued sports engagement in the context of chronic pain is associated with less pain-related distress and functional limitations when compared with those who discontinue sports involvement, thus may serve as a buffer in the context of chronic pain. The association of AI with pain-related distress suggests that there is emotional significance in the degree to which youth identify as an athlete. This may be beneficial to clinically assess in youth with chronic pain.

  View details for DOI 10.1097/AJP.0000000000000917

  View details for PubMedID 33543871

• Longitudinal Narrative Analysis of Parent Experiences During Graded Exposure Treatment for Children with Chronic Pain. The Clinical journal of pain Corey, J. R., Heathcote, L. C., Mahmud, F., Kronman, C., Mukerji, C., McGinnis, E., Noel, M., Sieberg, C., Simons, L. E. 2021

  Abstract

  OBJECTIVES: Parents have a vital influence over their child's chronic pain treatment and management. Graded exposure in-vivo treatment (GET) is emerging as a promising intervention for youth with chronic pain. Yet, little is known about how parents perceive GET and its impact on their child's pain condition. This study aimed to characterize caregivers' experiences over the course of their child's GET using longitudinal coding and thematic analysis of parent narratives.METHODS: Parent narratives of 15 youth who participated in GET for pediatric chronic pain ('GET Living') were elicited from unstructured dialogue at the start of each treatment session held between the parent(s) and pain psychologist. Narratives were coded for affect and content, and trends were examined in these codes across sessions. Common themes in parent narratives were developed through inductive thematic analysis.RESULTS: Parents showed an increase in positive affect, treatment confidence, and optimism over the course of treatment. Narratives also expressed more benefit-finding/growth and less anxiety and protectiveness across GET sessions, with more parents having a resolved orientation towards their child's pain by the final session. Five common themes were generated: Self-Awareness, Understanding of Their Child's Perspective, Perceived Treatment Benefit, Internalization of Treatment Principles, and Hopeful Concern for the Future.DISCUSSION: Analysis of parent narratives provides a rich and unique method for understanding a parent's journey during their child's chronic pain treatment. Clinical application of our findings can be used to guide future developments of targeted topics and interventions in the context of parenting a child with chronic pain.

  View details for DOI 10.1097/AJP.0000000000000921

  View details for PubMedID 33555695

• Gait Variability and Relationships With Fear, Avoidance, and Pain in Adolescents With Chronic Pain. Physical therapy Beebe, J. n., Kronman, C. n., Mahmud, F. n., Basch, M. n., Hogan, M. n., Li, E. n., Ploski, C. n., Simons, L. n. 2021

  Abstract

  Some children with chronic pain struggle with fear of pain, avoidance behaviors, and associated disability; however, movement adaptations in the context of chronic pain in childhood is virtually unknown. Variability in adaptive movement responses previously observed between individuals might be largely explained by the presence of problematic psychological drivers (eg, fear, avoidance). The goals of this study were to (1) quantify the variability of gait and (2) examine relationships among pain, fear, avoidance, function, perceived and objective, and gait variability.This study used a cross-sectional design. Eligible patients were between 8 and 17 years of age and had musculoskeletal, neuropathic, or headache pain that was not due to acute trauma (eg, active sprain) or any specific or systemic disease. Participants completed the Numeric Pain Rating Scale (NPRS), Fear of Pain Questionnaire (FOPQ), Functional Disability Inventory (FDI), and 6-Minute Walk Test (6MWT) and received kinematic gait analysis. Relationships were analyzed among these measures, and the self-report and functional measures were examined to determine whether they predicted gait variability (GaitSD).The 16 participants who were evaluated (13.8 [SD = 2.2] years of age; 13 female) had high NPRS scores (6.2 [SD = 2.1]), FOPQ-Fear scores (25.9 [SD = 12.1]), FOPQ-Avoidance scores (22.8 [SD = 10.2], and FDI scores (28.6 [SD = 9.4]) and low 6-Minute Walk Test (6MWT) distance (437.1 m [SD = 144.6]). Participants had greater GaitSD than age-predicted norms. Fear was related to self-selected GaitSD, and avoidance was related to both self-selected and standardized GaitSD. Avoidance predicted 43% and 47% of the variability in self-selected and standardized GaitSD, respectively.Gait variability was significantly related to both fear of pain and avoidance behaviors, suggesting the interplay of these psychological drivers with movement. FOPQ-Avoidance was robust in accounting for GaitSD.This study offers preliminary evidence in understanding movement adaptations associated with adolescents with chronic pain. They may lend to more directed interventions.

  View details for DOI 10.1093/ptj/pzab012

  View details for PubMedID 33482005

• Association of parental and adolescent emotion-related factors with adolescent chronic pain behaviors. Pain Koechlin, H., Beeckman, M., Meier, A. H., Locher, C., Goubert, L., Kossowsky, J., Simons, L. E. 2021

  Abstract

  Chronic pain is a prevalent condition in youth, and the pain experience is strongly influenced by emotional processes. Studying emotion variability and regulation (ER) may help better understand pain behavior. As the development of emotion-related abilities predominantly takes place in the family context, examining ER within parent-adolescent dyads is important. We set out to test the association of parent and adolescent ER and adolescent emotional variability with adolescent pain behavior (ie, pain interference, activity avoidance, and activity engagement). A sample of 56 adolescents (Mage = 14.5, 85.7% women) with chronic pain and one of their parents (92.9% mothers) participated in this study. Adolescents completed baseline measures of average pain intensity, ER, and mean positive and negative affect. Furthermore, adolescents completed an electronic diary for 14 consecutive days, reporting on emotional state, activity avoidance, activity engagement, and pain interference. Parents completed measures of ER and their own history of pain. We performed a variable selection procedure, the least absolute shrinkage and selection operator method, to determine important predictors of adolescent pain behavior. Adolescent high positive affect was associated with more activity engagement, less pain interference, and less activity avoidance, indicating that positive affect might enhance the willingness to engage in activities in the presence of pain. Adolescent ER strategy emotional reappraisal and parents' own history of pain were predictors of less activity engagement. Parent ER was not related to adolescent ER. In conclusion, our results highlight the potential of enhancing positive affect as an intervention target for chronic pain.

  View details for DOI 10.1097/j.pain.0000000000002508

  View details for PubMedID 35050962

• Evaluating Telehealth Implementation in the Context of Pediatric Chronic Pain Treatment during COVID-19. Children (Basel, Switzerland) Richardson, P. A., Parker, D. M., Chavez, K., Birnie, K. A., Krane, E. J., Simons, L. E., Cunningham, N. R., Bhandari, R. P. 2021; 8 (9)

  Abstract

  Telehealth has emerged as a promising healthcare delivery modality due to its ability to ameliorate traditional access-level barriers to treatment. In response to the onset of the novel coronavirus (COVID-19) pandemic, multidisciplinary pain clinics either rapidly built telehealth infrastructure from the ground up or ramped up existing services. As the use of telehealth increases, it is critical to develop data collection frameworks that guide implementation. This applied review provides a theoretically-based approach to capitalize on existing data sources and collect novel data to inform virtually delivered care in the context of pediatric pain care. Reviewed multisource data are (1) healthcare administrative data; (2) electronic chart review; (3) clinical health registries; and (4) stakeholder feedback. Preliminary telehealth data from an interdisciplinary pediatric chronic pain management clinic (PPMC) serving youth ages 8-17 years are presented to illustrate how relevant implementation outcomes can be extracted from multisource data. Multiple implementation outcomes were assessed, including telehealth adoption rates, patient clinical symptoms, and mixed-method patient-report telehealth satisfaction. This manuscript provides an applied roadmap to leverage existing data sources and incorporate stakeholder feedback to guide the implementation of telehealth in pediatric chronic pain settings through and beyond COVID-19. Strengths and limitations of the modeled data collection approach are discussed within the broader context of implementation science.

  View details for DOI 10.3390/children8090764

  View details for PubMedID 34572195

• DTI and MTR Measures of Nerve Fiber Integrity in Pediatric Patients With Ankle Injury. Frontiers in pediatrics Holmes, S. A., Karapanagou, A., Staffa, S. J., Zurakowski, D., Borra, R., Simons, L. E., Sieberg, C., Lebel, A., Borsook, D. 2021; 9: 656843

  Abstract

  Acute peripheral nerve injury can lead to chronic neuropathic pain. Having a standardized, non-invasive method to evaluate pathological changes in a nerve following nerve injury would help with diagnostic and therapeutic assessments or interventions. The accurate evaluation of nerve fiber integrity after injury may provide insight into the extent of pathology and a patient's level of self-reported pain. The aim of this investigation was to evaluate the extent to which peripheral nerve integrity could be evaluated in an acute ankle injury cohort and how markers of nerve fiber integrity correlate with self-reported pain levels in afferent nerves. We recruited 39 pediatric participants with clinically defined neuropathic pain within 3 months of an ankle injury and 16 healthy controls. Participants underwent peripheral nerve MRI using diffusion tensor (DTI) and magnetization transfer imaging (MTI) of their injured and non-injured ankles. The imaging window was focused on the branching point of the sciatic nerve into the tibial and fibular division. Each participant completed the Pain Detection Questionnaire (PDQ). Findings demonstrated group differences in DTI and MTI in the sciatic, tibial and fibular nerve in the injured ankle relative to healthy control and contralateral non-injured nerve fibers. Only AD and RD from the injured fibular nerve correlated with PDQ scores which coincides with the inversion-dominant nature of this particular ankle injuruy cohort. Exploratory analyses highlight the potential remodeling stages of nerve injury from neuropathic pain. Future research should emphasize sub-acute time frames of injury to capture post-injury inflammation and nerve fiber recovery.

  View details for DOI 10.3389/fped.2021.656843

  View details for PubMedID 34660471

• Pain stickiness in pediatric complex regional pain syndrome: A role for the nucleus accumbens. Neurobiology of pain (Cambridge, Mass.) Youssef, A. M., Peng, K., Kim, P. K., Lebel, A., Sethna, N. F., Kronman, C., Zurakowski, D., Borsook, D., Simons, L. E. 2021; 9: 100062

  Abstract

  Some individuals with chronic pain experience improvement in their pain with treatment, whereas others do not. The neurobiological reason is unclear, but an understanding of brain structure and functional patterns may provide insights into pain's responsivity to treatment. In this investigation, we used magnetic resonance imaging (MRI) techniques to determine grey matter density alterations on resting functional connectivity (RFC) strengths between pain responders and nonresponders in patients with complex regional pain syndrome. Brain metrics of pediatric patients at admission to an intensive pain rehabilitative treatment program were evaluated. Pain responders reported significant pain improvement at discharge and/or follow-up whereas nonresponders reported no improvements in pain, increases in pain, or emergence of new pain symptoms. The pain (responder/nonresponder) groups were compared with pain-free healthy controls to examine predictors of pain responder status via brain metrics. Our results show: (1) on admission, pain nonresponders had decreased grey matter density (GMD) within the nucleus accumbens (NAc) and reduced RFC strength between the NAc and the dorsolateral prefrontal cortex vs. responders; (2) Connectivity strength was positively correlated with change in pain intensity from admission to discharge; (3) Compared with pain-free controls, grey matter and RFC differences emerged only among pain nonresponders; and (4) Using a discriminative model, combining GMD and RFC strengths assessed at admission showed the highest prediction estimate (87%) on potential for pain improvement, warranting testing in a de novo sample. Taken together, these results support the idea that treatment responsiveness on pain is underpinned by concurrent brain structure and resting brain activity.

  View details for DOI 10.1016/j.ynpai.2021.100062

  View details for PubMedID 33732954

• Virtual Reality Augments Movement during Physical Therapy: A Pragmatic Randomized Trial. American journal of physical medicine & rehabilitation Hemphill, S. n., Rodriguez, S. n., Wang, E. n., Koeppen, K. n., Aitken-Young, B. n., Jackson, C. n., Simons, L. n., Caruso, T. J. 2021

  Abstract

  Virtual reality (VR) facilitates physical therapy (PT) via improved engagement. While shown to benefit specific patient populations, such as stroke patients, it is less established in otherwise healthy adults and children receiving outpatient PT. The primary objective was to compare total PT-guided Movement supplemented with VR (PTMVR) to PT guided Movement alone, without VR (PTM).This pragmatic, randomized, crossover study compared PTMVR to PTM in outpatients (ages 6-80). This community sample had variable PT indications (injury, postoperative, chronic pain) and in preexisting conditions, therefore participants served as their own controls. Participants received 10 minutes of both PTMVR and PTM, separated by five minutes. The primary outcome was differences in aggregate movement of PT guided exercises. Secondary outcomes explored OMNI rating of perceived exertion (RPE) and participant and physical therapist satisfaction. Paired t-tests, chi-squared tests, and regression models were used to analyze differences.The 41 participants (17 pediatric and 24 adult) moved significantly more during PTMVR compared to PTM (1120.88 meters vs 672.65 meters p < 0.001), regardless of which intervention was completed first. PTMVR treatment was associated with more movement of the target limbs, lower-body (p < 0.001), upper-body (p <0.05). OMNI RPE scores did not differ between those who started with PTMVR or PTM, and physical therapist and patient surveys endorsed PTMVR.Patients completed more PT guided movement during PTMVR than PTM and therapists and patients supported its use. Future studies will examine finer tracking of movements.

  View details for DOI 10.1097/PHM.0000000000001779

  View details for PubMedID 33935153

• Leveraging VR/AR to combat chronic pain in youth: Position paper from the Interdisciplinary Network on Virtual and Augmented (AR/VR) Technologies for Pain (INOVATE-Pain) Management. Journal of medical Internet research Logan, D. E., Simons, L. E., Caruso, T. n., Gold, J. I., Greenleaf, W. n., Griffin, A. n., King, C. n., Menendez, M. n., Olbrecht, V. n., Rodriguez, S. n., Silvia, M. n., Stinson, J. n., Wang, E. n., Williams, S. n., Wilson, L. n. 2021

  Abstract

  Virtual reality (VR) and augmented reality (AR) interventions are emerging as promising tools in the treatment of pediatric chronic pain conditions, but in this young field there is little consensus to guide the process of engaging in the development and evaluation of targeted VR-based interventions.The INOVATE-Pain consortium aims to advance the field of VR for pediatric chronic pain rehabilitation by providing guidance for best practices in the design, evaluation, and dissemination of VR-based interventions targeting this population.An interdisciplinary meeting of 16 academics, clinicians, industry and philanthropy partners was held in January 2020.Reviewing the state of the field, the consortium identified important directions for research-driven innovation in VR/AR clinical care, highlighted key opportunities and challenges facing the field, and established a consensus on best methodological practices to adopt in future efforts to advance the research and practice of VR/AR in pediatric pain. The consortium also identified important next steps to undertake to continue to advance the work in this promising new area of digital health pain interventions.To realize the promise of this realm of innovation, key ingredients for the success include productive partnerships among industry, academic, and clinical stakeholders, a uniform set of outcome domains and measures for standardized evaluation, and widespread access to the latest opportunities, tools and resources. The INOVATE-Pain collaborative hopes to promote the creation, rigorous yet efficient evaluation, and dissemination of innovative VR-based interventions to reduce pain and improve quality of life for children.

  View details for DOI 10.2196/25916

  View details for PubMedID 33667177

• Creating online animated videos to reach and engage youth: Lessons learned from pain science education and a call to action. Paediatric & neonatal pain Pate, J. W., Heathcote, L. C., Simons, L. E., Leake, H., Moseley, G. L. 2020; 2 (4): 131-138

  Abstract

  Engaging youth in evidence-based health education has the capacity to positively impact their experiences of health and illness across the lifespan. In particular, pain science education is now an established part of the treatment arsenal for persistent pain conditions in adults, and there are calls to build educational resources for youth with pain. In this paper, we argue that high-quality online animated videos are a potentially excellent medium to engage youth at a mass level in pain science education. We present and compare two collaborations between clinician-scientists and industry to create and disseminate online animated videos for pain science education ("Mysterious Science of Pain" and "Tame the Beast"). We discuss the advantages, disadvantages, and methods of evaluation for each approach, as well as summarizing overall lessons learned. We provide this information as a guiding framework for clinician-scientists to collaborate with industry in building engaging and impactful health education resources for young people.

  View details for DOI 10.1002/pne2.12015

  View details for PubMedID 35548258

  View details for PubMedCentralID PMC8975222

• ACTsmart: Guided Smartphone-Delivered Acceptance and Commitment Therapy for Chronic Pain-A Pilot Trial. Pain medicine (Malden, Mass.) Gentili, C., Zetterqvist, V., Rickardsson, J., Holmstrom, L., Simons, L. E., Wicksell, R. K. 2020

  Abstract

  BACKGROUND: Acceptance and commitment therapy (ACT) is a behavioral health intervention with strong empirical support for chronic pain but, to date, widespread dissemination is limited. Digital solutions improve access to care and can be integrated into patients' everyday lives.OBJECTIVE: ACTsmart, a guided smartphone-delivered ACT intervention, was developed to improve the accessibility of an evidence-based behavioral treatment for chronic pain. In the present study, we evaluated the preliminary efficacy of ACTsmart in adults with chronic pain.METHODS: The study was an open-label pilot trial. The treatment lasted for 8weeks, and participants completed all outcome measures at pretreatment and posttreatment and at 3-, 6-, and 12-month follow-ups, with weekly assessments of selected measures during treatment. The primary outcome was pain interference. The secondary outcomes were psychological flexibility, values, insomnia, anxiety, depressive symptoms, health-related quality of life, and pain intensity. All outcomes were analyzed using linear mixed-effects models.RESULTS: The sample consisted of 34 adults (88% women) with long-standing chronic pain (M=20.4years, SD=11.7). Compliance to treatment was high, and at the end of treatment, we observed a significant improvement in the primary outcome of pain interference (d = -1.01). All secondary outcomes significantly improved from pretreatment to posttreatment with small to large effect sizes. Improvements were maintained throughout 12months of follow-up.CONCLUSION: The results of this pilot study provide preliminary support for ACTsmart as an accessible and effective behavioral health treatment for adults with chronic pain and warrant a randomized controlled trial to further evaluate the efficacy of the intervention.

  View details for DOI 10.1093/pm/pnaa360

  View details for PubMedID 33200214

• Altered Brain Network Connectivity underlies Persistent Post-Traumatic Headache following mTBI in Youth. Journal of neurotrauma Lemme, J., Holmes, S., Sibai, D., Mar'i, J., Simons, L. E., Burstein, R., Zurakowski, D., Lebel, A., O'Brien, M., Upadhyay, J., Borsook, D. 2020

  Abstract

  BACKGROUND: Post Traumatic Headaches (PTH) are associated with mild traumatic brain injuries (mTBI) and may predict the persistence of other concussion related symptoms. Altered brain networks implicated in brain injury and the affective components of headache-related pain may underlie the resolution or persistence of PTH.OBJECTIVE: To evaluate the extent to which pain symptom reporting and functional brain changes are different in a cohort of young mTBI patients with resolved (PTH-R) and persistent (PTH-P) post-traumatic headache symptoms relative to healthy controls.METHODS: This was a cross-sectional investigation. Data from 59 participants (PTH-P=21; PTH-R=18; 20 healthy control) were between the ages of 12-24. Participants had no significant history of preexisting headaches, chronic pain, or psychiatric neurological conditions. The primary outcome was resting-state functional connectivity (RS-Fc) alterations between cohorts. Secondary outcomes were self-reported pain-related symptoms such as fear of pain and pain catastrophizing.RESULTS: Elevated scores were reported for fear of pain in both PTH cohorts. Relative to healthy controls, PTH-P cohort showed altered connectivity in brain regions such as the Frontal, Temporal and Cerebellar regions, as well as sub-cortical regions including the Amygdala and Accumbens. The PTH-R cohort showed altered RS-Fc between Cerebellar and Temporal lobe sub-regions.CONCLUSIONS: Our results indicate a core network of brain regions implicated in the affective pain response are functionally altered in PTH cohorts. Despite the resolution of symptoms, persons who experience PTH following a mTBI may experience ongoing functional brain abnormalities. Observed group differences may underlie symptom chronification.

  View details for DOI 10.1089/neu.2020.7189

  View details for PubMedID 33183144

• Symptom appraisal in uncertainty: a theory-driven thematic analysis with survivors of childhood cancer. Psychology & health Heathcote, L. C., Loecher, N., Simon, P., Spunt, S. L., Jordan, A., Tutelman, P. R., Cunningham, S., Schapira, L., Simons, L. E. 2020: 1–18

  Abstract

  OBJECTIVE: Somatic symptoms capture attention, demand interpretation, and promote health behaviors. Symptom appraisal is particularly impactful within uncertain health contexts such as cancer survivorship. Yet, little is known about how individuals make sense of somatic symptoms within uncertain health contexts, nor how this process guides health behaviors.DESIGN: 25 adolescent and young adult survivors of childhood cancer completed semi-structured interviews regarding how they appraise and respond to changing somatic sensations within the uncertain context of survivorship.MAIN OUTCOME MEASURES: Interviews were transcribed verbatim and subjected to a hybrid deductive-inductive thematic analysis, guided by the Cancer Threat Interpretation model.RESULTS: We constructed three themes. Symptoms as signals of bodily threat (theme 1) captured that participants described commonly interpreting and worrying about everyday sensations as indicating cancer recurrence or new illness. Playing detective with bodily signals (theme 2) captured participants' felt need to employ cognitive and behavioral strategies to determine whether somatic sensations indicated a credible health threat. These two themes are qualified by the final theme, Living with symptom-related uncertainty (theme 3), which captured participants' recognition that post-cancer symptoms are wily and influenced by psychological factors such as anxiety.CONCLUSIONS: These data highlight that making sense of everday somatic sensations can be particularly challenging following an experience of cancer. There is a need for novel symptom management approaches that target how somatic sensations are appraised and responded to as signals of bodily threat.

  View details for DOI 10.1080/08870446.2020.1836180

  View details for PubMedID 33073604

• The Concept of Pain Inventory (COPI): Assessing a Child's Concept of Pain. The Clinical journal of pain Pate, J. W., Simons, L. E., Hancock, M. J., Hush, J. M., Noblet, T., Pounder, M., Pacey, V. 2020

  Abstract

  OBJECTIVES: Clinical guidelines recommend that healthcare providers assist children to understand their experience of persistent pain, with pain science education a key component of clinical management in pediatric pain clinics. Currently, no tool exists to assess a child's concept of pain. The aim of this study was to develop such a tool and to evaluate its psychometric properties.METHODS: After a rigorous process to generate items, assess content validity, evaluate readability and understandability, and pre-test items, a cohort of 124 children (aged 8-12▒y) independently completed the measure on two occasions, along with additional measures of pain, function, and pain-related distress.RESULTS: The resulting unidimensional 14-item Concept of Pain Inventory (COPI) had acceptable internal consistency (alpha= 0.78) and moderate test-retest reliability (ICC (3,1) = 0.55 (95% CI 0.37 to 0.68)). Higher COPI scores reflect greater alignment with contemporary pain science. COPI scores were inversely correlated with pain intensity and functional disability, but unrelated to pain catastrophizing and pain-related fear. At 1-2 months follow-up, baseline COPI scores were inversely correlated with clinical variables of functional disability and pain intensity.DISCUSSION: These results support the COPI as a brief, psychometrically sound tool to assess a child's concept of pain. Clinically, this tool may facilitate individualized pain science education to target identified conceptual 'gaps' or misconceptions, as well as to evaluate the effectiveness of pain science education in children. Further research examining its efficacy and impact is warranted.

  View details for DOI 10.1097/AJP.0000000000000884

  View details for PubMedID 32960825

• mHealth for Pediatric Chronic Pain: State of the Art and Future Directions. Expert review of neurotherapeutics Richardson, P. A., Harrison, L. E., Heathcote, L. C., Rush, G., Shear, D., Lalloo, C., Hood, K., Wicksell, R. K., Stinson, J., Simons, L. E. 2020

  Abstract

  INTRODUCTION: Chronic pain conditions are common among children and engender cascading effects across social, emotional, and behavioral domains for the child and family. Mobile health (mHealth) describes the practice of delivering healthcare via mobile devices and may be an ideal solution to increase access and reach of evidence-based behavioral health interventions.AREAS COVERED: The aim of this narrative review is to present a state-of-the-art overview of evidence-based mHealth efforts within the field of pediatric chronic pain and consider new and promising directions for study. Given the nascent nature of the field, published mHealth interventions in all stages of development are discussed. Literature was identified through a non-systematic search in PubMed and Google Scholar, and a review of reference lists of papers that were identified as particularly relevant or foundational (within and outside of the chronic pain literature).EXPERT OPINION: mHealth is a promising interventional modality with early evidence suggesting it is primed to enhance behavioral health delivery and patient outcomes. There are many exciting future directions to be explored including drawing inspiration from digital health technology to generate new ways of thinking about the optimal treatment of pediatric chronic pain.

  View details for DOI 10.1080/14737175.2020.1819792

  View details for PubMedID 32881587

• From Boulder to Stockholm in 70 Years: Single Case Experimental Designs in Clinical Research PSYCHOLOGICAL RECORD Vlaeyen, J. S., Wicksell, R. K., Simons, L. E., Gentili, C., De, T., Tate, R. L., Vohra, S., Punja, S., Linton, S. J., Sniehotta, F. F., Onghena, P. 2020

  View details for DOI 10.1007/s40732-020-00402-5

  View details for Web of Science ID 000537678700001

• A BRIEF 10-ITEM MEASURE FOR RAPID IDENTIFICATION OF PAIN-RELATED FEAR-AVOIDANCE IN YOUTH WITH CHRONIC PAIN Rush, G., Heathcote, L. C., Bhandari, R., Timmers, I., Harrison, L., Simons, L. E. OXFORD UNIV PRESS INC. 2020: S787

  View details for Web of Science ID 000546262401807

• PSYCHOLOGICAL, NEUROBIOLOGIC AND FAMILIAL FACTORS THAT SHAPE LONG-TERM OUTCOMES OF CHILDREN WITH CHRONIC PAIN Kashikar-Zuck, S., Murray, C. B., Simons, L. E., Palermo, T. M. OXFORD UNIV PRESS INC. 2020: S425

  View details for Web of Science ID 000546262401061

• PAINFULLY MISSING SPORTS: THE ROLE OF SPORTS PARTICIPATION AND ATHLETIC IDENTITY IN PEDIATRIC CHRONIC PAIN Loecher, N., Simons, L. E., Heathcote, L. C. OXFORD UNIV PRESS INC. 2020: S788

  View details for Web of Science ID 000546262401808

• PREDICTING RECOVERY OR PERSISTENCE IN PEDIATRIC PAIN: INNOVATIVE TOOLS AND NOVEL STRATEGIES Simons, L. E. OXFORD UNIV PRESS INC. 2020: S426

  View details for Web of Science ID 000546262401064

• ATTENTION TO PAIN IN CHILDREN WITH CHRONIC PAIN: A CHILD VERSION OF THE PAIN VIGILANCE AND AWARENESS QUESTION-NAIRE (PVAQ-C) Heathcote, L. C., Simons, L. E. OXFORD UNIV PRESS INC. 2020: S627

  View details for Web of Science ID 000546262401477

• DIAGNOSTIC UNCERTAINTY IN PARENTS OF CHILDREN WITH CHRONIC PAIN Heirich, M., Heathcote, L. C., Tanna, V., Simons, L. E. OXFORD UNIV PRESS INC. 2020: S788

  View details for Web of Science ID 000546262401809

• Parent Responses to Their Child's Pain: Systematic Review and Meta-Analysis of Measures. Journal of pediatric psychology Harrison, L. E., Timmers, I., Heathcote, L. C., Fisher, E., Tanna, V., Duarte Silva Bans, T., Simons, L. E. 2020

  Abstract

  OBJECTIVE: Parent responses can have a major impact on their child's pain. The purpose of this systematic review is to (a) identify and describe measures assessing pain-related cognitive, affective, and behavioral responses in parents of children with chronic pain and (b) meta-analyze reported correlations between parent constructs and child outcomes (i.e., pain intensity, functional disability, and school functioning). Prospero protocol registration ID: CRD42019125496.METHODS: We conducted a systematic search of studies including a measure of parent/caregiver responses to their child's chronic pain. Study characteristics and correlations between parent measures and child outcomes were extracted. Data were summarized and meta-analyzed.RESULTS: Seventy-nine met inclusion criteria using 18 different measures of cognitive/affective (n=3), behavioral (n=5), and multidimensional responses (n=10). Measures were used a median of three times (range 1-48), predominantly completed by mothers (88%), and primarily in mixed pain samples. Psychometrics of measures were generally adequate. Meta-analyses were based on 42 papers across five measures. Results showed that each of the cognitive, affective, and behavioral parent constructs we examined was significantly associated with pain-related functional disability. A small number of measures assessing parent cognitions and affective functioning were associated with higher child pain intensity; however, the majority were not.CONCLUSION: Findings demonstrate that there is a wealth of measures available, with adequate reliability overall but a lack of psychometrics on temporal stability. Synthesizing data across studies revealed small effects between parent responses and child functioning, and even smaller and/or absent effects on child pain intensity.

  View details for DOI 10.1093/jpepsy/jsaa005

  View details for PubMedID 32150254

• ACTsmart - development and feasibility of digital Acceptance and Commitment Therapy for adults with chronic pain NPJ DIGITAL MEDICINE Gentili, C., Zetterqvist, V., Rickardsson, J., Holmstrom, L., Simons, L. E., Wicksell, R. K. 2020; 3 (1)

  View details for DOI 10.1038/s41746-020-0228-4

  View details for Web of Science ID 000513180700001

• ACTsmart - development and feasibility of digital Acceptance and Commitment Therapy for adults with chronic pain. NPJ digital medicine Gentili, C., Zetterqvist, V., Rickardsson, J., Holmström, L., Simons, L. E., Wicksell, R. K. 2020; 3 (1): 20

  Abstract

  Accessibility of evidence-based behavioral health interventions is one of the main challenges in health care and effective treatment approaches are not always available for patients that would benefit from them. Digitization has dramatically changed the health care landscape. Although mHealth has shown promise in addressing issues of accessibility and reach, there is vast room for improvements. The integration of technical innovations and theory driven development is a key concern. Digital solutions developed by industry alone often lack a clear theoretical framework and the solutions are not properly evaluated to meet the standards of scientifically proven efficacy. On the other hand, mHealth interventions developed in academia may be theory driven but lack user friendliness and are commonly technically outdated by the time they are implemented in regular care, if they ever are. In an ongoing project aimed at scientific innovation, the mHealth Agile Development and Evaluation Lifecycle was used to combine strengths from both industry and academia in the development of ACTsmart - a smartphone-based Acceptance and Commitment Therapy treatment for adult chronic pain patients. The present study describes the early development of ACTsmart, in the process of moving the product from alpha testing to a clinical trial ready solution.

  View details for DOI 10.1038/s41746-020-0228-4

  View details for PubMedID 33574443

• Parent physical and mental health contributions to interpersonal fear avoidance processes in pediatric chronic pain. Pain Birnie, K. A., Heathcote, L. C., Bhandari, R. P., Feinstein, A., Yoon, I. A., Simons, L. E. 2020

  Abstract

  Theoretical models and evidence increasingly identify chronic pain as a family issue. To date, much of this work has focused on risk conferred by parental chronic pain status despite evidence suggesting parent mental illness and non-pain-related chronic illness may also contribute to poorer chronic pain outcomes in children. This study is the first to test interpersonal fear avoidance processes as possible mechanisms through which parent health (mental and physical) influences pediatric chronic pain functioning. We used structural equation models (SEM) to test such an integrative model using cross-sectional data from a large clinical registry of 448 dyads of patients 8-18 years old (M=14.57 years; SD=2.38; 327 females) with mixed chronic pain and their parents (403 mothers). As expected, poorer parent global health was indirectly related to greater child pain interference via higher parent pain catastrophizing, and then via greater parent protective behaviors, and child pain catastrophizing. The model demonstrated excellent fit to the data (chi[5] = 5.04, ns; chi/df = 1.01; CFI = 1.00, RMSEA = .004 [90% confidence interval (CI) = .000-.066]). Exploratory multiple-group comparison SEM revealed moderation of specific model paths based on child age group (8- to 12-year-olds versus 13- to 18-year-olds) and parent pain status (present versus absent). This study integrates family models of pain with the interpersonal fear avoidance model to extend our mechanistic understanding of parental physical and mental health contributors to pediatric chronic pain.

  View details for DOI 10.1097/j.pain.0000000000001820

  View details for PubMedID 32011420

• Stuck on pain? Assessing children's vigilance and awareness of pain sensations. European journal of pain (London, England) Heathcote, L. C., Simons, L. E. 2020

  Abstract

  Attending towards pain is proposed as a key mechanism influencing the experience and chronification of pain. Persistent attention towards pain is proposed to drive poor outcomes in both adults and children with chronic pain. However, there are no validated self-report measures of pain-related attention for children.The goals of this study were to adapt the Pain Vigilance and Awareness Questionnaire (PVAQ) for use in a child sample, to preliminary examine its psychometric properties, and to assess its utility over and above a measure of general attentional capacities. We adapted the language of the PVAQ to be more easily understood by children as young as 8 years. In a sample of 160 children (8-18 years) with chronic pain, we examined the factor structure, internal consistency and criterion validity of the PVAQ-C.The PVAQ-C demonstrated excellent internal consistency (α = 0.92) and moderate-to-strong criterion validity. A one-factor structure best fit the data. Children who reported greater attention to pain also reported greater pain catastrophizing, fear of pain, avoidance of activities and poorer physical functioning. Pain-related attention remained a significant predictor of functioning while controlling for demographics, catastrophizing and fear-avoidance. Pain-related attention also significantly predicted child outcomes independent of the child's general attention control capacities, indicating added value of a pain-specific measure of attention.The PVAQ-C shows strong indices of internal reliability and criterion validity, and indicates unique predictive utility. It will be important to study the role of pain-related attention in youth within developmental and functional-motivational frameworks.Pain-related attention is proposed as a key factor influencing fear-avoidance outcomes in both adults and youth with chronic pain, yet no self-report measures of pain-related attention have been validated for children. This paper presents a child version of the Pain Vigilance and Awareness Questionnaire (PVAQ-C), which indicates strong internal consistency, criterion validity and unique predictive validity, and provides evidence to support the Fear-Avoidance Model in youth with chronic pain.

  View details for DOI 10.1002/ejp.1581

  View details for PubMedID 32383315

• Chronic pain ADHERENCE AND SELF-MANAGEMENT IN PEDIATRIC POPULATIONS Parker, D. M., Harrison, L. E., Simons, L. E., Modi, A. C., Driscoll, K. A. 2020: 133-158

  View details for DOI 10.1016/B978-0-12-816000-8.00006-2

  View details for Web of Science ID 000816887700007

• Exploring the underlying mechanism of pain-related disability in hypermobile adolescents with chronic musculoskeletal pain. Scandinavian journal of pain van Meulenbroek, T. n., Huijnen, I. P., Simons, L. E., Conijn, A. E., Engelbert, R. H., Verbunt, J. A. 2020

  Abstract

  Objectives A significant proportion of adolescents with chronic musculoskeletal pain (CMP) experience difficulties in physical functioning, mood and social functioning, contributing to diminished quality of life. Generalized joint hypermobility (GJH) is a risk factor for developing CMP with a striking 35-48% of patients with CMP reporting GJH. In case GJH occurs with one or more musculoskeletal manifestations such as chronic pain, trauma, disturbed proprioception and joint instability, it is referred to as generalized hypermobility spectrum disorder (G-HSD). Similar characteristics have been reported in children and adolescents with the hypermobile Ehlers-Danlos Syndrome (hEDS). In the management of CMP, a biopsychosocial approach is recommended as several studies have confirmed the impact of psychosocial factors in the development and maintenance of CMP. The fear-avoidance model (FAM) is a cognitive-behavioural framework that describes the role of pain-related fear as a determinant of CMP-related disability. Content Pubmed was used to identify existing relevant literature focussing on chronic musculoskeletal pain, generalized joint hypermobility, pain-related fear and disability. Relevant articles were cross-referenced to identify articles possibly missed during the primary screening. In this paper the current state of scientific evidence is presented for each individual component of the FAM in hypermobile adolescents with and without CMP. Based on this overview, the FAM is proposed explaining a possible underlying mechanism in the relations between GJH, pain-related fear and disability. Summary and outlook It is assumed that GJH seems to make you more vulnerable for injury and experiencing more frequent musculoskeletal pain. But in addition, a vulnerability for heightened pain-related fear is proposed as an underlying mechanism explaining the relationship between GJH and disability. Further scientific confirmation of this applied FAM is warranted to further unravel the underlying mechanism. In explaining disability in individuals with G-HSD/hEDS, it is important to focus on both the physical components related to joint hypermobility, in tandem with the psychological components such as pain-related fear, catastrophizing thoughts and generalized anxiety.

  View details for DOI 10.1515/sjpain-2020-0023

  View details for PubMedID 32862151

• ACTsmart - development and feasibility of digital Acceptance and Commitment Therapy for adults with chronic pain. NPJ digital medicine Gentili, C. n., Zetterqvist, V. n., Rickardsson, J. n., Holmström, L. n., Simons, L. E., Wicksell, R. K. 2020; 3: 20

  Abstract

  Accessibility of evidence-based behavioral health interventions is one of the main challenges in health care and effective treatment approaches are not always available for patients that would benefit from them. Digitization has dramatically changed the health care landscape. Although mHealth has shown promise in addressing issues of accessibility and reach, there is vast room for improvements. The integration of technical innovations and theory driven development is a key concern. Digital solutions developed by industry alone often lack a clear theoretical framework and the solutions are not properly evaluated to meet the standards of scientifically proven efficacy. On the other hand, mHealth interventions developed in academia may be theory driven but lack user friendliness and are commonly technically outdated by the time they are implemented in regular care, if they ever are. In an ongoing project aimed at scientific innovation, the mHealth Agile Development and Evaluation Lifecycle was used to combine strengths from both industry and academia in the development of ACTsmart - a smartphone-based Acceptance and Commitment Therapy treatment for adult chronic pain patients. The present study describes the early development of ACTsmart, in the process of moving the product from alpha testing to a clinical trial ready solution.

  View details for DOI 10.1038/s41746-020-0228-4

  View details for PubMedID 32128450

  View details for PubMedCentralID PMC7018849

• Something Else Going On? Diagnostic Uncertainty in Children with Chronic Pain and Their Parents. Children (Basel, Switzerland) Tanna, V. n., Heathcote, L. C., Heirich, M. S., Rush, G. n., Neville, A. n., Noel, M. n., Pate, J. W., Simons, L. E. 2020; 7 (10)

  Abstract

  Diagnostic uncertainty, the perceived lack of an accurate explanation of the patient's health problem, remains relatively unstudied in children. This study examined the prevalence, familial concordance, and correlates of diagnostic uncertainty in children and their parents presenting to a multidisciplinary pain clinic in the United States. One hundred and twenty-six parents and 91 of their children (Mage = 13.93 years, range = 8-18 years) completed a brief three-item measure of diagnostic uncertainty, as well as measures of pain-related distress and functioning. Forty-eight percent of children and 37% of parents believed something else was going on with the child's pain that doctors had not found out about yet. Across the three items, 66%-77% of children and their parents agreed in their endorsement of diagnostic uncertainty. Parents who believed that something else was going on with their child's pain had children with higher avoidance of pain-related activities (F = 5.601, p = 0.020) and lower pain willingness (F = 4.782, p = 0.032). Neither parent nor child diagnostic uncertainty was significantly related to the child's pain-related functioning. Diagnostic uncertainty, particularly in parents, is relevant in the experience of pediatric chronic pain and warrants further investigation as both a risk factor and therapeutic target.

  View details for DOI 10.3390/children7100165

  View details for PubMedID 33020423

• Graded exposure treatment for adolescents with chronic pain (GET Living): Protocol for a randomized controlled trial enhanced with single case experimental design. Contemporary clinical trials communications Simons, L. E., Harrison, L. E., O'Brien, S. F., Heirich, M. S., Loecher, N., Boothroyd, D. B., Vlaeyen, J. W., Wicksell, R. K., Schofield, D., Hood, K. K., Orendurff, M., Chan, S., Lyons, S. 2019; 16: 100448

  Abstract

  Chronic musculoskeletal pain in adolescence is a significant public health concern with 3-5% of adolescents suffering from significant pain-related disability. Pain-related fear and avoidance of activities has been found to have a significant influence on pain outcomes in children and adolescents and is a risk factor for less favorable response to treatment. To address this need, we developed graded exposure treatment for youth with chronic pain (GET Living). We describe the rationale, design, and implementation of a two-group randomized controlled trial (RCT) enhanced with single-case experimental design (SCED) methodology with a sample of 74 adolescents with chronic musculosketal pain and their parent caregivers. GET Living includes education, behavioral exposures, and parent intervention jointly delivered by pain psychology and physical therapy providers. The multidisciplinary pain management control group includes pain psychology delivered education and pain self-management skills training (e.g., relaxation, cognitive skills) and separate physical therapy. Assessments include brief daily diaries (baseline to discharge, 7-days at 3-month and 6-month follow-up), comprehensive in-person evaluations at baseline and discharge, and questionnaire across all time points (baseline, discharge, 3-month and 6-month follow-up). Primary outcome is pain-related fear avoidance. Secondary outcome is functional disability. We also outline all additional outcomes, exploratory outcomes, covariates, and implementation measures. The objective is to offer a mechanism-based, targeted intervention to youth with musculoskeletal pain to enhance likelihood of return to function.

  View details for DOI 10.1016/j.conctc.2019.100448

  View details for PubMedID 31650069

• Talking to Teens about Pain: A Modified Delphi Study of Adolescent Pain Science Education. Canadian journal of pain = Revue canadienne de la douleur Leake, H. B., Heathcote, L. C., Simons, L. E., Stinson, J., Kamper, S. J., Williams, C. M., Burgoyne, L. L., Craigie, M., Kammers, M., Moen, D., Pate, J. W., Szeto, K., Moseley, G. L. 2019; 3 (1): 200-208

  Abstract

  Background: Persistent pain is a prevalent condition that negatively influences physical, emotional, social and family functioning in adolescents. Pain science education is a promising therapy for adults, yet to be thoroughly investigated for persistent pain in adolescents. There is a need to develop suitable curricula for adolescent pain science education. Methods: An interdisciplinary meeting of 12 clinicians and researchers was held during March 2018 in Adelaide, South Australia. An a priori objective of the meeting was to identify and gain consensus on key learning objectives for adolescent pain science education using a modified-Delphi process. Results and Conclusion: Consensus was reached via a modified Delphi process for seven learning objectives to form the foundation of a curriculum: 1) Pain is a protector; 2) The pain system can become overprotective; 3) Pain is a brain output; 4) Pain is not an accurate marker of tissue state; 5) There are many potential contributors to anyone's pain; 6) We are all bioplastic and; 7) Pain education is treatment. Recommendations are made for promising areas for future research in adolescent pain science education.

  View details for DOI 10.1080/24740527.2019.1682934

  View details for PubMedID 35005410

  View details for PubMedCentralID PMC8730612

• Symptom monitoring and the uncertain threat of disease recurrence: A deductive thematic analysis with adolescent and young adult (AYA) cancer survivors. Heathcote, L. C., Loecher, N., Spunt, S. L., Simon, P., Dahl, G., Moiceanu, S., Cruanes, G., Tutelman, P., Schapira, L., Mueller, C., Chiu, B., Simons, L. AMER SOC CLINICAL ONCOLOGY. 2019

  View details for DOI 10.1200/JCO.2019.37.31_suppl.147

  View details for Web of Science ID 000518224200145

• Rapid identification and clinical indices of fear-avoidance in youth with chronic pain. Pain Heathcote, L. C., Bhandari, R. P., Timmers, I., Harrison, L. E., Simons, L. E. 2019

  Abstract

  Pain-related fear and avoidance are increasingly demonstrated to play an important role in adult and childhood chronic pain. The Fear of Pain Questionnaire for Children (FOPQC) is a 24-item measure of pain-related fear-avoidance in youth that has demonstrated good indices of reliability and validity, treatment responsiveness, and associations with brain circuitry alterations. This study describes the development and psychometric examination of the FOPQC-SF, a short form of the original measure. We selected 10 items for the short form that best represented the content and two-factor (Fear and Avoidance) structure of the original measure from a cohort of 613 youth (Mage = 14.7 years) with chronic pain. Next, confirmatory factor analyses from a second sample of 526 youth (Mage = 14.7 years) with chronic pain who completed the FOPQC-SF supported the original two-factor model but indicated that one item should be moved to the avoidance subscale. The FOPQC-SF demonstrates strong internal consistency and moderate-to-strong construct and criterion validity. Three-month test-retest reliability estimates (N=94) were strong and there was preliminary evidence of responsivity to change. To aid integration into intervention trials and clinical practice, we provide clinical reference points and a criterion to assess reliable change. The short form could be used for rapid identification of pain-related fear and avoidance in youth during clinic evaluations, and is optimized for clinical registries.

  View details for DOI 10.1097/j.pain.0000000000001742

  View details for PubMedID 31688496

• How an Understanding of Our Ability to Adhere to Verbal Rules Can Increase Insight Into (Mal)adaptive Functioning in Chronic Pain JOURNAL OF PAIN Beeckman, M., Hughes, S., Kissi, A., Simons, L. E., Goubert, L. 2019; 20 (10): 1141–54

  View details for DOI 10.1016/j.jpain.2019.02.013

  View details for Web of Science ID 000492459600003

• BREAKING THE FEAR AVOIDANCE CYCLE: EXPOSURE TREATMENT FOR YOUTH WITH CHRONIC PAIN Simons, L. E. ELSEVIER SCIENCE INC. 2019: S96

  View details for DOI 10.1016/j.jaac.2019.07.523

  View details for Web of Science ID 000518857301082

• A Network Analysis of Potential Antecedents and Consequences of Pain-Related Activity Avoidance and Activity Engagement in Adolescents. Pain medicine (Malden, Mass.) Beeckman, M., Simons, L. E., Hughes, S., Loeys, T., Goubert, L. 2019

  Abstract

  OBJECTIVE: This study sets out to identify potential daily antecedents and consequences of pain-related activity avoidance and engagement behavior in adolescents with chronic pain.METHODS: Adolescents (N=65, Mage = 14.41) completed baseline self-reports and a diary for 14days. Afternoon and evening reports were used to infer a network structure of within-day associations between pain intensity, pain-related fear, pain catastrophizing, affect, and pain-related activity avoidance and engagement behavior. Baseline psychological flexibility was examined as a potential resilience factor.RESULTS: Activity avoidance in the evening was predicted by pain-related fear and avoidance earlier that afternoon. Activity engagement was predicted by positive affect and activity engagement in the afternoon. Pain-related behavior in the afternoon was not related to subsequent changes in pain intensity, pain-related fear, pain catastrophizing, or affect. Pain-related fear in the afternoon was predictive of increased levels of pain and pain catastrophizing in the evening. Both pain-related fear and pain catastrophizing in the evening were predicted by negative affect in the afternoon. Psychological flexibility was associated with lower levels of daily activity avoidance and buffered the negative association between pain intensity and subsequent activity engagement.CONCLUSIONS: This study provides insight into unique factors that trigger and maintain activity avoidance and engagement and into the role of psychological flexibility in pediatric pain. Future work should focus on both risk and resilience factors and examine the role of psychological flexibility in chronic pediatric pain in greater detail.

  View details for DOI 10.1093/pm/pnz211

  View details for PubMedID 31498397

• Psychological Flexibility as a Resilience Factor in Individuals With Chronic Pain. Frontiers in psychology Gentili, C., Rickardsson, J., Zetterqvist, V., Simons, L. E., Lekander, M., Wicksell, R. K. 2019; 10: 2016

  Abstract

  Resilience factors have been suggested as key mechanisms in the relation between symptoms and disability among individuals with chronic pain. However, there is a need to better operationalize resilience and to empirically evaluate its role and function. The present study examined psychological flexibility as a resilience factor in relation to symptoms and functioning among 252 adults with chronic pain applying for participation in a digital ACT-based self-help treatment. Participants completed measures of symptoms (pain intensity, and anxiety), functioning (pain interference and depression), as well as the hypothesized resilience factor psychological flexibility (measured as avoidance, value obstruction, and value progress). As expected, symptoms, functioning and resilience factors were significantly associated. Hierarchical linear regression analyses showed that psychological flexibility significantly contributed to the prediction of pain interference and depression when adjusting for age, pain and anxiety. Also, participants with low levels of psychological flexibility were more likely to be on sick leave. Furthermore, a series of multiple mediation analyses showed that psychological flexibility had a significant indirect effect on the relationship between symptoms and functioning. Avoidance was consistently shown to contribute to the indirect effect. Results support previous findings and suggest the importance of psychological flexibility as a resilience factor among individuals with chronic pain and anxiety.

  View details for DOI 10.3389/fpsyg.2019.02016

  View details for PubMedID 31551871

  View details for PubMedCentralID PMC6734029

• Psychological Flexibility as a Resilience Factor in Individuals With Chronic Pain FRONTIERS IN PSYCHOLOGY Gentili, C., Rickardsson, J., Zettergvist, V., Simons, L. E., Lekander, M., Wicksell, R. K. 2019; 10

  View details for DOI 10.3389/fpsyg.2019.02016

  View details for Web of Science ID 000483576300001

• Parent psychological flexibility in the context of pediatric pain: Brief assessment and associations with parent behaviour and child functioning EUROPEAN JOURNAL OF PAIN Timmers, I., Simons, L. E., Hernandez, J. M., McCracken, L. M., Wallace, D. P. 2019; 23 (7): 1340–50

  View details for DOI 10.1002/ejp.1403

  View details for Web of Science ID 000475495900010

• Somatic Symptoms in Pediatric Patients With Chronic Pain: Proposed Clinical Reference Points for the Children's Somatic Symptoms Inventory (Formerly the Children's Somatization Inventory) JOURNAL OF PAIN Stone, A. L., Walker, L. S., Heathcote, L. C., Hernandez, J., Basch, M. C., Wilson, A. C., Simons, L. E. 2019; 20 (8): 932–40

  View details for DOI 10.1016/j.jpain.2019.02.005

  View details for Web of Science ID 000482544600007

• Varying Screen Size for Passive Video Distraction During Induction of Anesthesia in Low Risk Children: A Pilot Randomized Controlled Trial. Paediatric anaesthesia Rodriguez, S., Jang, O., Hernandez, J. M., George, A. J., Caruso, T. J., Simons, L. 2019

  Abstract

  BACKGROUND: Preoperative anxiety affects up to 65% of children who undergo anesthesia induction and often results in uncooperative behaviour. Electronic devices have been used to distract children to reduce anxiety and create a more enjoyable preoperative experience. Few studies have compared the effects of different video delivery systems on preoperative anxiety.AIM: The primary aim was to determine if a large projection based video screen mounted to a patient's bed decreased anxiety when compared to a tablet during mask induction of anesthesia in children from 4-10 years of age.METHODS: We performed a prospective, randomized trial to determine differences in our primary outcome, preoperative anxiety, between the large Bedside Entertainment and Relaxation Theater (BERT) and a smaller tablet screen. Secondary outcomes included 1) induction compliance, 2) child fear, 3) frequency of emergence delirium, and 4) satisfaction.RESULTS: In examining the primary outcome for 52 patients, there was a main effect for time on mYPAS scores, f(2, 51)=13.18, p<0.01. mYPAS scores significantly increased across time for both groups. The interaction for time (T0, T1 or T2) x group (BERT vs. Tablet) was not significant, f(2, 51)=1.96, p=0.15; thus changes in mYPAS scores across time did not differ by group status. There was no significant difference in induction compliance, child fear, emergence delirium, or satisfaction between the two groups.CONCLUSION: In a low risk population, preoperative anxiety was low and induction compliance was high when pairing screen based distraction interventions, regardless of size, with parental presence at induction of anesthesia. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30916447

• Pain neuroscience education on YouTube PEERJ Heathcote, L. C., Pate, J. W., Park, A. L., Leake, H. B., Moseley, G., Kronman, C. A., Fischer, M., Timmers, I., Simons, L. E. 2019; 7: e6603

  Abstract

  The Internet in general, and YouTube in particular, is now one of the most popular sources of health-related information. Pain neuroscience education has become a primary tool for managing persistent pain, based in part on the discovery that information about pain can change pain. Our objective was to examine the availability, characteristics, and content of YouTube videos that address the neuroscience of pain.We conducted a systematic review of videos on YouTube using the search terms "pain education", "what is pain", and "pain brain" in January 2018. Videos were included if they were in English, were under 10 minutes long, and included information on the neuroscience of pain. Videos were coded for (i) descriptive characteristics (e.g., number of views, duration on YouTube), (ii) source and style, (iii) whether or not they addressed seven pre-determined target concepts of pain neuroscience education (e.g., 'Pain is not an accurate marker of tissue state'), and (iv) how engaging they were.We found 106 unique videos that met the inclusion criteria. The videos ranged from having four views to over five million views (Mdn = 1,163 views), with the three most highly viewed videos accounting for 75% of the total views. Animated videos were much more highly viewed than non-animated videos. Only a small number of videos had been posted by a clearly-identifiable reputable source such as an academic or medical institution (10%), although a number of videos were posted by healthcare professionals and professional medical societies. For a small number of videos (7%), the source was unclear. We found 17 videos that addressed at least one target concept of pain neuroscience science education, only nine of which were considered to be at least somewhat engaging. The target concept 'Pain is a brain output' was considered to be well addressed by the most videos (N = 11), followed by 'Pain is a protector' (N = 10). We found only one video that adequately addressed all seven target concepts of pain neuroscience education.YouTube contains a variety of videos that practitioners, patients, and families may view to access pain neuroscience education information. A small portion of these videos addressed one or more target concepts of pain neuroscience education in an engaging manner. It is yet to be determined to what extent patients are able to learn information from these videos, to what extent the videos promote behavior change, and thus to what extent the videos may be useful for clinical practice.

  View details for PubMedID 30923652

• How an understanding of our ability to adhere to verbal rules can increase insight into (mal)adaptive functioning in chronic pain. The journal of pain : official journal of the American Pain Society Beeckman, M., Hughes, S., Kissi, A., Simons, L. E., Goubert, L. 2019

  Abstract

  Research on chronic pain has traditionally focused on how direct pain experiences lead to maladaptive thoughts, feelings, and actions which set the stage for, and maintain, pain-related disability. Yet the capacity for language (and more specifically verbal instructions or rules) to put people into indirect contact with pain has never been systematically investigated. In this paper we introduce a novel theoretical perspective on verbal processes and discuss how the study of verbal rules may increase our understanding of both maladaptive and adaptive functioning in chronic pain. Several useful characteristics of verbal rules and rule-following in the context of chronic pain are outlined. Future research directions and implications for clinical practice are then discussed. Perspective: This focus article argues that by studying verbal rules and rule-following we will gain a better understanding of (mal)adaptive functioning in the context of chronic pain. Future research directions are outlined and suggestions for improving clinical practice are considered.

  View details for PubMedID 30822535

• Somatic symptoms in pediatric patients with chronic pain: Proposed clinical reference points for the Children's Somatic Symptoms Inventory (formerly Children's Somatization Inventory). The journal of pain : official journal of the American Pain Society Stone, A. L., Walker, L. S., Heathcote, L. C., Hernandez, J. M., Basch, M. C., Wilson, A. C., Simons, L. E. 2019

  Abstract

  Among youth with chroic pain, elevated somatic symptoms across multiple body systems have been associated with greater emotional distress and functional disability and could represent poor adaptation to pain. The Children's Somatic Symptoms Inventory (formerly the Children's Somatization Inventory) is commonly used to assess somatic symptoms in children. However, no studies have evaluated the clinical utility of the measure in the assessment of pediatric patients with chronic pain. This study evaluated the factor structure and clinical relevance of the 24-item Children's Somatic Symptoms Inventory (CSSI-24) in youth (n = 1150) with mixed chronic pain complaints presenting to a tertiary pain clinic. CSSI-24 total scores were equal or superior to factor scores as indicators of patients' clinical characteristics (functional disability, pain catastrophizing, fear of pain, anxiety and depressive symptoms) and parental catastrophizing and protective responses. Tertile-derived clinical reference points for the CSSI-24 total score (<18: low, 19 - 31: moderate, ≥ 32: high) significantly differed on measures of clinical characteristics and parent factors. Controlling for age, sex, pain intensity and primary pain complaint, the high somatic symptoms group exhibited significantly greater health care utilization compared to the moderate and low groups. Assessment of somatic symptoms in pediatric patients with chronic pain may provide useful information regarding patients' psychosocial risk and tendency to access health services. Perspective: Clinical reference points based on the CSSI-24 total scores meaningfully differentiated youth with chronic pain on measures of emotional distress, functioning, parent catastrophizing and protective responses, and health care utilization. Assessing somatic symptoms could provide useful information regarding a pediatric patient's psychosocial risk, tendency to access health services, and need for enhanced care coordination.

  View details for PubMedID 30771592

• PRISM: a brief screening tool to identify risk in parents of youth with chronic pain PAIN Simons, L. E., Holley, A., Phelps, E., Wilson, A. C. 2019; 160 (2): 367–74

  View details for DOI 10.1097/j.pain.0000000000001403

  View details for Web of Science ID 000462394100010

• Varying Screen Size for Passive Video Distraction During Induction of Anesthesia in Low Risk Children: A Pilot Randomized Controlled Trial Pediatric Anesthesia Rodriguez, S., Jang, O., Hernandez, J. M., George, A., Caruso, T., Simons, L. 2019: 648–55

  Abstract

  Preoperative anxiety affects up to 65% of children who undergo anesthesia induction and often results in uncooperative behavior. Electronic devices have been used to distract children to reduce anxiety and create a more enjoyable preoperative experience. Few studies have compared the effects of different video delivery systems on preoperative anxiety.The primary aim was to determine if a large projection-based video screen mounted to a patient's bed decreased anxiety when compared to a tablet during mask induction of anesthesia in children from 4-10 years of age.We performed a prospective, randomized trial to determine differences in our primary outcome, preoperative anxiety, between the large Bedside Entertainment and Relaxation Theater (BERT) and a smaller tablet screen. Secondary outcomes included (a) induction compliance; (b) child fear; (c) frequency of emergence delirium; and (d) satisfaction.In examining the primary outcome for 52 patients, there was a main effect for time on mYPAS scores, f(2, 51) = 13.18, P < 0.01. mYPAS scores significantly increased across time for both groups. The interaction for time (T0, T1 or T2) × group (BERT vs Tablet) was not significant, f(2, 51) = 1.96, P = 0.15; thus changes in mYPAS scores across time did not differ by group status. There was no significant difference in induction compliance, child fear, emergence delirium, or satisfaction between the two groups.In a low-risk population, preoperative anxiety was low and induction compliance was high when pairing screen-based distraction interventions, regardless of size, with parental presence at induction of anesthesia.

  View details for DOI 10.1111/pan.13636

• Best-Evidence for the Rehabilitation of Chronic Pain Part 1: Pediatric Pain. Journal of clinical medicine Harrison, L. E., Pate, J. W., Richardson, P. A., Ickmans, K. n., Wicksell, R. K., Simons, L. E. 2019; 8 (9)

  Abstract

  Chronic pain is a prevalent and persistent problem in middle childhood and adolescence. The biopsychosocial model of pain, which accounts for the complex interplay of the biological, psychological, social, and environmental factors that contribute to and maintain pain symptoms and related disability has guided our understanding and treatment of pediatric pain. Consequently, many interventions for chronic pain are within the realm of rehabilitation, based on the premise that behavior has a broad and central role in pain management. These treatments are typically delivered by one or more providers in medicine, nursing, psychology, physical therapy, and/or occupational therapy. Current data suggest that multidisciplinary treatment is important, with intensive interdisciplinary pain rehabilitation (IIPT) being effective at reducing disability for patients with high levels of functional disability. The following review describes the current state of the art of rehabilitation approaches to treat persistent pain in children and adolescents. Several emerging areas of interventions are also highlighted to guide future research and clinical practice.

  View details for DOI 10.3390/jcm8091267

  View details for PubMedID 31438483

• Investigating How Parental Instructions and Protective Responses Mediate the Relationship Between Parental Psychological Flexibility and Pain-Related Behavior in Adolescents With Chronic Pain: A Daily Diary Study. Frontiers in psychology Beeckman, M., Simons, L. E., Hughes, S., Loeys, T., Goubert, L. 2019; 10: 2350

  Abstract

  Background: Parental behavior can influence how well adolescents cope with chronic pain. Previous research has largely focused on how parents negatively impact adolescent functioning. Yet more recent work suggests that parents - and particularly parental psychological flexibility - can foster better adolescent pain-related functioning. In this study we examined if parental protective responses and instructions to engage in activities in the presence of pain mediate the impact of parental psychological flexibility and acceptance of adolescent pain on adolescents' daily pain-related behavior.Method: Fifty-six adolescents with chronic pain (M age = 14.5 years, 86% girls) and one of their parents (93% mothers) were recruited at initial evaluation at two pediatric pain clinics in the US. Parents completed baseline questionnaires assessing psychologically flexible parenting and acceptance of adolescent pain. Next, parents and adolescents completed a 14-day self-report diary assessing adolescent activity-avoidance and activity-engagement in the presence of pain (adolescent report), and parental protective responses and instructions for their adolescent to engage in activities (parent report).Results: Psychologically flexible parenting and acceptance of adolescent pain in parents were indirectly related to lower daily adolescent activity-avoidance, via their negative association with daily parental protective responses. Positive associations also emerged between baseline psychologically flexible parenting and overall levels of adolescent activity-engagement via its negative association with overall levels of parental protectiveness across the 14-day period. Psychologically flexible parenting and parental acceptance of adolescent pain were also indirectly related to daily decreases in adolescent activity-avoidance via their association with daily increases in parental activity-engagement instructions. These baseline parental resilience factors were also positively related to overall levels of parental engagement instructions, a route via which an indirect association with both higher overall activity-engagement as well as higher overall activity-avoidance in the adolescent was observed.Conclusion: Our findings suggest an (indirect) adaptive role of parental psychological flexibility on adolescent daily pain-related behavior via its impact on parental protective behavior. If our findings replicate, they would suggest that these parental behaviors could be targeted in pain treatments that include both adolescents and their parents. Future research could further examine the impact of parental instructions on pain-related behavior in adolescents with chronic pain.

  View details for DOI 10.3389/fpsyg.2019.02350

  View details for PubMedID 31681125

• Talking to Teens about Pain: A Modified Delphi Study of Adolescent Pain Science Education CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR Leake, H. B., Heathcote, L. C., Simons, L. E., Stinson, J., Kamper, S. J., Williams, C. M., Burgoyne, L. L., Craigie, M., Kammers, M., Moen, D., Pate, J. W., Szeto, K., Moseley, G. 2019; 3 (1): 200–208

  View details for DOI 10.1080/24740527.2019.1682934

  View details for Web of Science ID 000616374900023

• Digitally enabled patient-reported outcome measures in cancer care - Authors' reply. The Lancet. Oncology Heathcote, L. C., Goldberg, D. S., Eccleston, C., Spunt, S. L., Simons, L. E., Sharpe, L., Earp, B. D. 2019; 20 (1): e3

  View details for PubMedID 30614475

• Parent psychological flexibility in the context of pediatric pain: Brief assessment and associations with parent behavior and child functioning. European journal of pain (London, England) Timmers, I. n., Simons, L. E., Hernandez, J. M., McCracken, L. M., Wicksell, R. K., Wallace, D. P. 2019

  Abstract

  The parent's role in the context of pediatric chronic pain is essential. There is growing evidence that parent psychological flexibility positively impacts child functioning. To assess parents' abilities to respond with psychological flexibility to their child's pain, the Parent Psychological Flexibility Questionnaire (PPFQ) was developed. Here, we aim to validate the 10-item version of the questionnaire in an English-speaking population and to evaluate associations with parent behavior, child pain acceptance and functioning.578 parent-child dyads presenting at a pediatric pain clinic were included (92% mothers, average child age 15.2 ± 1.6y). The PPFQ was completed by the parent. Parent and child also completed other standardized questionnaires. In addition to confirmatory factor analysis and assessments of reliability and validity of the PPFQ-10, a mediation analysis was performed to examine the direct and indirect effects of parent psychological flexibility on child functioning.Confirmatory factor analysis supported the three-factor model with subscales for Values-Based Action, Pain Willingness and Emotional Acceptance, and the PPFQ-10 demonstrated strong psychometric properties. After controlling for child pain, parent psychological flexibility indirectly affected child functioning through its association with both parent behavior (i.e., protectiveness) and child pain acceptance.Our findings provide further support for use of the PPFQ-10 and the importance of assessing and addressing parent psychological flexibility in the context of child chronic pain. Our data show that parent psychological flexibility has an important adaptive role and can impact child functioning through two different routes, both of which can be actively targeted in treatment. This article is protected by copyright. All rights reserved.

  View details for PubMedID 31002473

• Shifting brain circuits in pain chronicity. Human brain mapping Youssef, A. M., Azqueta-Gavaldon, M. n., Silva, K. E., Barakat, N. n., Lopez, N. n., Mahmud, F. n., Lebel, A. n., Sethna, N. F., Zurakowski, D. n., Simons, L. E., Kraft, E. n., Borsook, D. n. 2019

  Abstract

  The evaluation of brain changes to a specific pain condition in pediatric and adult patients allows for insights into potential mechanisms of pain chronicity and possibly long-term brain changes. Here we focused on the primary somatosensory system (SS) involved in pain processing, namely the ventroposterolateral thalamus (VPL) and the primary somatosensory cortex (SI). We evaluated, using MRI, three specific processes: (a) somatotopy of changes in the SS for different pain origins (viz., foot vs. arm); (b) differences in acute (ankle sprain versus complex regional pain syndrome-CRPS); and (c) differences of the effects of CRPS on SS in pediatric versus adult patients. In all cases, age- and sex-matched individuals were used as controls. Our results suggest a shift in concurrent gray matter density (GMD) and resting functional connectivity strengths (rFC) across pediatric and adult CRPS with (a) differential patterns of GMD (VPL) and rFC (SI) on SS in pediatric vs. adult patterns that are consistent with upper and lower limb somatotopical organization; and (b) widespread GMD alterations in pediatric CRPS from sensory, emotional and descending modulatory processes to more confined sensory-emotional changes in adult CRPS and rFC patterns from sensory-sensory alterations in pediatric populations to a sensory-emotional change in adult populations. These results support the idea that pediatric and adult CRPS are differentially represented and may reflect underlying differences in pain chronification across age groups that may contribute to the well-known differences between child and adult pain vulnerability and resilience.

  View details for DOI 10.1002/hbm.24709

  View details for PubMedID 31298464

• Digitally enabled patient-reported outcome measures in cancer care reply LANCET ONCOLOGY Heathcote, L. C., Goldberg, D. S., Eccleston, C., Spunt, S. L., Simons, L. E., Sharpe, L., Earp, B. D. 2019; 20 (1): E3

  View details for DOI 10.1016/S1470-2045(18)30910-0

  View details for Web of Science ID 000454901700003

• Brain signatures of threat-safety discrimination in adolescent chronic pain. Pain Heathcote, L. C., Timmers, I. n., Kronman, C. A., Mahmud, F. n., Hernandez, J. M., Bentley, J. n., Youssef, A. M., Pine, D. S., Borsook, D. n., Simons, L. E. 2019

  Abstract

  Approximately 1.7 million youth suffer from debilitating chronic pain in the US alone, conferring risk for continued pain in adulthood. Abberations in threat-safety (T-S) discrimination are proposed to contribute to pain chronicity in adults and youth by interacting with pain-related distress. Yet, few studies have examined the neural circuitry underlying T-S discrimination in patients with chronic pain or how T-S discrimination relates to pain-related distress. In this study, 91 adolescents (10-24 years; 78 females) including 30 chronic pain patients with high pain-related distress, 29 chronic pain patients with low pain-related distress, and 32 healthy peers without chronic pain completed a developmentally-appropriate T-S learning paradigm. We measured self-reported fear, psychophysiology (skin conductance response), and functional MRI responses (N = 72 after fMRI exclusions). After controlling for age and anxiety symptoms, patients with high pain-related distress showed altered self-reported fear and fronto-limbic activity in response to learned threat and safety cues compared to both patients with low pain-related distress and healthy controls. Specifically, adolescent patients with high pain-related distress reported elevated fear and showed elevated limbic (hippocampus, amygdala) activation in response to a learned threat cue (CS+). In addition, they showed decreased frontal (vmPFC) activation and aberrant fronto-limbic connectivity in response to a learned safety cue (CS-). Patients with low pain-related distress and healthy controls appeared strikingly similar across brain and behavior. These findings indicate that altered T-S discrimination, mediated by fronto-limbic activation and connectivity, may be one mechanism maintaining pain chronicity in adolescents with high levels of pain-related distress.

  View details for DOI 10.1097/j.pain.0000000000001753

  View details for PubMedID 31764389

• Risk and Resilience in Pediatric Pain: The Roles of Parent and Adolescent Catastrophizing and Acceptance CLINICAL JOURNAL OF PAIN Feinstein, A. B., Sturgeon, J. A., Bhandari, R. P., Yoon, I. A., Ross, A. C., Huestis, S. E., Griffin, A. T., Simons, L. E. 2018; 34 (12): 1096–1105

  View details for DOI 10.1097/AJP.0000000000000639

  View details for Web of Science ID 000450434900002

• When pain gets stuck: the evolution of pain chronification and treatment resistance PAIN Borsook, D., Youssef, A. M., Simons, L., Elman, I., Eccleston, C. 2018; 159 (12): 2421–36

  Abstract

  It is well-recognized that, despite similar pain characteristics, some people with chronic pain recover, whereas others do not. In this review, we discuss possible contributions and interactions of biological, social, and psychological perturbations that underlie the evolution of treatment-resistant chronic pain. Behavior and brain are intimately implicated in the production and maintenance of perception. Our understandings of potential mechanisms that produce or exacerbate persistent pain remain relatively unclear. We provide an overview of these interactions and how differences in relative contribution of dimensions such as stress, age, genetics, environment, and immune responsivity may produce different risk profiles for disease development, pain severity, and chronicity. We propose the concept of "stickiness" as a soubriquet for capturing the multiple influences on the persistence of pain and pain behavior, and their stubborn resistance to therapeutic intervention. We then focus on the neurobiology of reward and aversion to address how alterations in synaptic complexity, neural networks, and systems (eg, opioidergic and dopaminergic) may contribute to pain stickiness. Finally, we propose an integration of the neurobiological with what is known about environmental and social demands on pain behavior and explore treatment approaches based on the nature of the individual's vulnerability to or protection from allostatic load.

  View details for PubMedID 30234696

  View details for PubMedCentralID PMC6240430

• Is Empathy for Pain Unique in Its Neural Correlates? A Meta-Analysis of Neuroimaging Studies of Empathy FRONTIERS IN BEHAVIORAL NEUROSCIENCE Timmers, I., Park, A. L., Fischer, M. D., Kronman, C. A., Heathcote, L. C., Hernandez, J., Simons, L. E. 2018; 12

  View details for DOI 10.3389/fnbeh.2018.00289

  View details for Web of Science ID 000451428200001

• Is Empathy for Pain Unique in Its Neural Correlates? A Meta-Analysis of Neuroimaging Studies of Empathy. Frontiers in behavioral neuroscience Timmers, I., Park, A. L., Fischer, M. D., Kronman, C. A., Heathcote, L. C., Hernandez, J. M., Simons, L. E. 2018; 12: 289

  Abstract

  Empathy is an essential component of our social lives, allowing us to understand and share other people's affective and sensory states, including pain. Evidence suggests a core neural network-including anterior insula (AI) and mid-cingulate cortex (MCC)-is involved in empathy for pain. However, a similar network is associated to empathy for non-pain affective states, raising the question whether empathy for pain is unique in its neural correlates. Furthermore, it is yet unclear whether neural correlates converge across different stimuli and paradigms that evoke pain-empathy. We performed a coordinate-based activation likelihood estimation (ALE) meta-analysis to identify neural correlates of empathy, assess commonalities and differences between empathy for pain and for non-pain negative affective states, and differences between pain-empathy evoking stimuli (i.e., facial pain expressions vs. acute pain inflictions) and paradigms (i.e., perceptual/affective vs. cognitive/evaluative paradigms). Following a systematic search, data from 128 functional brain imaging studies presenting whole-brain results of an empathy condition vs. baseline/neutral condition were extracted. Synthesizing neural correlates of empathy confirmed a core network comprising AI, MCC, postcentral gyrus, inferior parietal lobe, thalamus, amygdala, and brainstem. There was considerable overlap in networks for empathy for pain and empathy for non-pain negative affective states. Important differences also arose: empathy for pain uniquely activated bilateral mid-insula and more extensive MCC. Regarding stimuli, painful faces and acute pain inflictions both evoked the core empathy regions, although acute pain inflictions activated additional regions including medial frontal and parietal cortex. Regarding paradigms, both perceptual/affective and cognitive/evaluative paradigms recruited similar neural circuitry, although cognitive/evaluative paradigms activated more left MCC regions while perceptual/affective paradigms activated more right AI. Taken together, our findings reveal that empathy for pain and empathy for non-pain negative affective states share considerable neural correlates, particularly in core empathy regions AI and MCC. Beyond these regions, important differences emerged, limiting generalizability of findings across different affective/sensory states. Within pain-empathy studies, the core regions were recruited robustly irrespective of stimuli or instructions, allowing one to tailor designs according to specific needs to some extent, while ensuring activation of core regions.

  View details for DOI 10.3389/fnbeh.2018.00289

  View details for PubMedID 30542272

  View details for PubMedCentralID PMC6277791

• Advancing shared decision making for symptom monitoring in people living beyond cancer LANCET ONCOLOGY Heathcote, L. C., Goldberg, D. S., Eccleston, C., Spunt, S. L., Simons, L. E., Sharpe, L., Earp, B. D. 2018; 19 (10): E556–E563

  Abstract

  Wellbeing after successful cancer treatment depends on more than merely reducing the risk of disease recurrence. Cancer survival can be characterised by uncertainty, fear, and the interpretation of bodily sensations as potentially symptomatic of cancer recurrence. This fear can lead to over-vigilance about bodily sensations and precautionary visits to the doctor, both of which can increase the chance of early detection but can also increase anxiety and decrease quality of life. In this Personal View, we consider the medical, psychological, and ethical issues related to the practice of self-directed symptom monitoring after completion of cancer treatment, focusing on the role of doctor-patient communication. We ask how clinicians can account for the plurality of values that patients might have when it comes to deciding on how to manage and respond to experiences of post-cancer symptoms. We advocate a shared decision-making approach that incorporates the assessment of an individual's cancer recurrence risks as well as psychosocial considerations regarding fear of cancer recurrence and mental health. We aim to raise awareness of the potential quality-of-life implications of symptom-monitoring practices, emphasising the need for a balance between physical and psychological health in people living beyond cancer.

  View details for PubMedID 30303128

• Precipitating events in child and adolescent chronic musculoskeletal pain. Pain reports Becker, A. J., Heathcote, L. C., Timmers, I., Simons, L. E. 2018; 3 (Suppl 1): e665

  Abstract

  Introduction: The epidemiology of chronic pain in youth has been increasingly documented over the past decade. However, the precipitating events associated with the onset of pediatric chronic pain are not well studied.Objectives: Understanding the events that precede the onset of pain, and are reported by patients as germane to the early stages of their pain, may add one piece to the puzzle of the causal etiology of pediatric chronic pain disorders.Methods: We conducted a retrospective chart review of 320 young people attending a tertiary care chronic pain clinic with musculoskeletal chronic pain.Results: Approximately two-thirds of patients reported a precipitating event for their pain; injury was the most commonly reported event, followed by a chronic disease, then an infection or illness. Surgery was the least commonly reported event. About one-third of patients did not report any precipitating event for their pain. Patients with neuropathic pain were even more likely to report a precipitating event compared to those with localized and diffuse musculoskeletal pain. Patients with localized musculoskeletal pain and neuropathic pain were most likely to report an injury, whereas patients with diffuse musculoskeletal pain were most likely to report a chronic disease. We found little to no evidence that the presence or type of precipitating event was associated with patients' psychological or physical functioning.Conclusion: This study adds to the epidemiological evidence base for pediatric chronic pain disorders.

  View details for PubMedID 30324167

• Precipitating events in child and adolescent chronic musculoskeletal pain PAIN REPORTS Becker, A. J., Heathcote, L. C., Timmers, I., Simons, L. E. 2018; 3 (7)

  View details for DOI 10.1097/PR9.0000000000000665

  View details for Web of Science ID 000660773200002

• Risk and Resilience in Pediatric Pain: The Roles of Parent and Adolescent Catastrophizing and Acceptance. The Clinical journal of pain Feinstein, A. B., Sturgeon, J. A., Bhandari, R. P., Yoon, I. A., Ross, A., Huestis, S., Griffin, A., Simons, L. 2018

  Abstract

  OBJECTIVES: Both pediatric and parent pain catastrophizing and pain acceptance are key factors associated with pediatric pain outcomes; however, the interactive effects of these factors within the parent-child dyad have yet to be tested. The aims of this study were to examine: (1) the mediating role of child catastrophizing between parent catastrophizing and child outcomes (pain interference and mobility), (2) the mediating role of child acceptance between parent acceptance and child outcomes, and (3) whether child acceptance buffers the relation between parent catastrophizing and child catastrophizing, which in turn impacts child outcomes.METHODS: Cross-sectional data from 324 youth with chronic pain ages 10 to 17 years (M age=14.72, (SD=2.12); 73.1% female; 59% Caucasian) and their parents were collected. Participants completed measures assessing pediatric PROMIS domains (mobility and pain interference), pain catastrophizing, pain acceptance, and child pain intensity. Mediation was conducted via 1000-draw bootstrap-adjusted analyses in Mplus.RESULTS: Parent pain catastrophizing was indirectly associated with child pain interference via child catastrophizing but was not associated with mobility difficulties in the mediation model. Parent pain acceptance was indirectly associated with both child pain interference and mobility via child acceptance. We did not find evidence of child acceptance buffering parent and child pain catastrophizing.DISCUSSION: The findings of this study highlight the need for caregiver involvement in multidisciplinary treatments to mitigate risk and enhance resilience in youth with chronic pain.

  View details for PubMedID 30028367

• Cumulative effects of multiple pain sites in youth with chronic pain EUROPEAN JOURNAL OF PAIN Basch, M. C., Chow, E. T., Logan, D. E., Borsook, D., Schechter, N. L., Simons, L. E. 2018; 22 (6): 1134-1141

  Abstract

  The experience of persistent pain in multiple locations is common in youth. Based on current literature, youth with multiple pain sites (MPS) are at risk of experiencing poorer emotional outcomes and a spread of symptoms into late adolescence and adulthood. Little is known regarding the association between MPS with physical and school functioning domains, particularly after initiation of multidisciplinary pain treatment. Therefore, the objective of this study was to examine the association of MPS with disability and school functioning among youth with chronic pain.A total of 195 patients with chronic pain, aged 8-17, and their parents completed measures assessing patient distress and functioning at a multidisciplinary pain clinic evaluation and at 4-month follow-up.At evaluation, 63% of patients presented with MPS; 25% reporting MPS endorsed pain in five or more locations. When controlling for relevant demographic and emotional distress factors, MPS were associated with lower school functioning at evaluation with a persistent trend at follow-up. Although MPS were not a significant predictor of pain-related disability at evaluation, it emerged as significant at follow-up.Potentially due to the MPS load and the inverse effects that such a pain state has on function, such patients may be at risk for poorer health and school-related outcomes. The mechanisms influencing these relationships appear to extend beyond psychological/emotional factors and warrant further investigation in order to aid in our understanding of youth with MPS.Youth with MPS may be at risk for experiencing poorer physical and school functioning in comparison with single-site peers, despite treatment initiation. Further research is warranted to inform assessment and treatment approaches for this subgroup of patients.

  View details for DOI 10.1002/ejp.1201

  View details for Web of Science ID 000434963400012

  View details for PubMedID 29436161

  View details for PubMedCentralID PMC5995652

• Parent Attributions of Ambiguous Symptoms in Their Children: A Preliminary Measure Validation in Parents of Children with Chronic Pain. Children (Basel, Switzerland) Heathcote, L. C., Williams, S. E., Smith, A. M., Sieberg, C. B., Simons, L. E. 2018; 5 (6)

  Abstract

  How parents attribute cause to their child’s physical symptoms is likely important in understanding how the parent responds to the child, as well as the child’s health outcomes, especially within the context of chronic illness. Here, we adapt the Symptom Interpretation Questionnaire for parent report (SIQ-PR) and provide preliminary validation in a sample of parents of children with chronic pain (N = 311). Confirmatory factor analysis revealed that the SIQ-PR structure is consistent with the original measure, with three distinct attribution types: psychological (emotional/affective), somatic (illness/disease), and environmental (situational/transient) causes. All three subscales demonstrated satisfactory to good internal consistency, and temporal stability. Parents typically endorsed more than one attribution for each symptom, indicating that parents of children with chronic pain have a multidimensional interpretation of physical symptoms in their children. Further, parent psychological and somatic attributions, but not environmental attributions, were significantly associated with (i) parent protective responses towards their child, and (ii) the child’s self-reported somatic and psychological symptoms, indicating convergent and divergent validity. The SIQ-PR may be a useful measure for future studies investigating intergenerational and interpersonal models of pediatric chronic pain, and more broadly, to examine parent attributions of children’s ambiguous symptoms within the context of childhood chronic illness.

  View details for PubMedID 29899299

• Parent Attributions of Ambiguous Symptoms in Their Children: A Preliminary Measure Validation in Parents of Children with Chronic Pain CHILDREN-BASEL Heathcote, L. C., Williams, S. E., Smith, A. M., Sieberg, C. B., Simons, L. E. 2018; 5 (6)

  View details for DOI 10.3390/children5060076

  View details for Web of Science ID 000436273300013

• The Incidence of Adverse Childhood Experiences (ACEs) and Their Association With Pain-related and Psychosocial Impairment in Youth With Chronic Pain CLINICAL JOURNAL OF PAIN Nelson, S., Simons, L. E., Logan, D. 2018; 34 (5): 402–8

  Abstract

  Adverse childhood experiences (ACEs) in youth have been found to be frequently associated with several chronic illnesses, including chronic pain. However, this relationship remains poorly understood. Previous research has examined the association between ACEs and chronic pain, but these have primarily been examined in the context of adults with limited assessment of ACEs and individual pain conditions. The primary objectives of this study were to examine the incidence and psychological/pain-related correlates of ACEs in a sample of youth with chronic pain. Exploratory analyses were also examined using primary pain diagnosis and number of pain locations.Data were gathered using retrospective data from a clinical databank. Participants were 141 youth aged 9 to 19 with chronic pain who presented for evaluation at a multidisciplinary pain clinic. Information on ACEs exposure, pain diagnostic information, pain-related impairment, and psychosocial functioning were gathered via self-report and retrospective review of the medical record.Results revealed that over 80% of youth with chronic pain reported at least 1 ACE in their lifetime. Further, multiple and univariate analyses of variance revealed that ACEs exposure is significantly associated with greater symptoms of anxiety, depression, and fear of pain, with ≥3 ACEs associated with greatest impairment in functioning. No relationships were found between ACEs and increased pain-related disability or pain intensity.ACEs exposure in youth with chronic pain occurs frequently and can be associated with increased psychosocial but not functional impairment. Future research is needed to further examine the relationship between ACEs and chronic pain in youth in a prospective manner.

  View details for PubMedID 28877141

• Rapid Screening of Risk in Pediatric Headache: Application of the Pediatric Pain Screening Tool JOURNAL OF PEDIATRIC PSYCHOLOGY Heathcote, L. C., Rabner, J., Lebel, A., Hernandez, J. M., Simons, L. E. 2018; 43 (3): 243–51

  Abstract

  The current study examined the application of a screening tool to identify biopsychosocial risk factors and derive prognostic risk groups in children and adolescents with headache pain.Youth (n = 242, 8-17 years, 75.6% female) presenting for evaluation at a tertiary pediatric headache clinic completed the nine-item Pediatric Pain Screening Tool (PPST) as well as measures of functional disability, pain catastrophizing, fear of pain, anxiety, and depressive symptoms. In addition, 119 patients reported on functional disability at 2-month follow-up.The PPST demonstrated discriminant validity that ranged from fair to good for identifying significant disability and high emotional distress. Receiver operating characteristic curve analyses indicated that established cutoff scores were appropriate for the current sample, and thus participants were classified into low-risk (21%), medium-risk (31%), and high-risk (48%) groups. Only 1-6% of patients who met reference standard case status for disability and emotional distress were classified as low risk, whereas 64-90% of patients who met reference standard case status were classified as high risk, suggesting robust stratification.The nine-item PPST may be a useful tool for efficiently identifying young patients with headache who are at risk of poor outcomes, and effectively classifying them into risk groups that could drive stratified treatment directly targeting patient needs.

  View details for PubMedID 29048551

• Feeling the Pressure to Be Perfect: Effect on Pain-Related Distress and Dysfunction in Youth With Chronic Pain JOURNAL OF PAIN Randall, E. T., Smith, K. R., Kronman, C. A., Conroy, C., Smith, A. M., Simons, L. E. 2018; 19 (4): 418–29

  Abstract

  Despite clinical observation of perfectionistic tendencies among youth with chronic pain and their parents as well as established relationships between perfectionism and functional somatic symptoms in adults and youth, no research in the pediatric pain literature has examined perfectionism. This study explored the role of various types of youth and parent perfectionism on youth and parent pain-related distress and behavior and youth pain-related dysfunction. At admission, 239 parent-child pairs from outpatient and day-treatment rehabilitation settings completed several questionnaires assessing perfectionism, pain-related distress, and pain-related dysfunction. Bivariate correlations indicated that socially prescribed perfectionism in youth and parents was linked to youth pain duration, parent and youth pain-related distress and behavior, and youth somatization. Indirect relations showed that youth socially prescribed perfectionism was the only form of perfectionism directly associated with youth somatization whereas all forms of youth perfectionism were indirectly associated with somatization and functional disability through increases in youth pain-related fear and catastrophizing. Additionally, socially prescribed perfectionism was the only type of parent perfectionism linked to youth pain-related dysfunction (somatization, functional disability) through its association with youth pain-related fear. Findings support clinical observations that parent and youth perfectionism is a psychosocial factor that should be targeted in pediatric chronic pain treatment.Perfectionism in youth with chronic pain and their parents was indirectly linked to youth pain-related dysfunction through its effect on youth pain-related catastrophizing and fear. Findings support clinical observations that parent and youth perfectionism is a psychosocial factor that should be targeted in pediatric chronic pain treatment.

  View details for PubMedID 29248510

• Assessment of Pain Anxiety, Pain Catastrophizing, and Fear of Pain in Children and Adolescents With Chronic Pain: A Systematic Review and Meta-Analysis JOURNAL OF PEDIATRIC PSYCHOLOGY Fisher, E., Heathcote, L. C., Eccleston, C., Simons, L. E., Palermo, T. M. 2018; 43 (3): 314–25

  Abstract

  To conduct a systematic review of pain anxiety, pain catastrophizing, and fear of pain measures psychometrically established in youth with chronic pain. The review addresses three specific aims: (1) to identify measures used in youth with chronic pain, summarizing their content, psychometric properties, and use; (2) to use evidence-based assessment criteria to rate each measure according to the Society of Pediatric Psychology (SPP) guidelines; (3) to pool data across studies for meta-analysis of shared variance in psychometric performance in relation to the primary outcomes of pain intensity, disability, generalized anxiety, and depression.We searched Medline, Embase, PsycINFO, and relevant literature for possible studies to include. We identified measures studied in youth with chronic pain that assessed pain anxiety, pain catastrophizing, or fear of pain and extracted the item-level content. Study and participant characteristics, and correlation data were extracted for summary and meta-analysis, and measures were rated using the SPP evidence-based assessment criteria.Fifty-four studies (84 papers) met the inclusion criteria, including seven relevant measures: one assessed pain anxiety, three pain catastrophizing, and three fear of pain. Overall, five measures were rated as "well established." We conducted meta-analyses on four measures with available data. We found significant positive correlations with the variables pain intensity, disability, generalized anxiety, and depression.Seven measures are available to assess pain anxiety, pain catastrophizing, and fear of pain in young people with chronic pain, and most are well established. We present implications for practice and directions for future research.

  View details for PubMedID 29049813

• Mental Health Screening of Medically-Admitted Patients With Cystic Fibrosis PSYCHOSOMATICS Garcia, G., Snell, C., Sawicki, G., Simons, L. E. 2018; 59 (2): 158–68

  Abstract

  Multi-national studies have identified an increased risk for depression and anxiety among the cystic fibrosis population. People with cystic fibrosis and depression have decreased lung function, adherence, and quality of life, and increased health care utilization. This is a pilot study of mental health screening and referral of patients with cystic fibrosis in a large tertiary medical center.Patients with a diagnosis of cystic fibrosis aged 8 and older, medically admitted to a tertiary hospital, were screened for eligibility and offered mental health screening for depression and anxiety.Patients indicating elevated rates of anxiety, depression, or suicidal ideation were offered a psychiatric consultation, and all participants were offered mental health referrals. Health-related outcomes were gathered via medical record review.The pediatric population showed elevated rates/at risk of depression (17%), anxiety (22%) and clinically-elevated depression (5%), and anxiety (11%). Twenty-two percent of the youth reported suicidal ideation. The adult population reported mild rates of depression (11%), anxiety (28%), and suicidality (11%). The mental health screening process resulted in 1 mental health referral, 16 patients eligible for psychiatric consultation, and 4 completed psychiatric consultations.This study represents a pilot mental health screening in the inpatient medical setting. The results indicate an elevated rate of depression, anxiety, and suicidal ideation, and a protocol for responding to elevated responses via psychiatric consultation. This study indicates the need for further exploration of implementation of mental health screening, rapid response to suicidal ideation, referral process, and treatment interventions.

  View details for PubMedID 28985975

• Pediatric Headache and Sleep Disturbance: A Comparison of Diagnostic Groups HEADACHE Rabner, J., Kaczynski, K. J., Simons, L. E., LeBel, A. 2018; 58 (2): 217–28

  Abstract

  To examine whether sleep disturbance differs by headache diagnosis in a pediatric sample, and whether this effect remains when other factors affecting sleep are included.Primary headache disorders can be severe and disabling, impacting a child's functioning and quality of life. Many children and adolescents with chronic headaches also experience sleep difficulties, and there is likely a bidirectional relationship between headaches and sleep difficulties. Sleep problems may intensify functional and developmental difficulties in youth with chronic headaches. Despite this, research on sleep has largely been conducted only on those with migraines, with a dearth of studies including samples with tension-type headache (TTH) or new daily persistent-headache (NDPH).This retrospective chart review included 527 patients, ages 7-17 years, with a primary headache diagnosis of migraine (n = 278), TTH (n = 157), and NDPH (n = 92). Patients completed measures of disability, anxiety, and depression and their parents completed measures of sleep disturbance.Sleep disturbance was greater in patients with TTH (10.34 ± 5.94, P = .002) and NDPH (11.52 ± 6.40, P < .001) than migraine (8.31 ± 5.89). Across patient groups, greater sleep disturbance was significantly associated with higher levels of functional disability (rs ≥ .16), anxiety (rs ≥ .30), and depression (rs ≥ .32). Additionally, higher pain levels were significantly associated with greater sleep disturbance among TTH patients (r = .23), with this association non-significant among the other headache groups. When simultaneously examining demographic, pain-related, and emotional distress factors, older age, higher levels of disability and depression, and NDPH diagnosis were all significant predictors of greater sleep disturbance (r2  = .25).Assessment and treatment of sleep problems in pediatric patients with chronic headache is important with several contextual and headache diagnostic factors influencing the severity of sleep disturbance.

  View details for PubMedID 29044497

• Children With Chronic Pain: Response Trajectories After Intensive Pain Rehabilitation Treatment JOURNAL OF PAIN Simons, L. E., Sieberg, C. B., Conroy, C., Randall, E. T., Shulman, J., Borsook, D., Berde, C., Sethna, N. F., Logan, D. E. 2018; 19 (2): 207–18

  Abstract

  Intensive pain rehabilitation programs for children with chronic pain are effective for many patients. However, characteristics associated with treatment response have not been well documented. In this article we report trajectories of pain and functional impairment in patients with chronic pain up to 1 year after intensive pain rehabilitation and examine baseline factors associated with treatment response. Patients (n = 253) with chronic pain and functional disability were assessed at 5 time points (admission, discharge, 1-month, 4-month, and 12-month follow-ups). Individual trajectories were empirically grouped using SAS PROC TRAJ. For functional disability, 2 groups emerged: treatment responders (88%) and nonresponders (12%). Using a binomial logistic regression model to predict disability trajectory group, no baseline variables were significant predictors for the disability trajectory group. For pain, 3 groups emerged: early treatment responders (35%), late treatment responders (38%), and nonresponders (27%). Using multinomial regression analyses to predict pain trajectory group, older age, higher pain scores, fewer social difficulties, higher anxiety levels, and lower readiness to change were characteristics that distinguished nonresponders from responders; no significant predictors distinguished the late responders from the early responders. These results provide key information on the baseline factors that influence intensive pain rehabilitation outcomes, including risk factors that predict treatment nonresponse. Our findings have implications for developing more targeted treatment interventions.Deriving groups of individuals with differing treatment response trajectories stimulates new thinking regarding potential mechanisms that may be driving these outcomes.

  View details for PubMedID 29102693

• A Child's Concept of Pain: An International Survey of Pediatric Pain Experts. Children (Basel, Switzerland) Pate, J. W., Hush, J. M., Hancock, M. J., Moseley, G. L., Butler, D. S., Simons, L. E., Pacey, V. 2018; 5 (1)

  Abstract

  A child's 'concept of pain' refers to how they understand what pain actually is, what function pain serves, and what biological processes are thought to underpin it. We aimed to determine pediatric pain experts' opinions of: (1) the importance and usefulness of assessing a child's concept of pain in clinical and/or research settings; (2) the usefulness of the content of items within currently published adult-targeted resources for assessing a child's concept of pain; and (3) important domains of a child's concept of pain to assess. Forty-nine pediatric pain experts (response rate = 75.4%) completed an online survey. Descriptive statistics and frequency of responses were analyzed. Experts from all included disciplines reported that assessing a child's concept of pain is important and useful both clinically and in a research setting (>80% reported very or extremely useful for each item). Experts considered that the content of 13 items from currently published adult-targeted resources was useful, but the wording was too complex for children aged 8-12 years. Experts considered that all seven of the proposed domains of a child's concept of pain was important to assess. The findings can be used to inform the development of an assessment tool for a child's concept of pain.

  View details for DOI 10.3390/children5010012

  View details for PubMedID 29342976

  View details for PubMedCentralID PMC5789294

• Dutch version of the Fear of Pain Questionnaire for adolescents with chronic pain DISABILITY AND REHABILITATION Dekker, C., Bastiaenen, C. G., de Vries, J. E., Simons, L. E., Goossens, M. B., Verbunt, J. F. 2018; 40 (11): 1326–32

  Abstract

  Fear of pain is important in the development and maintenance of chronic pain. The Fear of Pain Questionnaire-Child version has been developed to assess pain related fear in children and adolescents.Translating the original questionnaire into Dutch, and investigating internal consistency and construct validity to enable use in the Dutch pain rehabilitation setting for treatment and research.Cross-sectional validation study: After forward and back translation of the FOPQ-C, adolescents (11-22 years old) with chronic musculoskeletal pain completed an assessment containing the Dutch Fear of Pain Questionnaire, and questionnaires about demographics, pain catastrophizing, functional disability, and pain intensity. Internal consistency and construct validity were evaluated through exploratory factor analysis (principal axis factoring with oblique rotation) and hypotheses testing using pain catastrophizing, functional disability, and pain intensity as comparative constructs.Eighty-six adolescents completed the assessment. Exploratory factor analysis resulted in a two-factor structure, explaining 43% of the variance. Internal consistency was strong (Cronbach's α = 0.92 total scale, α = 0.88 factor 1, and α = .86 factor 2). Five out of 6 hypotheses were confirmed.The Dutch version demonstrated good internal consistency and good construct validity in a population of adolescents with chronic musculoskeletal pain. Implications for rehabilitation The Fear of Pain Questionnaire-Child version was developed to measure fear of pain and avoidance in children and adolescents with chronic pain. Identification of fear of pain and activities that are being avoided are important during screening and assessment of the adolescent for chronic pain rehabilitation treatment. The presence of fear of pain and/or avoidance behavior is important information to shape and target multidisciplinary rehabilitation treatment.

  View details for PubMedID 28637153

• Validation of the German fear of pain questionnaire in a sample of children with mixed chronic pain conditions EUROPEAN JOURNAL OF PAIN Flack, F., Gerlach, A. L., Simons, L. E., Zernikow, B., Hechler, T. 2017; 21 (7): 1224-1233

  Abstract

  To date, no German instrument exists to measure pain-related fear in paediatric pain populations. The objective of the current study was to determine the construct validity of the translated German fear of pain questionnaire for children (GFOPQ-C) in a sample of children with mixed chronic pain disorders by testing the underlying factor structure, and its psychometric properties.N = 241 children with mixed chronic pain disorders (aged 8-19 years) presenting to a specialized pain clinic completed the GFOPQ-C and several other pain, fear and disability measures.The two-factor structure of the FOPQ-C (fear, avoidance) was replicated. Internal consistency for the shortened German version was good for both subscales (Fear subscale: α = 0.89; avoidance subscale: α = 0.76). As expected, the fear subscale correlated highly with anxiety sensitivity (r = 0.63), pain catastrophizing (r = 0.62) and general anxiety (r = 0.54), while the avoidance subscale was more closely related to disability (r = 0.24) and school functioning (r = 0.28). Pain-related fear differed in children with chronic pain depending on their pain location with higher fear ratings in children with abdominal pain and musculoskeletal pain.The GFOPQ-C is a valid instrument that assesses two distinct dimensions of pain-related fear in children: fear and avoidance. Future research is needed to evaluate the impact of increased pain-related fear on outcomes over time as well as to examine pain-related fear among healthy children. This will enhance our knowledge of who might be particularly vulnerable to potentially dysfunctional trajectories, such as ongoing pain or anxiety symptoms.The current study validates the first tool to assess pain-related fear in German-speaking children with chronic pain. Findings support two distinct domains: fear and activity avoidance.

  View details for DOI 10.1002/ejp.1022

  View details for Web of Science ID 000406872000012

  View details for PubMedID 28370851

• Photographs of Daily Activities (PHODA)-Youth English: Validating a targeted assessment of worry and anticipated pain. Pain Simons, L., Pielech, M., McAvoy, S., Conroy, C., Hogan, M., Verbunt, J., Goossens, M. 2017

  Abstract

  PHODA is an electronic measure that individualizes and guides treatment for individuals with chronic pain. Implicit in its design is recognition that pain-related fear is a driving force that impedes treatment progress. With this tool, patients visually rate their expectations about the harmful consequences of specific movements. This study aimed to (1) develop and validate PHODA-Youth English (PHODA-YE) and (2) evaluate the potential impact of PHODA-YE assessment on treatment outcomes. Participants were 195 youth, age 8 to 20 years, who presented to an outpatient pain clinic for evaluation (n = 99), or enrolled at the Pediatric Pain Rehabilitation Center (PPRC) intensive program (PPRC; n = 96). All patients completed the PHODA-YE along with measures of emotional functioning and disability. Patients in the PPRC completed the measure at both admission and discharge. After eliminating infrequently endorsed and poorly loading items, factor analytic procedures yielded a 4-subscale, 50-item measure with strong internal consistency (from 0.92 to 0.97 across subscales). Fear, avoidance, and functional disability were strongly associated with PHODA-YE scores, supporting construct validity. Within the PPRC sample, PHODA-YE was sensitive to changes over time in relation to functional improvements. Across the PPRC sample, patients found it helpful to complete the PHODA and target feared activities. Altogether, the PHODA-YE is a valid and concrete assessment tool that rapidly identifies specific activities and movements that elicit fearful responses from patients.

  View details for DOI 10.1097/j.pain.0000000000000855

  View details for PubMedID 28134656

• Social Risk and Resilience Factors in Adolescent Chronic Pain: Examining the Role of Parents and Peers. Journal of pediatric psychology Ross, A. C., Simons, L. E., Feinstein, A. B., Yoon, I. A., Bhandari, R. P. 2017

  Abstract

  The current study focuses on social risk and resilience in an adolescent population with chronic pain. Prior research identifies parental cognitions and behaviors as influential in youths' experiences of chronic pain and pain-related disability. Adolescent development is characterized by greater autonomy from parents and an increased emphasis on peer relationships. Study aims explore the potential protective effect of high-quality adolescent peer relationships on associations between parent and adolescent cognitive and behavioral responses to pain.238 adolescents with mixed-etiology chronic pain and their parents completed Pediatric Collaborative Health Outcomes Information Registry (Peds-CHOIR) electronic questionnaires prior to their initial visit to a tertiary pediatric pain clinic. Variables in this study include parent catastrophizing, parent protective behavior, adolescent peer relationship quality, adolescent catastrophizing, adolescent functional impairment, and demographic and pain characteristics.As expected, associations between parent and adolescent cognitive and behavioral pain responses were moderated by peer relationship quality. Contrary to expectations, for adolescents endorsing low-quality peer relationships, maladaptive adolescent outcomes were elevated across levels of parental cognitions and behaviors. For adolescents endorsing high-quality peer relationships, adolescent and parent pain responses were linearly related.This study highlights the salience of both family and peer processes in functional outcomes among adolescents with chronic pain. Results suggest that adolescents' adaptive responses to chronic pain may be best supported by the simultaneous presence of adaptive parenting and high-quality peer relationships. Understanding the larger social context in which an adolescent exists is informative in specifying models that predict adaptive outcomes or magnify risks.

  View details for PubMedID 29048554

• Development of the Parent Responses to School Functioning Questionnaire. The journal of pain : official journal of the American Pain Society Barber Garcia, B. N., Gray, L. S., Simons, L. E., Logan, D. E. 2017; 18 (10): 1277–86

  Abstract

  Parents play an important role in supporting school functioning in youth with chronic pain, but no validated tools exists to assess parental responses to child and adolescent pain behaviors in the school context. Such a tool would be useful in identifying targets of change to reduce pain-related school impairment. The goal of this study was to develop and preliminarily validate the Parent Responses to School Functioning Questionnaire (PRSF), a parent self-report measure of this construct. After initial expert review and pilot testing, the measure was administered to 418 parents of children (ages 6-17 years) seen for initial multidisciplinary chronic pain clinic evaluation. The final 16-item PRSF showed evidence of good internal consistency (α = .82) and 2-week test-retest reliability (intraclass correlation coefficient = .87). Criterion validity was demonstrated by significant correlations with school absence rates and overall school functioning, and construct validity was demonstrated by correlations with general parental responses to pain. Three subscales emerged capturing parents' personal distress, parents' level of distrust of the school, and parents' expectations and behaviors related to their child's management of challenging school situations. These results provide preliminary support for the PRSF as a psychometrically sound tool to assess parents' responses to child pain in the school setting.The 16-item PRSF measures parental responses to their child's chronic pain in the school context. The clinically useful measure can inform interventions aimed reducing functional disability in children with chronic pain by enhancing parents' ability to respond adaptively to child pain behaviors.

  View details for PubMedID 28729215

• The Sleep Hygiene Inventory for Pediatrics: Development and Validation of a New Measure of Sleep in a Sample of Children and Adolescents With Chronic Headache. Journal of child neurology Rabner, J. n., Kaczynski, K. J., Simons, L. E., Lebel, A. A. 2017; 32 (13): 1040–46

  Abstract

  Sleep plays a pivotal role in children and adolescents with headache. Although several sleep measures exist, no developed measures target the sleep issues common in pediatric patients with headache. The Sleep Hygiene Inventory for Pediatrics (SHIP) was developed for clinical purposes to fulfill this need. The aim of this study was to validate the SHIP for potential research applications in a sample of 1078 children and adolescents (7-17 years) with a primary headache diagnosis. Measure validation included assessments of internal consistency, construct validity, and criterion validity. The SHIP demonstrated strong internal consistency (Cronbach α = 0.84). The SHIP differentiated well between participants for whom sleep was and was not a clinical concern ( P < .001; d =1.65), and was positively correlated with anxiety, depression, and disability. These analyses suggest that the SHIP is a psychometrically strong and valid assessment of sleep habits in pediatric patients with headache.

  View details for PubMedID 28854844

• Predictors and trajectories of chronic postoperative pain following hip preservation surgery JOURNAL OF HIP PRESERVATION SURGERY Sieberg, C. B., Klajn, J., Wong, C., Bowen, G., Simons, L. E., Millis, M. B. 2017; 4 (1): 45–53

  Abstract

  Factors contributing to chronic postoperative pain (CPOP) are poorly defined in young people and developmental considerations are poorly understood. With over 5 million children undergoing surgery yearly and 25% of adults referred to chronic pain clinics identifying surgery as the antecedent, there is a need to elucidate factors that contribute to CPOP in surgical patients. The present study includes patients undergoing hip preservation surgery at a children's hospital. The HOOS and SF-12 Health Survey were administered to 614 pre-surgical patients with 421 patients completing follow-up (6-months, 1-year and 2-years post-surgery). Pain, quality of life, and functioning across time were examined for each group within the population. A three trajectory model (low pain, pain improvement and high pain) emerged indicating three categories of treatment responders. Pain trajectory groups did not differ significantly on gender, pre-surgical age, BMI, prior hip surgery, surgical type, joint congruence or Tönnis grade. The groups differed significantly from each other on pre-surgical pain, pain chronicity, quality of life and functioning. Those in the high pain and pain improvement groups endorsed having pre-surgical depression at significantly higher rates and lower pre-surgical quality of life compared to those in the low pain group (P < 0.01). Those in the high pain group reported significantly worse pre-surgical functioning compared to those in the pain improvement (P < 0.0001) and low pain groups (P < 0.0001).The results demonstrate the need for preoperative screening prior to hip preservation surgery, as there may be a subset of patients who are predisposed to chronic pain independent of hip health.

  View details for PubMedID 28630720

• Pain Neuroscience Education: State of the Art and Application in Pediatrics. Children (Basel, Switzerland) Robins, H., Perron, V., Heathcote, L. C., Simons, L. E. 2016; 3 (4)

  Abstract

  Chronic pain is a widespread problem in the field of pediatrics. Many interventions to ameliorate pain-related dysfunction have a biobehavioral focus. As treatments for chronic pain (e.g., increased movement) often stand in stark contrast to treatments for an acute injury (e.g., rest), providing a solid rationale for treatment is necessary to gain patient and parent buy-in. Most pain treatment interventions incorporate psychoeducation, or pain neuroscience education (PNE), as an essential component, and in some cases, as a stand-alone approach. The current topical review focuses on the state of pain neuroscience education and its application to pediatric chronic pain. As very little research has examined pain neuroscience education in pediatrics, we aim to describe this emerging area and catalyze further work on this important topic. As the present literature has generally focused on adults with chronic pain, pain neuroscience education merits further attention in the realm of pediatric pain in order to be tailored and implemented in this population.

  View details for DOI 10.3390/children3040043

  View details for PubMedID 28009822

  View details for PubMedCentralID PMC5184818

• Predicting Postsurgical Satisfaction in Adolescents With Idiopathic Scoliosis: The Role of Presurgical Functioning and Expectations. Journal of pediatric orthopedics Sieberg, C. B., Manganella, J., Manalo, G., Simons, L. E., Hresko, M. T. 2016: -?

  Abstract

  There is a need to better assess patient satisfaction and surgical outcomes. The purpose of the current study is to identify how preoperative expectations can impact postsurgical satisfaction among youth with adolescent idiopathic scoliosis undergoing spinal fusion surgery.The present study includes patients with adolescent idiopathic scoliosis undergoing spinal fusion surgery enrolled in a prospective, multicentered registry examining postsurgical outcomes. The Scoliosis Research Society Questionnaire-Version 30, which assesses pain, self-image, mental health, and satisfaction with management, along with the Spinal Appearance Questionnaire, which measures surgical expectations was administered to 190 patients before surgery and 1 and 2 years postoperatively. Regression analyses with bootstrapping (with n=5000 bootstrap samples) were conducted with 99% bias-corrected confidence intervals to examine the extent to which preoperative expectations for spinal appearance mediated the relationship between presurgical mental health and pain and 2-year postsurgical satisfaction.Results indicate that preoperative mental health, pain, and expectations are predictive of postsurgical satisfaction.With the shifting health care system, physicians may want to consider patient mental health, pain, and expectations before surgery to optimize satisfaction and ultimately improve clinical care and patient outcomes.Level I-prognostic study.

  View details for PubMedID 27379786

• The Longitudinal Impact of Parent Distress and Behavior on Functional Outcomes Among Youth With Chronic Pain JOURNAL OF PAIN Chow, E. T., Otis, J. D., Simons, L. E. 2016; 17 (6): 729-738

  Abstract

  Accumulating evidence supports the concurrent association between parent distress and behavior and child functioning in the context of chronic pain, with existing longitudinal studies limited to a pediatric surgical context that identify parent catastrophizing as influential. In this study, we examined how parent factors assessed at a multidisciplinary pediatric pain clinic evaluation affect child psychological and functional outcomes over time. A cohort of 195 patients with chronic pain (ages 8-17 years) and their parents who presented for a multidisciplinary evaluation completed measures at baseline and at 4-month follow-up. Patients completed measures of pain catastrophizing, pain-related fear and avoidance, generalized anxiety, depressive symptoms, and functional disability. Parents completed measures of pain catastrophizing, pain-related fear and avoidance, and protective responses to child pain. Parent-reported child school functioning was also collected. Parent distress and behavior was concurrently associated with child distress and functioning at evaluation. After controlling for baseline child functioning, baseline parent avoidance and protective behavior emerged as significant predictors of child functioning at 4-month follow-up. Parent distress and behavior influence child distress and functioning over time and these findings identify key parent domains to target in the context of a child's pain treatment.Parent behavior, specifically avoidance and protective responses, influence child distress and functioning over time. Child pain treatment interventions should include influential parent factors to ensure successful outcomes.

  View details for DOI 10.1016/j.jpain.2016.02.014

  View details for Web of Science ID 000377628000010

  View details for PubMedID 26993960

  View details for PubMedCentralID PMC4885759

• Rapid treatment-induced brain changes in pediatric CRPS BRAIN STRUCTURE & FUNCTION Erpelding, N., Simons, L., Lebel, A., Serrano, P., Pielech, M., Prabhu, S., Becerra, L., Borsook, D. 2016; 221 (2): 1095-1111

  Abstract

  To date, brain structure and function changes in children with complex regional pain syndrome (CRPS) as a result of disease and treatment remain unknown. Here, we investigated (a) gray matter (GM) differences between patients with CRPS and healthy controls and (b) GM and functional connectivity (FC) changes in patients following intensive interdisciplinary psychophysical pain treatment. Twenty-three patients (13 females, 9 males; average age ± SD = 13.3 ± 2.5 years) and 21 healthy sex- and age-matched controls underwent magnetic resonance imaging. Compared to controls, patients had reduced GM in the primary motor cortex, premotor cortex, supplementary motor area, midcingulate cortex, orbitofrontal cortex, dorsolateral prefrontal cortex (dlPFC), posterior cingulate cortex, precuneus, basal ganglia, thalamus, and hippocampus. Following treatment, patients had increased GM in the dlPFC, thalamus, basal ganglia, amygdala, and hippocampus, and enhanced FC between the dlPFC and the periaqueductal gray, two regions involved in descending pain modulation. Accordingly, our results provide novel evidence for GM abnormalities in sensory, motor, emotional, cognitive, and pain modulatory regions in children with CRPS. Furthermore, this is the first study to demonstrate rapid treatment-induced GM and FC changes in areas implicated in sensation, emotion, cognition, and pain modulation.

  View details for DOI 10.1007/s00429-014-0957-8

  View details for Web of Science ID 000371380100022

  View details for PubMedID 25515312

  View details for PubMedCentralID PMC4470894

• Fear of pain in children and adolescents with neuropathic pain and complex regional pain syndrome PAIN Simons, L. E. 2016; 157 (2): S90-S97

  Abstract

  A significant proportion of children and adolescents with chronic pain endorse elevated pain-related fear. Pain-related fear is associated with high levels of disability, depressive symptoms, and school impairment. Because of faulty nerve signaling, individuals with neuropathic pain and complex regional pain syndrome may be more prone to develop pain-related fear as they avoid use of and neglect the affected body area(s), resulting in exacerbated symptoms, muscle atrophy, maintenance of pain signaling, and ongoing pain-related disability. Not surprisingly, effective treatments for elevated pain-related fears involve exposure to previously avoided activities to downregulate incorrect pain signaling. In the context of intensive interdisciplinary pain treatment of youth with neuropathic pain, decreasing pain-related fear is associated with improved physical and psychological functioning, whereas high initial pain-related fear is a risk factor for less treatment responsiveness. An innovative approach to targeting pain-related fear and evidence of a neural response to treatment involving decoupling of the amygdala with key fear circuits in youth with complex regional pain syndrome suggest breakthroughs in our ability to ameliorate these issues.

  View details for DOI 10.1097/j.pain.0000000000000377

  View details for Web of Science ID 000379971700014

  View details for PubMedID 26785161

  View details for PubMedCentralID PMC4721261

• Fear and Reward Circuit Alterations in Pediatric CRPS FRONTIERS IN HUMAN NEUROSCIENCE Simons, L. E., Erpelding, N., Hernandez, J. M., Serrano, P., Zhang, K., LeBel, A. A., Sethna, N. F., Berde, C. B., Prabhu, S. P., Becerra, L., Borsook, D. 2016; 9

  Abstract

  In chronic pain, a number of brain regions involved in emotion (e.g., amygdala, hippocampus, nucleus accumbens, insula, anterior cingulate, and prefrontal cortex) show significant functional and morphometric changes. One phenotypic manifestation of these changes is pain-related fear (PRF). PRF is associated with profoundly altered behavioral adaptations to chronic pain. For example, patients with a neuropathic pain condition known as complex regional pain syndrome (CRPS) often avoid use of and may even neglect the affected body area(s), thus maintaining and likely enhancing PRF. These changes form part of an overall maladaptation to chronic pain. To examine fear-related brain circuit alterations in humans, 20 pediatric patients with CRPS and 20 sex- and age-matched healthy controls underwent functional magnetic resonance imaging (fMRI) in response to a well-established fearful faces paradigm. Despite no significant differences on self-reported emotional valence and arousal between the two groups, CRPS patients displayed a diminished response to fearful faces in regions associated with emotional processing compared to healthy controls. Additionally, increased PRF levels were associated with decreased activity in a number of brain regions including the right amygdala, insula, putamen, and caudate. Blunted activation in patients suggests that (a) individuals with chronic pain may have deficits in cognitive-affective brain circuits that may represent an underlying vulnerability or consequence to the chronic pain state; and (b) fear of pain may contribute and/or maintain these brain alterations. Our results shed new light on altered affective circuits in patients with chronic pain and identify PRF as a potentially important treatment target.

  View details for DOI 10.3389/fnhum.2015.00703

  View details for Web of Science ID 000368426600001

  View details for PubMedCentralID PMC4717323

• State of the art in biobehavioral approaches to the management of chronic pain in childhood. Pain management Simons, L. E., Basch, M. C. 2016; 6 (1): 49-61

  Abstract

  Chronic pain in childhood is prevalent, persistent and significantly impactful on most domains of life. The chronic pain experience occurs within a complex biopsychosocial framework, with particular emphasis on the social context. Currently, psychological treatments involve a cognitive-behavioral therapy treatment plan, providing some combination of psychoeducation, self-regulation training, maladaptive cognition identification, behavioral exposure and parent involvement. New treatment areas are emerging, such as group- and internet-based cognitive-behavioral therapy, motivational interviewing, comorbid obesity intervention and intensive multidisciplinary rehabilitation. Preliminary studies of emerging treatments demonstrate encouraging results; however, treatment effectiveness hinges on accurate matching of patient to treatment modality. Overall, the current direction of the field promises many innovative breakthroughs to ameliorate suffering in youth with chronic pain.

  View details for DOI 10.2217/pmt.15.59

  View details for PubMedID 26678858

  View details for PubMedCentralID PMC4976863

• Pain neuroscience education: State of the art and application in pediatrics Children Robins, H., Perron, V., Heathcote, L. C., Simons, L. E. 2016; 3 (43)

  Abstract

  Chronic pain is a widespread problem in the field of pediatrics. Many interventions to ameliorate pain-related dysfunction have a biobehavioral focus. As treatments for chronic pain (e.g., increased movement) often stand in stark contrast to treatments for an acute injury (e.g., rest), providing a solid rationale for treatment is necessary to gain patient and parent buy-in. Most pain treatment interventions incorporate psychoeducation, or pain neuroscience education (PNE), as an essential component, and in some cases, as a stand-alone approach. The current topical review focuses on the state of pain neuroscience education and its application to pediatric chronic pain. As very little research has examined pain neuroscience education in pediatrics, we aim to describe this emerging area and catalyze further work on this important topic. As the present literature has generally focused on adults with chronic pain, pain neuroscience education merits further attention in the realm of pediatric pain in order to be tailored and implemented in this population.

  View details for DOI 10.3390/children3040043

  View details for PubMedCentralID PMC5184818

• Validation of a measure of children's perceptions of their oncology camp experience: a national study PSYCHO-ONCOLOGY Wu, Y. P., Hung, M., Franklin, J. D., Samhouri, M., Simons, L. E., Amylon, M. D. 2016; 25 (1): 112-114

  View details for DOI 10.1002/pon.3792

  View details for Web of Science ID 000368819100015

  View details for PubMedID 25736248

• "Pain Can't Stop Me": Examining Pain Self-Efficacy and Acceptance as Resilience Processes Among Youth With Chronic Headache JOURNAL OF PEDIATRIC PSYCHOLOGY Kalapurakkel, S., Carpino, E. A., Lebel, A., Simons, L. E. 2015; 40 (9): 926-933

  Abstract

  To examine pain self-efficacy and pain acceptance in relation to functioning in pediatric patients with chronic headache.Participants were 209 youth aged 8-17 years who presented for a multidisciplinary pediatric headache clinic evaluation. They completed measures of pain self-efficacy and pain acceptance and a standard battery of clinical measures including indicators of emotional functioning.Pain self-efficacy and acceptance were associated with less disability, better school functioning, and fewer depressive symptoms. While taking into account several demographic and pain-related variables, pain self-efficacy had a greater association with less functional disability, while pain acceptance had a greater association with less depressive symptoms and better school functioning.These findings indicate that both resilience processes can serve to positively interact with functioning and symptoms of depression. Ultimately, this study suggests that higher levels of pain self-efficacy and pain acceptance in an individual experiencing pain are associated with more positive outcomes.

  View details for DOI 10.1093/jpepsy/jsu091

  View details for Web of Science ID 000363215600010

  View details for PubMedID 25324532

  View details for PubMedCentralID PMC4592326

• Topical Review: Resilience Resources and Mechanisms in Pediatric Chronic Pain JOURNAL OF PEDIATRIC PSYCHOLOGY Cousins, L. A., Kalapurakkel, S., Cohen, L. L., Simons, L. E. 2015; 40 (9): 840-845

  Abstract

  To apply resilience theory and the extant literature to propose a resilience-risk model for pediatric chronic pain and provide an agenda for research and clinical practice in pediatric chronic pain resilience. Literature review to develop a resilience-risk model for pediatric chronic pain.The chronic pain literature has identified unique individual and social/environmental resilience resources and pain-related resilience mechanisms that promote pain adaptation. These data support our ecological resilience-risk model for pediatric chronic pain, and the model highlights novel directions for clinical and research efforts for youth with chronic pain.The examination of pediatric chronic pain from a strengths-based approach might lead to novel clinical avenues to empower youth to positively adapt and live beyond their pain.

  View details for DOI 10.1093/jpepsy/jsv037

  View details for Web of Science ID 000363215600002

  View details for PubMedID 25979085

  View details for PubMedCentralID PMC4643616

• Living Life With My Child's Pain The Parent Pain Acceptance Questionnaire (PPAQ) CLINICAL JOURNAL OF PAIN Smith, A. M., Sieberg, C. B., Odell, S., Randall, E., Simons, L. E. 2015; 31 (7): 633-641

  Abstract

  Parents' emotional, cognitive, and behavioral responses are highly influential on children's pain and functional outcomes. One important response to pediatric pain is acceptance: the degree to which an individual participates in routine daily activities in the presence of pain and is willing to let pain be a part of their life without efforts to control or avoid it. However, no tool currently exists to assess parents' own acceptance of their child's pain. The aim of this study was to validate the Parent Pain Acceptance Questionnaire (PPAQ).The PPAQ was administered to 310 parents of youth with chronic pain in an outpatient pediatric headache program and a day hospital pain rehabilitation program. An exploratory factor analysis revealed 2 factors for the PPAQ: an 11-item Activity Engagement scale and a 4-item Acceptance of Pain-related Thoughts and Feelings scale.The PPAQ total score and subscales demonstrated strong internal consistency. Greater parent pain acceptance was positively associated with child pain acceptance, and was negatively correlated with parent protective behaviors, parent minimizing behaviors, parent and child pain catastrophizing, and child fear of pain. Parent protective behaviors and child pain acceptance both served as mediators of the relationship between parent pain acceptance and child functional disability.The PPAQ is a valid measure of parent pain acceptance and may provide valuable insights into parent responses to child pain and the ways in which parent acceptance influences child outcomes. Clinical implications and suggestions for future research are discussed.

  View details for DOI 10.1097/AJP.0000000000000140

  View details for Web of Science ID 000356588200005

  View details for PubMedID 25119514

  View details for PubMedCentralID PMC4326631

• Systematic Review on Intensive Interdisciplinary Pain Treatment of Children With Chronic Pain PEDIATRICS Hechler, T., Kanstrup, M., Holley, A. L., Simons, L. E., Wicksell, R., Hirschfeld, G., Zernikow, B. 2015; 136 (1): 115-127

  Abstract

  Pediatric debilitating chronic pain is a severe health problem, often requiring complex interventions such as intensive interdisciplinary pain treatment (IIPT). Research is lacking regarding the effectiveness of IIPT for children. The objective was to systematically review studies evaluating the effects of IIPT.Cochrane, Medline/Ovid, PsycInfo/OVID, PubMed, PubPsych, and Web of Science were searched. Studies were included if (1) treatment was coordinated by ≥3 health professionals, (2) treatment occurred within an inpatient/day hospital setting, (3) patients were <22 years, (4) patients experienced debilitating chronic pain, (5) the study was published in English, and (6) the study had ≥10 participants at posttreatment. The child's pain condition, characteristics of the IIPT, and 5 outcome domains (pain intensity, disability, school functioning, anxiety, depressive symptoms) were extracted at baseline, posttreatment, and follow-up.One randomized controlled trial and 9 nonrandomized treatment studies were identified and a meta-analysis was conducted separately on pain intensity, disability, and depressive symptoms revealing positive treatment effects. At posttreatment, there were large improvements for disability, and small to moderate improvements for pain intensity and depressive symptoms. The positive effects were maintained at short-term follow-up. Findings demonstrated extreme heterogeneity.Effects in nonrandomized treatment studies cannot be attributed to IIPT alone. Because of substantial heterogeneity in measures for school functioning and anxiety, meta-analyses could not be computed. There is preliminary evidence for positive treatment effects of IIPT, but the small number of studies and their methodological weaknesses suggest a need for more research on IIPTs for children.

  View details for DOI 10.1542/peds.2014-3319

  View details for Web of Science ID 000357296000054

  View details for PubMedID 26101358

• Longitudinal stability of medication adherence among adolescent solid organ transplant recipients PEDIATRIC TRANSPLANTATION Loiselle, K. A., Gutierrez-Colina, A. M., Eaton, C. K., Simons, L. E., Devine, K. A., Mee, L. L., Blount, R. L. 2015; 19 (4): 428-435

  Abstract

  Solid organ transplantation requires ongoing adherence to immunosuppressants and other medications. Although adolescence is a risk factor for poor medication-taking, little is known about the patterns of adherence within individuals over time. This study aimed to examine the stability of adherence over time using three different assessment techniques. Sixty-six AYA transplant recipients and/or their caregiver completed interviews of adherence at baseline and at least one yr later. Serum immunosuppressant assay levels were collected via medical chart review. Non-adherence percentages based on AYA report, caregiver report, and bioassay did not differ from Time 1 to Time 2. However, correlations for these measures across time were non-significant. Further, the majority of AYAs shifted to a different adherence category from Time 1 to Time 2. Overall, these results demonstrate individual variability in non-adherence over the course of adolescence and young adulthood and highlight the importance of frequent assessment across time for solid organ transplant recipients.

  View details for DOI 10.1111/petr.12480

  View details for Web of Science ID 000354182500023

  View details for PubMedID 25879392

• Clinical Cutoffs for Adherence Barriers in Solid Organ Transplant Recipients: How Many Is Too Many? JOURNAL OF PEDIATRIC PSYCHOLOGY Eaton, C. K., Lee, J. L., Simons, L. E., Devine, K. A., Mee, L. L., Blount, R. L. 2015; 40 (4): 431-441

  Abstract

  The current study used multiple statistical methods to determine empirically derived and clinically relevant cutoff scores on the Adolescent Medication Barriers Scale (AMBS) and Parent Medication Barriers Scale (PMBS) to detect adolescents and young adults with solid organ transplants who experienced medication nonadherence or negative medical outcomes.Participants included 71 patients and 80 caregivers. Cutoff scores were determined via receiver operating characteristic curve analyses, t-test analyses, and the sensitivity and specificity of using certain cutoff scores.AMBS scores of ≥3 barriers and PMBS scores of ≥2 barriers were determined as the ideal cutoffs for identifying patients meeting criteria for the outcome variables.Clinicians should consider using these recommended cutoff scores when assessing adherence barriers in adolescents and young adults with solid organ transplants and their families. Patients or caregivers endorsing barriers above the cutoffs may benefit from further assessment or intervention to address barriers, nonadherence, or related medical issues.

  View details for DOI 10.1093/jpepsy/jsu102

  View details for Web of Science ID 000354702900007

  View details for PubMedID 25418331

• Living in fear of your child's pain: the parent fear of pain questionnaire PAIN Simons, L. E., Smith, A., Kaczynski, K., Basch, M. 2015; 156 (4): 694-702

  Abstract

  Fear and avoidance have been consistently associated with poor pain-related outcomes in children. In the context of the pediatric pain experience, parent distress and behaviors can be highly influential. This study validated the Parent Fear of Pain Questionnaire (PFOPQ) to assess a parent's fears and avoidance behaviors associated with their child's pain. Using the PFOPQ in conjunction with measures of parent and child pain-related variables, we tested the interpersonal fear-avoidance model (IFAM). The sample comprised 321 parents and their child with chronic or new-onset pain who presented to a multidisciplinary outpatient pain clinic. An exploratory factor analysis yielded a 4-factor structure for the PFOPQ consisting of Fear of Pain, Fear of Movement, Fear of School, and Avoidance. As hypothesized, Fear of Pain was most closely related to parent pain catastrophizing and child fear of pain, whereas Avoidance was most closely related to parent protective behaviors and child avoidance of activities. In testing the IFAM, parent behavior contributed directly and indirectly to child avoidance, whereas parent fear and catastrophizing contributed indirectly to child avoidance through parent behavior and child fear and catastrophizing, in turn, influencing child functional disability levels. This study provides the first measure of parent pain-related fears and avoidance behaviors and evaluates the theorized IFAM. These results underscore the important influence of parents on child pain-related outcomes and put forth a psychometrically sound measure to assess parent fear and avoidance in the context of their child's pain.

  View details for DOI 10.1097/j.pain.0000000000000100

  View details for Web of Science ID 000352330900016

  View details for PubMedID 25630026

  View details for PubMedCentralID PMC4366345

• Anxiety sensitivity and fear of pain in paediatric headache patients EUROPEAN JOURNAL OF PAIN Cappucci, S., Simons, L. E. 2015; 19 (2): 246-252

  Abstract

  Recent research suggests that anxiety sensitivity (AS) may be a critical factor in the maintenance of chronic pain. Converging lines of evidence also propose a relationship between AS and fear of pain (FOP) that may result from interoceptive fear conditioning in interoceptively biased individuals. While some AS and FOP research has been carried out in adults, literature exploring this relationship is sparse in clinical paediatric populations.This study investigated the hypotheses that FOP mediates the relationships between AS and disability as well as AS and somatization in children and adolescents with chronic headache pain. Mediation models were investigated using bootstrap regression analyses.Results indicate that the AS-disability relationship is mediated by FOP, whereas AS seems to contribute both directly and indirectly to somatization.These results provide evidence for the pivotal role of AS in the paediatric chronic pain model. The findings of this study further emphasize the application of the fear-avoidance model in children and provide new evidence for the critical role of AS in a paediatric headache population.

  View details for DOI 10.1002/ejp.542

  View details for Web of Science ID 000348567300013

  View details for PubMedID 24925092

  View details for PubMedCentralID PMC4265313

• Fear and Reward Circuit Alterations in Pediatric CRPS. Frontiers in human neuroscience Simons, L. E., Erpelding, N., Hernandez, J. M., Serrano, P., Zhang, K., LeBel, A. A., Sethna, N. F., Berde, C. B., Prabhu, S. P., Becerra, L., Borsook, D. 2015; 9: 703-?

  Abstract

  In chronic pain, a number of brain regions involved in emotion (e.g., amygdala, hippocampus, nucleus accumbens, insula, anterior cingulate, and prefrontal cortex) show significant functional and morphometric changes. One phenotypic manifestation of these changes is pain-related fear (PRF). PRF is associated with profoundly altered behavioral adaptations to chronic pain. For example, patients with a neuropathic pain condition known as complex regional pain syndrome (CRPS) often avoid use of and may even neglect the affected body area(s), thus maintaining and likely enhancing PRF. These changes form part of an overall maladaptation to chronic pain. To examine fear-related brain circuit alterations in humans, 20 pediatric patients with CRPS and 20 sex- and age-matched healthy controls underwent functional magnetic resonance imaging (fMRI) in response to a well-established fearful faces paradigm. Despite no significant differences on self-reported emotional valence and arousal between the two groups, CRPS patients displayed a diminished response to fearful faces in regions associated with emotional processing compared to healthy controls. Additionally, increased PRF levels were associated with decreased activity in a number of brain regions including the right amygdala, insula, putamen, and caudate. Blunted activation in patients suggests that (a) individuals with chronic pain may have deficits in cognitive-affective brain circuits that may represent an underlying vulnerability or consequence to the chronic pain state; and (b) fear of pain may contribute and/or maintain these brain alterations. Our results shed new light on altered affective circuits in patients with chronic pain and identify PRF as a potentially important treatment target.

  View details for DOI 10.3389/fnhum.2015.00703

  View details for PubMedID 26834606

  View details for PubMedCentralID PMC4717323

• Parents--to help or hinder pain memories in children. Pain Simons, L. E., Sieberg, C. B. 2015; 156 (5): 761–62

  View details for PubMedID 25734996

  View details for PubMedCentralID PMC4405457

• Fear of pain in pediatric headache CEPHALALGIA Simons, L. E., Pielech, M., Cappucci, S., Lebel, A. 2015; 35 (1): 36-44

  Abstract

  The current study provides the first measure of pain-related fear for pediatric headache patients.From a large pediatric headache clinic, a cross-sectional cohort of 206 children and adolescents completed measures of pain-related fear, anxiety sensitivity, catastrophizing, pain acceptance, functional disability, and school functioning.The two-factor solution of the Fear of Pain Questionnaire (FOPQ) was confirmed from the originally derived structure with pediatric headache patients. Simultaneously regressing FOPQ subscales fear of pain and activity avoidance on theorized construct validity measures demonstrated that fear of pain was more closely linked with anxiety sensitivity and pain catastrophizing while activity avoidance had a strong negative association with pain acceptance (activity engagement and pain willingness). Pain-related fear was not significantly associated with pain level. After controlling for demographic factors and pain, fear of pain and activity avoidance accounted for an additional 26% of the variance in functional disability and school functioning outcomes, with activity avoidance accounting for much of this relationship.Although typically considered an influential construct among musculoskeletal patients, pain-related fear is also an important factor influencing functioning among pediatric headache patients, with the dimension of activity avoidance particularly salient.

  View details for DOI 10.1177/0333102414534084

  View details for Web of Science ID 000346208200004

  View details for PubMedID 24812036

  View details for PubMedCentralID PMC4224998

• Perspectives on the clinical significance of functional pain syndromes in children JOURNAL OF PAIN RESEARCH Basch, M. C., Chow, E. T., Logan, D. E., Schechter, N. L., Simons, L. E. 2015; 8: 675-686

  Abstract

  Functional pain syndromes (FPS) characterize a subset of individuals who experience pain and related symptoms and disability without clear structural or disease etiology. In the pediatric population, FPS hold high clinical importance due to significant prevalence rates and potential to persist into adulthood. Although extensive research has been executed to disambiguate FPS, the syndromes that fall within its spectrum remain conceptually complex and sometimes ill-defined. This paper provides an overview of available research on the classification and multifaceted etiology of FPS in youth and their effects on interpersonal, psychological, and familial function. Vital aspects of a successful multidisciplinary approach to treating this population are described; however, it is evident that future research requires more longitudinal studies.

  View details for DOI 10.2147/JPR.S55586

  View details for Web of Science ID 000364721900001

  View details for PubMedID 26504406

  View details for PubMedCentralID PMC4605245

• Pain catastrophizing in children with chronic pain and their parents: proposed clinical reference points and reexamination of the Pain Catastrophizing Scale measure. Pain Pielech, M., Ryan, M., Logan, D., Kaczynski, K., White, M. T., Simons, L. E. 2014; 155 (11): 2360-2367

  Abstract

  The current study aimed to validate the child and parent pain catastrophizing scale in a large chronic pain sample and to identify child pain catastrophizing clinical reference points. Patients and parents (n=697) evaluated at a pediatric pain program completed the Pain Catastrophizing Scale, child (PCS-C) and parent (PCS-P) reports, along with additional measures of psychological functioning. The measure's psychometric properties were examined, as were relations across demographic, pain, and psychological characteristics and pain catastrophizing. Clinical reference points were identified for the PCS-C from differences in pain catastrophizing across levels of disability, depressive symptoms, and anxiety. Overall, we did not find support for the hypothesized 3-dimension structure, and we recommend potentially removing items 7 and 8 for both the PCS-P and PCS-C as a result of floor/ceiling effects. The 11-item PCS-C is most parsimonious as a unitary construct, while the 11-item PCS-P comprises 2 factors. Although parent catastrophizing was significantly associated with child outcomes after controlling for pain level, it was no longer significant when accounting for child catastrophizing. When comparing PCS-C scores based on child outcomes, significant differences emerged for low, moderate, and high catastrophizing levels. It appears that the influence of parent catastrophizing on outcomes can be explained through its impact on child catastrophizing levels. PCS-C reference points derived from this large sample can aid clinicians in assessment and treatment planning, in turn increasing the utility of the PCS-C for both clinical and research purposes.

  View details for DOI 10.1016/j.pain.2014.08.035

  View details for PubMedID 25180013

  View details for PubMedCentralID PMC4253605

• Pain catastrophizing in children with chronic pain and their parents: Proposed clinical reference points and reexamination of the PCS measure PAIN Pielech, M., Ryan, M., Logan, D., Kaczynski, K., White, M. T., Simons, L. E. 2014; 155 (11): 2360-2367

  Abstract

  The current study aimed to validate the child and parent pain catastrophizing scale in a large chronic pain sample and to identify child pain catastrophizing clinical reference points. Patients and parents (n=697) evaluated at a pediatric pain program completed the Pain Catastrophizing Scale, child (PCS-C) and parent (PCS-P) reports, along with additional measures of psychological functioning. The measure's psychometric properties were examined, as were relations across demographic, pain, and psychological characteristics and pain catastrophizing. Clinical reference points were identified for the PCS-C from differences in pain catastrophizing across levels of disability, depressive symptoms, and anxiety. Overall, we did not find support for the hypothesized 3-dimension structure, and we recommend potentially removing items 7 and 8 for both the PCS-P and PCS-C as a result of floor/ceiling effects. The 11-item PCS-C is most parsimonious as a unitary construct, while the 11-item PCS-P comprises 2 factors. Although parent catastrophizing was significantly associated with child outcomes after controlling for pain level, it was no longer significant when accounting for child catastrophizing. When comparing PCS-C scores based on child outcomes, significant differences emerged for low, moderate, and high catastrophizing levels. It appears that the influence of parent catastrophizing on outcomes can be explained through its impact on child catastrophizing levels. PCS-C reference points derived from this large sample can aid clinicians in assessment and treatment planning, in turn increasing the utility of the PCS-C for both clinical and research purposes.

  View details for DOI 10.1016/j.pain.2014.08.035

  View details for Web of Science ID 000345413400018

  View details for PubMedCentralID PMC4253605

• The responsive amygdala: Treatment-induced alterations in functional connectivity in pediatric complex regional pain syndrome PAIN Simons, L. E., PIELECH, M., Erpelding, N., Linnman, C., Moulton, E., Sava, S., Lebel, A., Serrano, P., Sethna, N., Berde, C., Becerra, L., Borsook, D. 2014; 155 (9): 1727-1742

  Abstract

  The amygdala is a key brain region with efferent and afferent neural connections that involve complex behaviors such as pain, reward, fear, and anxiety. This study evaluated resting state functional connectivity of the amygdala with cortical and subcortical regions in a group of chronic pain patients (pediatric complex regional pain syndrome) with age-sex matched control subjects before and after intensive physical-biobehavioral pain treatment. Our main findings include (1) enhanced functional connectivity from the amygdala to multiple cortical, subcortical, and cerebellar regions in patients compared with control subjects, with differences predominantly in the left amygdala in the pretreated condition (disease state); (2) dampened hyperconnectivity from the left amygdala to the motor cortex, parietal lobe, and cingulate cortex after intensive pain rehabilitation treatment within patients with nominal differences observed among healthy control subjects from time 1 to time 2 (treatment effects); (3) functional connectivity to several regions key to fear circuitry (prefrontal cortex, bilateral middle temporal lobe, bilateral cingulate, hippocampus) correlated with higher pain-related fear scores; and (4) decreases in pain-related fear associated with decreased connectivity between the amygdala and the motor and somatosensory cortex, cingulate, and frontal areas. Our data suggest that there are rapid changes in amygdala connectivity after an aggressive treatment program in children with chronic pain and intrinsic amygdala functional connectivity activity serving as a potential indicator of treatment response.

  View details for DOI 10.1016/j.pain.2014.05.023

  View details for Web of Science ID 000341873000009

  View details for PubMedID 24861582

  View details for PubMedCentralID PMC4157948

• Longitudinal Stability of Specific Barriers to Medication Adherence JOURNAL OF PEDIATRIC PSYCHOLOGY Lee, J. L., Eaton, C., Gutierrez-Colina, A. M., Devine, K., Simons, L. E., Mee, L., Blount, R. L. 2014; 39 (7): 667-676

  Abstract

  Higher levels of barriers are related to lower medication adherence and negative medical outcomes in pediatric transplant recipients. Although total number of barriers appears to be stable over time, it is unclear whether the same is true for specific barriers. This study examined the frequency of endorsement and the stability of specific barriers over 18 months.Participants included 63 parents and 51 adolescents and young adults. Transplant types included 39 kidneys, 16 livers, 10 hearts, and 1 double lung. Participants completed measures of perceived barriers to adherence at Time 1 (T1) and Time 2 (T2).The majority of parent- and adolescent-reported specific barriers showed a positive relationship from T1 to T2. Few specific barriers showed significant differences in the level of endorsement between time points.Specific barriers to medication adherence tend to be stable over time. Patients' specific barriers appear unlikely to change without targeted intervention.

  View details for DOI 10.1093/jpepsy/jsu026

  View details for Web of Science ID 000339919200001

  View details for PubMedID 24824613

• The Interplay of Pain-Related Self-Efficacy and Fear on Functional Outcomes Among Youth With Headache JOURNAL OF PAIN Carpino, E., Segal, S., Logan, D., Lebel, A., Simons, L. E. 2014; 15 (5): 527-534

  Abstract

  Pain-related self-efficacy and pain-related fear have been proposed as opposing predictors of pain-related functional outcomes in youth with chronic pain. Self-efficacy is a potential resiliency factor that can mitigate the influence that pain-related fear has on outcomes in youth with chronic pain. Drawing from theoretical assertions tested among adults with chronic pain, this study aimed to determine whether pain-related self-efficacy mediates the adverse influence of pain-related fear on functional outcomes in a sample of youth with chronic headache. In a cross-sectional design of 199 youth with headache, self-efficacy was strongly associated with fear, disability, school impairment, and depressive symptoms. Pain intensity and self-efficacy were only modestly related, indicating that level of pain has less influence on one's confidence functioning with pain. Self-efficacy partially mediated relationships between pain-related fear and both functional disability and school functioning but did not mediate the relationship between pain-related fear and depressive symptoms. These results suggest that confidence in the ability to function despite pain and fear avoidance each uniquely contributes to pain-related outcomes in youth with chronic headache. These results further suggest that treatment for chronic headache in youth must focus not only on decreasing pain-related fear but also on enhancing a patient's pain-related self-efficacy.Pain-related self-efficacy is an important resiliency factor impacting the influence of pain-related fear on functional disability and school functioning in youth with headache. Enhancing self-efficacy may be a key mechanism for improving behavioral outcomes. Clinicians can reduce pain-related fear and enhance pain-related self-efficacy through interventions that encourage accomplishment and self-confidence.

  View details for DOI 10.1016/j.jpain.2014.01.493

  View details for Web of Science ID 000335711700008

  View details for PubMedID 24462790

  View details for PubMedCentralID PMC4012017

• The Human Amygdala and Pain: Evidence From Neuroimaging HUMAN BRAIN MAPPING Simons, L. E., Moulton, E. A., Linnman, C., Carpino, E., Becerra, L., Borsook, D. 2014; 35 (2): 527-538

  Abstract

  The amygdala, a small deep brain structure involved in behavioral processing through interactions with other brain regions, has garnered increased attention in recent years in relation to pain processing. As pain is a multidimensional experience that encompasses physical sensation, affect, and cognition, the amygdala is well suited to play a part in this process. Multiple neuroimaging studies of pain in humans have reported activation in the amygdala. Here, we summarize these studies by performing a coordinate-based meta-analysis within experimentally induced and clinical pain studies using an activation likelihood estimate analysis. The results are presented in relation to locations of peak activation within and outside of amygdala subregions. The majority of studies identified coordinates consistent with human amygdala cytoarchitecture indicating reproducibility in neuroanatomical labeling across labs, analysis methods, and imaging modalities. Differences were noted between healthy and clinical pain studies: in clinical pain studies, peak activation was located in the laterobasal region, suggestive of the cognitive-affective overlay present among individuals suffering from chronic pain; while the less understood superficial region of the amygdala was prominent among experimental pain studies. Taken together, these findings suggest several important directions for further research exploring the amygdala's role in pain processing.

  View details for DOI 10.1002/hbm.22199

  View details for Web of Science ID 000329532400017

  View details for PubMedID 23097300

  View details for PubMedCentralID PMC3920543

• Intrinsic brain networks normalize with treatment in pediatric complex regional pain syndrome NEUROIMAGE-CLINICAL Becerra, L., Sava, S., Simons, L. E., Drosos, A. M., Sethna, N., Berde, C., LeBel, A. A., Borsook, D. 2014; 6: 347-369

  Abstract

  Pediatric complex regional pain syndrome (P-CRPS) offers a unique model of chronic neuropathic pain as it either resolves spontaneously or through therapeutic interventions in most patients. Here we evaluated brain changes in well-characterized children and adolescents with P-CRPS by measuring resting state networks before and following a brief (median = 3 weeks) but intensive physical and psychological treatment program, and compared them to matched healthy controls. Differences in intrinsic brain networks were observed in P-CRPS compared to controls before treatment (disease state) with the most prominent differences in the fronto-parietal, salience, default mode, central executive, and sensorimotor networks. Following treatment, behavioral measures demonstrated a reduction of symptoms and improvement of physical state (pain levels and motor functioning). Correlation of network connectivities with spontaneous pain measures pre- and post-treatment indicated concomitant reductions in connectivity in salience, central executive, default mode and sensorimotor networks (treatment effects). These results suggest a rapid alteration in global brain networks with treatment and provide a venue to assess brain changes in CRPS pre- and post-treatment, and to evaluate therapeutic effects.

  View details for DOI 10.1016/j.nicl.2014.07.012

  View details for Web of Science ID 000349668500040

  View details for PubMedID 25379449

  View details for PubMedCentralID PMC4218937

• Habenula functional resting-state connectivity in pediatric CRPS JOURNAL OF NEUROPHYSIOLOGY Erpelding, N., Sava, S., Simons, L. E., Lebel, A., Serrano, P., Becerra, L., Borsook, D. 2014; 111 (2): 239-247

  Abstract

  The habenula (Hb) is a small brain structure located in the posterior end of the medial dorsal thalamus and through medial (MHb) and lateral (LHb) Hb connections, it acts as a conduit of information between forebrain and brainstem structures. The role of the Hb in pain processing is well documented in animals and recently also in acute experimental pain in humans. However, its function remains unknown in chronic pain disorders. Here, we investigated Hb resting-state functional connectivity (rsFC) in patients with complex regional pain syndrome (CRPS) compared with healthy controls. Twelve pediatric patients with unilateral lower-extremity CRPS (9 females; 10-17 yr) and 12 age- and sex-matched healthy controls provided informed consent to participate in the study. In healthy controls, Hb functional connections largely overlapped with previously described anatomical connections in cortical, subcortical, and brainstem structures. Compared with controls, patients exhibited an overall Hb rsFC reduction with the rest of the brain and, specifically, with the anterior midcingulate cortex, dorsolateral prefrontal cortex, supplementary motor cortex, primary motor cortex, and premotor cortex. Our results suggest that Hb rsFC parallels anatomical Hb connections in the healthy state and that overall Hb rsFC is reduced in patients, particularly connections with forebrain areas. Patients' decreased Hb rsFC to brain regions implicated in motor, affective, cognitive, and pain inhibitory/modulatory processes may contribute to their symptomatology.

  View details for DOI 10.1152/jn.00405.2013

  View details for Web of Science ID 000329922600002

  View details for PubMedID 24155006

  View details for PubMedCentralID PMC3921385

• Pain Prevalence and Trajectories Following Pediatric Spinal Fusion Surgery JOURNAL OF PAIN Sieberg, C. B., Simons, L. E., Edelstein, M. R., Deangelis, M. R., Pielech, M., Sethna, N., Hresko, M. T. 2013; 14 (12): 1694-1702

  Abstract

  Factors contributing to pain following surgery are poorly understood, with previous research largely focused on adults. With approximately 6 million children undergoing surgery each year, there is a need to study pediatric persistent postsurgical pain. The present study includes patients with adolescent idiopathic scoliosis undergoing spinal fusion surgery enrolled in a prospective, multicentered registry examining postsurgical outcomes. The Scoliosis Research Society Questionnaire-Version 30, which includes pain, activity, mental health, and self-image subscales, was administered to 190 patients prior to surgery and at 1 and 2 years postsurgery. A subset (n = 77) completed 5-year postsurgery data. Pain prevalence at each time point and longitudinal trajectories of pain outcomes derived from SAS PROC TRAJ were examined using analyses of variance and post hoc pairwise analyses across groups. Thirty-five percent of patients reported pain in the moderate to severe range presurgery. One year postoperation, 11% reported pain in this range, whereas 15% reported pain at 2 years postsurgery. At 5 years postsurgery, 15% of patients reported pain in the moderate to severe range. Among the 5 empirically derived pain trajectories, there were significant differences on self-image, mental health, and age. Identifying predictors of poor long-term outcomes in children with postsurgical pain may prevent the development of chronic pain into adulthood.This investigation explores the prevalence of pediatric pain following surgery, up to 5 years after spinal fusion surgery. Five pain trajectories were identified and were distinguishable on presurgical characteristics of age, mental health, and self-image. This is the largest study to examine longitudinal pediatric pain trajectories after surgery.

  View details for DOI 10.1016/j.jpain.2013.09.005

  View details for Web of Science ID 000328519800016

  View details for PubMedID 24290449

  View details for PubMedCentralID PMC3873090

• Connecting parents of children with chronic pain through art therapy. Clinical practice in pediatric psychology Pielech, M., Sieberg, C. B., Simons, L. E. 2013; 1 (3): 214-226

  Abstract

  To help address the unique needs of parents of children with chronic pain, a four module, parent-only, group art therapy curriculum was designed and implemented within an interdisciplinary pain rehabilitation treatment program. We evaluated perceived satisfaction and helpfulness of the group intervention.Fifty-three parents of children experiencing chronic pain enrolled in a day hospital interdisciplinary pain rehabilitation program participated. The voluntary parent art therapy group was offered one time per week for one hour. Participants completed a measure of satisfaction, helpfulness, and perceived social support at the end of each group session.Parents enjoyed participating in the group, agreed that they would try art therapy again, and found it to be a helpful, supportive, and validating experience.Initial results are promising that group art therapy is an appropriate and helpful means of supporting parents of children with chronic pain during interdisciplinary pain rehabilitation.

  View details for PubMedID 24563827

• Health-Related Quality of Life and Perceived Need for Mental Health Services in Adolescent Solid Organ Transplant Recipients JOURNAL OF CLINICAL PSYCHOLOGY IN MEDICAL SETTINGS Reed-Knight, B., Loiselle, K. A., Devine, K. A., Simons, L. E., Mee, L. L., Blount, R. L. 2013; 20 (1): 88-96

  Abstract

  The purpose of the current investigation was to assess interest in mental health services among parents of adolescent solid organ transplant recipients and the relationship between parent perceived need for mental health services and patient health-related quality of life (HRQOL). Sixty-three parents rated interest in receiving 10 mental health services, and patient HRQOL ratings were gathered from adolescent transplant recipients and their parents. Ninety-four percent of parents expressed some level of interest in at least one of the proposed services, with over 40 % indicating maximum interest. Parents' perceived need for mental health services was inversely related to adolescent and parent reports of HRQOL on the behavior, mental health, family cohesion, and parental impact-emotional domains. Results suggest that parents of adolescent solid organ transplant recipients are interested in receiving mental health services for their families. Assessment of need for mental health services and HRQOL may inform the medical team of families requiring intervention.

  View details for DOI 10.1007/s10880-012-9303-6

  View details for Web of Science ID 000316228500011

  View details for PubMedID 22581075

  View details for PubMedCentralID PMC3916010

• What Does It Take? Comparing Intensive Rehabilitation to Outpatient Treatment for Children With Significant Pain-Related Disability JOURNAL OF PEDIATRIC PSYCHOLOGY Simons, L. E., Sieberg, C. B., Pielech, M., Conroy, C., Logan, D. E. 2013; 38 (2): 213-223

  Abstract

  This study compared outcomes between day hospital pain rehabilitation patients and patients engaged in outpatient multidisciplinary pain treatment.This study included 100 children who presented for an initial tertiary care pain clinic evaluation. 50 patients enrolled in intensive day hospital pain rehabilitation and 50 patients pursued outpatient multidisciplinary treatment. Across 2 time points, children completed measures of functional disability, pain-related fear, and readiness to change and parents completed measures of pain-related fear and readiness to change.Across both treatment modalities, patients and parents reported improvements. Patients enrolled in intensive pain rehabilitation had significantly larger improvements in functional disability, pain-related fear, and readiness to change. Parents of day hospital patients reported larger declines in child pain-related fear and increased readiness to change compared with their outpatient counterparts. Discussion For patients with high levels of pain-related disability and distress, intensive pain rehabilitation provides rapid, dramatic improvements in functioning.

  View details for DOI 10.1093/jpepsy/jss109

  View details for Web of Science ID 000315417800011

  View details for PubMedID 23104827

  View details for PubMedCentralID PMC3695659

• Patients with pain are not all the same: considering fear of pain and other individual factors in treatment. Pain management Simons, L. E., Sieberg, C. B., Coakley, R. M. 2013; 3 (2): 87-89

  View details for DOI 10.2217/pmt.12.85

  View details for PubMedID 24645990

  View details for PubMedCentralID PMC4060630

• Growing Up in the Society of Pediatric Psychology: Reflections of an Early Career Psychologist JOURNAL OF PEDIATRIC PSYCHOLOGY Simons, L. E. 2013; 38 (2): 132-134

  View details for DOI 10.1093/jpepsy/jss121

  View details for Web of Science ID 000315417800003

  View details for PubMedID 23241351

  View details for PubMedCentralID PMC3695660

• Fear of Pain in the Context of Intensive Pain Rehabilitation Among Children and Adolescents With Neuropathic Pain: Associations With Treatment Response JOURNAL OF PAIN Simons, L. E., Kaczynski, K. J., Conroy, C., Logan, D. E. 2012; 13 (12): 1151-1161

  Abstract

  Recent research has implicated pain-related fear in relation to functional outcomes in children with chronic pain. The current study examined fear of pain, disability, and depression within the context of an intensive pain rehabilitation program. One hundred forty-five children and adolescents who participated in an intensive interdisciplinary pediatric pain rehabilitation day program were assessed in this study. Patients completed measures of pain intensity, pain-related fears, functional disability, and depressive symptoms at admission, discharge, and on average, 2 months postdischarge. After controlling for pain intensity, pain-related fear was significantly related to disability and depressive symptoms at all time points. As predicted, a decline in pain-related fear was significantly associated with a decrease in disability and depressive symptoms. Interestingly, high levels of pain-related fears at admission predicted less reduction in functional disability and depression at discharge, suggesting that high levels of pain-related fear may be a risk factor in relation to treatment outcomes. Overall, results indicate that the relationship between fear of pain and changes in disability and depressive symptoms are closely linked, with fear of pain playing an important role in treatment.This paper presents results underscoring the importance of pain-related fear in relation to treatment response for children and adolescents with chronic pain. These findings support the need to develop and implement interventions that target reductions in pain-related fear.

  View details for DOI 10.1016/j.jpain.2012.08.007

  View details for Web of Science ID 000312280200002

  View details for PubMedID 23085089

  View details for PubMedCentralID PMC3508158

• A Day-hospital Approach to Treatment of Pediatric Complex Regional Pain Syndrome Initial Functional Outcomes CLINICAL JOURNAL OF PAIN Logan, D. E., Carpino, E. A., Chiang, G., Condon, M., Firn, E., Gaughan, V. J., Hogan, M., Leslie, D. S., Olson, K., Sager, S., Sethna, N., Simons, L. E., Zurakowski, D., Berde, C. B. 2012; 28 (9): 766-774

  Abstract

  To examine clinical outcomes of an interdisciplinary day-hospital treatment program (comprised of physical, occupational, and cognitive-behavioral therapies with medical and nursing services) for pediatric complex regional pain syndrome (CRPS).The study is a longitudinal case series of consecutive patients treated in a day-hospital pediatric pain rehabilitation program. Participants were 56 children and adolescents with ages 8 to 18 years (median=14 y) with CRPS spectrum conditions who failed to progress sufficiently with a previous outpatient and/or inpatient treatments. Patients participated in daily physical therapy, occupational therapy, and psychological treatment and received nursing and medical care as necessary. The model places equal emphasis on physical and cognitive-behavioral approaches to pain management. Median duration of stay was 3 weeks. Outcome measures included assessments of physical, occupational, and psychological functioning at program admission, discharge, and at posttreatment follow-up at a median of 10 months after discharge. Scores at discharge and follow-up were compared with measures on admission by Wilcoxon tests, paired t tests, or analysis of variance as appropriate, with corrections for multiple comparisons.Outcomes demonstrate clinically and statistically significant improvements from admission to discharge in pain intensity (P<0.001), functional disability (P<0.001), subjective report of limb function (P<0.001), timed running (P<0.001), occupational performance (P<0.001), medication use (P<0.01), use of assistive devices (P<0.001), and emotional functioning (anxiety, P<0.001; depression, P<0.01). Functional gains were maintained or further improved at follow-up.A day-hospital interdisciplinary rehabilitation approach seems effective in reducing disability and improving physical and emotional functioning and occupational performance among children and adolescents with CRPSs that have failed to improve with outpatient treatment.

  View details for DOI 10.1097/AJP.0b013e3182457619

  View details for Web of Science ID 000309658500003

  View details for PubMedID 22688602

  View details for PubMedCentralID PMC3884573

• The Fear Avoidance Model of Chronic Pain: Examination for Pediatric Application JOURNAL OF PAIN Simons, L. E., Kaczynski, K. J. 2012; 13 (9): 827-835

  Abstract

  The current study examined the Fear Avoidance (FA) model of chronic pain in pediatric chronic pain patients. Multiple structural equation models were tested in the current study with pairwise parameter comparisons made between younger children (8-12 years) and adolescents (13-17 years). Within a sample of 350 children and adolescents, we examined functional disability and depressive symptoms in separate models with the following predictor variables-pain, pain catastrophizing, fear of pain, and avoidance of activities-after controlling for duration of pain. For a subset of patients (n = 151), we also tested a brief prospective outcome model with baseline predictor variables and functional disability at 1-month follow-up. The FA models predicting functional disability concurrently and prospectively were an excellent fit to the data. The theorized FA model for depression was a poor fit. When the model was modified to include direct pathways from the cognitive processes of pain catastrophizing and fear of pain to depressive symptoms, the model fit was significantly improved. In the examination of developmental differences between younger children and adolescent patients, duration of pain contributed to the model for younger children, whereas pain-related fears were more influential for adolescent patients.The FA model of chronic pain appears to be applicable for pediatric patients with some modification to account for developmental differences across childhood. We discuss the developmental, theoretical, and clinical implications of these results.

  View details for DOI 10.1016/j.jpain.2012.05.002

  View details for Web of Science ID 000309034400002

  View details for PubMedID 22832693

  View details for PubMedCentralID PMC3438388

• Changes in willingness to self-manage pain among children and adolescents and their parents enrolled in an intensive interdisciplinary pediatric pain treatment program PAIN Logan, D. E., Conroy, C., Sieberg, C. B., Simons, L. E. 2012; 153 (9): 1863-1870

  Abstract

  The importance of willingness to adopt a self-management approach to chronic pain has been demonstrated in the context of cognitive-behaviorally oriented interdisciplinary pain treatment programs for adults, both as a treatment outcome and as a process that facilitates functional improvements. Willingness to self-manage pain has not been studied in pediatric interdisciplinary pain treatment settings. Study aims were (1) to investigate willingness to self-manage pain among children and parents undergoing intensive interdisciplinary pain treatment and (2) to determine whether increased willingness to self-manage pain influenced functional treatment outcomes. A total of 157 children ages 10 to 18 and their parents enrolled in a pediatric pain rehabilitation program completed the Pain Stages of Change Questionnaire (PSOCQ youth and parent versions) at pretreatment, posttreatment, and short-term follow-up. They also reported on pain, functional disability, depressive symptoms, fear of pain, and use of passive and accommodative coping strategies. Results show that willingness to self-manage pain increased during treatment among both children and parents, with gains maintained at follow-up. Increases in children's readiness to self-manage pain from pretreatment to posttreatment were associated with decreases in functional disability, depressive symptoms, fear of pain, and use of adaptive coping strategies. Increases in parents' readiness to adopt a pain self-management approach were associated with changes in parent-reported fear of pain but not with other child outcomes. Few associations emerged between pretreatment willingness to self-manage pain and posttreatment outcomes. Findings suggest that interdisciplinary pediatric pain rehabilitation may facilitate increased willingness to self-manage pain, which is associated with improvements in function and psychological well-being.

  View details for DOI 10.1016/j.pain.2012.05.027

  View details for Web of Science ID 000307299500016

  View details for PubMedID 22749194

  View details for PubMedCentralID PMC3884572

• Anxiety and functional disability in a large sample of children and adolescents with chronic pain PAIN RESEARCH & MANAGEMENT Simons, L. E., Sieberg, C. B., Claar, R. L. 2012; 17 (2): 93-97

  Abstract

  Anxiety is the most common psychiatric condition in children and adolescents, and is linked to significant disruptions across domains of function. Due to the avoidant nature of anxiety and pain-related disability, studying anxiety symptoms in children with chronic and recurrent pain conditions is important.To examine anxiety symptoms in a large cohort of children and adolescents evaluated for complex chronic and recurrent pain conditions.Through retrospective chart review, data on anxiety, pain and functional disability were collected from 655 children evaluated at a multidisciplinary pain clinic over a three-year period.Approximately 11% of children and adolescents reported clinically elevated anxiety symptoms, with elevated levels across dimensions of anxiety ranging from 14% (social anxiety, worry) to 27% (physiological). In addition, a notable 31% of the sample potentially minimized their anxiety by responding in a socially desirable manner. Anxiety was linearly associated with greater pain-related functional disability, but was not directly correlated with pain. Moderation analyses revealed that at low levels of worry, higher levels of pain were associated with greater functional disability, whereas at high levels of worry, pain no longer predicted the level of functional disability.These findings document the prevalence of anxiety in children and adolescents with chronic pain, and also extend recent studies examining the complex relationships among pain, anxiety and pain-related disability.

  View details for Web of Science ID 000302480400005

  View details for PubMedID 22518371

• Too sick for school? Parent influences on school functioning among children with chronic pain PAIN Logan, D. E., Simons, L. E., Carpino, E. A. 2012; 153 (2): 437-443

  Abstract

  Parental responses to children with chronic pain have been shown to influence the extent of the child's functional disability, but these associations have not been well studied in relation to children's pain-related school functioning. The current study tests the hypothesis that parental pain catastrophizing and parental protective responses to child pain influence the extent of school impairment in children with chronic pain. A mediational model was tested to determine whether parental protective behaviors serve a mediating role between parental pain catastrophizing and child school impairment. Study participants were a clinical sample of 350 children ages 8-17 years with chronic pain and their parents. Measures of pain characteristics, demographic characteristics, child depressive symptoms, school attendance rates, overall school functioning, parental pain catastrophizing, and parental protective responses to pain were collected. Results show that, controlling for the known influences of pain intensity and child depressive symptoms, parental pain catastrophizing and parental protective responses to child pain each independently predict child school attendance rates and reports of overall school impairment. Parental protectiveness was found to mediate the association between parental cognitions (i.e., parent pain catastrophizing) and child school functioning outcomes. These findings underscore the importance of intervening with parents to foster parental responses to child pain that help children engage and succeed in the school environment despite pain.

  View details for DOI 10.1016/j.pain.2011.11.004

  View details for Web of Science ID 000299319800026

  View details for PubMedID 22169177

  View details for PubMedCentralID PMC3884564

• Do Parent Protective Responses Mediate the Relation Between Parent Distress and Child Functional Disability Among Children With Chronic Pain? JOURNAL OF PEDIATRIC PSYCHOLOGY Sieberg, C. B., Williams, S., Simons, L. E. 2011; 36 (9): 1043-1051

  Abstract

  To examine whether protective parent responses mediate the relation between parent distress and child functioning.At a pain clinic evaluation, 157 families participated. Parents completed measures of global distress (BSI-18), distress in the context of their child's pain (BAP-PIQ), and protective responses to their child's pain. Children completed measures of functional disability and pain.BAP-PIQ subscales were significantly associated with child functional disability, whereas BSI subscales were unrelated. Protective parent responses partially mediated the relation between parent distress and child functional disability for depression, anxiety, and catastrophizing. However, parent protective behavior fully mediated the relationship between parent helplessness and child functional disability, indicating that feelings of parent helplessness did not uniquely contribute to child functional disability. Discussion Results suggest that when treating youth with chronic pain, parental distress in the context of children's pain needs to be addressed.

  View details for DOI 10.1093/jpepsy/jsr043

  View details for Web of Science ID 000295804600009

  View details for PubMedID 21742755

• Measuring parent beliefs about child acceptance of pain: A preliminary validation of the Chronic Pain Acceptance Questionnaire, parent report PAIN Simons, L. E., Sieberg, C. B., Kaczynski, K. J. 2011; 152 (10): 2294-2300

  Abstract

  Parent perceptions of and responses to pain have been identified as important factors in understanding pain-related disability among children and adolescents with chronic pain. The ability to accept chronic pain rather than focus on ways to avoid or control it has been linked to positive outcomes in chronic pain research. To examine parent beliefs about child acceptance of pain, the Chronic Pain Acceptance Questionnaire, parent report (CPAQ-P), was developed and administered to 195 parents of children with persistent pain evaluated in a multidisciplinary pain clinic. Analyses support the internal consistency of the CPAQ-P (α=.89) and 1-month stability estimates were acceptable for the total scale score (α=.72), and results suggest some responsivity to change. Exploratory factor analysis identified a 2-factor model with 4 items removed from the original 20-item measure. Confirmatory factor analysis strongly supported the modified version. For construct validity, parent beliefs about child acceptance were negatively correlated with parent pain catastrophizing and parent fear of pain. Greater acceptance was also negatively associated with protective parent responses to pain. These results support the CPAQ-P as a promising measure for assessing parent beliefs about child acceptance of pain and reinforce the importance of the social context and parental influence on child functioning.

  View details for DOI 10.1016/j.pain.2011.06.018

  View details for Web of Science ID 000295213700020

  View details for PubMedID 21783324

  View details for PubMedCentralID PMC3557831

• Readiness to change in pediatric chronic pain: Initial validation of adolescent and parent versions of the Pain Stages of Change Questionnaire PAIN Guite, J. W., Logan, D. E., Simons, L. E., Blood, E. A., Kerns, R. D. 2011; 152 (10): 2301-2311

  Abstract

  Despite the clinical importance of readiness to change in predicting treatment outcomes among adults, no studies have examined this construct among pediatric pain patients. Because parents play a key role in adolescent pain management, both adolescent and parent readiness to adopt a self-management approach to pain merit further study. The primary goal of the current study was to validate adolescent and parent-report adaptations of the adult Pain Stages of Change Questionnaire (PSOCQ). Participants included 259 adolescent patients with chronic pain syndromes and their parents presenting to 2 pediatric pain management clinics. Using confirmatory factor analytic techniques, a 4-factor solution was supported for the parent version (PSOCQ-P) that included Precontemplation, Contemplation, Action, and Maintenance factors, whereas the adolescent version (PSOCQ-A) version supported a three-factor model that combines the Action and Maintenance scales. Within both versions, each of the factors was found to be internally consistent. The PSOCQ-A and PSOCQ-P showed evidence of criterion validity through significant correlations with coping strategies and pain catastrophizing. Stability findings at 4 and 8 weeks after a multidisciplinary pain clinic evaluation are reported. Associations between pediatric PSOCQ scores and demographic, pain, and functional domains were explored to inform future research. Further validation of the PSOCQ-A and PSOCQ-P measures with new, separate samples of pediatric pain patients and parents are needed before use in clinical contexts.

  View details for DOI 10.1016/j.pain.2011.06.019

  View details for Web of Science ID 000295213700021

  View details for PubMedID 21802852

  View details for PubMedCentralID PMC3222695

• Anxiety, Coping, and Disability: A Test of Mediation in a Pediatric Chronic Pain Sample JOURNAL OF PEDIATRIC PSYCHOLOGY Kaczynski, K. J., Simons, L. E., Claar, R. L. 2011; 36 (8): 932-941

  Abstract

  To evaluate pain coping as a mediator of associations between anxiety and functional disability and anxiety and somatic symptoms in adolescents with chronic pain.Participants (mean age = 14.76 years, range: 12-17 years) included 280 patients (212 girls) with chronic pain who underwent multidisciplinary evaluation at a tertiary pain clinic in a northeast pediatric hospital. Patients completed measures of current pain, anxiety, active, passive, and accommodative pain coping, functional disability, and somatic symptoms.Structural equation modeling was employed. The association between anxiety and disability was fully mediated by passive coping. The association between anxiety and somatic symptoms was not mediated by coping.Links between anxiety symptoms and pain-related outcomes in adolescents with chronic pain are complex. Assessing how an adolescent copes with his/her pain provides further understanding of this relationship.

  View details for DOI 10.1093/jpepsy/jsr024

  View details for Web of Science ID 000294121800010

  View details for PubMedID 21551124

• Predictors of Long-Term Health-Related Quality of Life in Adolescent Solid Organ Transplant Recipients JOURNAL OF PEDIATRIC PSYCHOLOGY Devine, K. A., Reed-Knight, B., Loiselle, K. A., Simons, L. E., Mee, L. L., Blount, R. L. 2011; 36 (8): 891-901

  Abstract

  This study aimed to identify prospective predictors of health-related quality of life (HRQOL) for adolescent solid organ (kidney, liver, heart, lung) transplant recipients.Data regarding demographics, individual/transplant characteristics, and environmental characteristics were gathered from 66 adolescent transplant recipients and their families at baseline and used to predict the physical functioning, mental health, and general health perceptions domains of HRQOL 18 months later.Baseline levels of HRQOL explained the greatest amount of variance in levels of HRQOL at follow-up; however, specific demographic (i.e., income), individual/transplant (i.e., adherence, frequency of rescheduled clinic appointments, and presence of a rejection episode), and environmental factors (i.e., family conflict) contributed to the variance in HRQOL domains beyond baseline levels.This study identified certain modifiable individual and environmental factors and non-modifiable risk factors associated with lower future HRQOL. Transplant centers should begin screening and addressing these factors to potentially improve HRQOL.

  View details for DOI 10.1093/jpepsy/jsr007

  View details for Web of Science ID 000294121800006

  View details for PubMedID 21343144

  View details for PubMedCentralID PMC3935000

• The Fear of Pain Questionnaire (FOPQ): Assessment of Pain-Related Fear Among Children and Adolescents With Chronic Pain JOURNAL OF PAIN Simons, L. E., Sieberg, C. B., Carpino, E., Logan, D., Berde, C. 2011; 12 (6): 677-686

  Abstract

  An important construct in understanding pain-related disability is pain-related fear. Heightened pain-related fear may result in behavioral avoidance leading to disuse, disability, and depression; whereas confrontation of avoided activities may result in a reduction of fear over time and reengagement with activities of daily living. Although there are several measures to assess pain-related fear among adults with chronic pain, none exist for children and adolescents. The aim of the current study was to develop a new tool to assess avoidance and fear of pain with pediatric chronic pain patients: the Fear of Pain Questionnaire, child report (FOPQ-C), and Fear of Pain Questionnaire, parent proxy report (FOPQ-P). After initial pilot testing, the FOPQ-C and FOPQ-P were administered to 299 youth with chronic pain and their parents at an initial multidisciplinary pain treatment evaluation. The FOPQ demonstrated very strong internal consistency of .92 for the child and parent versions. One-month stability estimates were acceptable and suggested responsivity to change. For construct validity, the FOPQ correlated with generalized anxiety, pain catastrophizing, and somatization. Evidence of criterion-related validity was found with significant associations for the FOPQ with pain, healthcare utilization, and functional disability. These results support the FOPQ as a psychometrically sound measure.Pain-related fear plays an important role in relation to emotional distress and pain-related disability among children and adolescents with chronic pain. Identification of patients with high levels of fear avoidance of pain with the FOPQ will inform how to proceed with psychological and physical therapy interventions for chronic pain.

  View details for DOI 10.1016/j.jpain.2010.12.008

  View details for Web of Science ID 000291959100007

  View details for PubMedID 21354866

• Adolescents' pain coping profiles: Expectations for treatment, functional outcomes and adherence to psychological treatment recommendations PAIN RESEARCH & MANAGEMENT Claar, R. L., Simons, L. E. 2011; 16 (3): 192-196

  Abstract

  To explore how adolescents' pain coping profiles relate to their expectations regarding psychological treatment recommendations, and to examine patients' functioning and engagement in psychological treatment three months following a multidisciplinary pain clinic evaluation.Adolescents and their parents completed measures of pain coping strategies, treatment expectations, pain ratings, somatic symptoms, school absences and functional disability. Parents also reported whether patients followed through with psychological treatment recommendations.Adaptive copers and their parents were more likely to expect psychological treatments to be helpful; however, at follow-up, there were no significant group differences in patients' participation in psychological treatment. Patients in both groups experienced significantly lower levels of somatic symptoms and functional disability, and had fewer school absences from the initial evaluation to the follow-up.The results of the present study identify preliminary clinical implications for the way in which practitioners in multidisciplinary pain clinics present recommendations for psychological treatment to patients and their families.

  View details for Web of Science ID 000292042700007

  View details for PubMedID 21766070

• Prospective comparison of parent and adolescent report of health-related quality of life in adolescent solid organ transplant recipients PEDIATRIC TRANSPLANTATION Devine, K. A., Reed-Knight, B., Simons, L. E., Mee, L. L., Blount, R. L. 2010; 14 (8): 1000-1006

  Abstract

  This 18-month prospective investigation sought to examine changes in HRQOL over time for adolescent solid organ transplant recipients. Additionally, this study examined the relationship between adolescent and parent report of HRQOL and compared parent report of HRQOL to published normative data. Forty-eight adolescent-parent dyads completed the CHQ, a measure of HRQOL, at two time periods. Parent and adolescent reports of HRQOL were stable over time. ICCs between parent and adolescent reports were significant and moderate across most domains of HRQOL, with the exception of family cohesion, physical functioning, and bodily pain. However, mean differences indicated that parents perceived significantly worse self-esteem and general health perceptions compared to their adolescents. Compared to normative data, parents reported significantly lower HRQOL across several domains, including adolescents' physical functioning and the emotional impact of their adolescent's condition on themselves. However, parents also reported higher levels of family cohesion. Results indicate that assessment of HRQOL for transplant recipients should include multiple reporters and that HRQOL as reported by adolescents and parents is generally stable over time without intervention. Further research is needed to understand factors related to differential HRQOL outcomes.

  View details for DOI 10.1111/j.1399-3046.2010.01392.x

  View details for Web of Science ID 000285229500011

  View details for PubMedID 20846240

• Medication Barriers Predict Adolescent Transplant Recipients' Adherence and Clinical Outcomes at 18-Month Follow-up JOURNAL OF PEDIATRIC PSYCHOLOGY Simons, L. E., McCormick, M. L., Devine, K., Blount, R. L. 2010; 35 (9): 1038-1048

  Abstract

  To prospectively validate the Parent and Adolescent Medication Barriers Scales (PMBS and AMBS) for assessing perceived barriers to medication adherence in adolescent transplant recipients by examining the relations of perceived barriers to medication adherence and clinical outcomes at 18-month follow-up.Of the 82 adolescent recipients enrolled in the initial cohort, 66 families participated in the follow-up. Relations among barriers, adherence, and clinical outcomes were examined.Reported barriers demonstrated temporal stability over an extended span of time. Adolescent-perceived barriers of Disease Frustration/Adolescent Issues and parent-perceived barriers of Regimen Adaptation/Cognitive Issues were associated with poorer adherence to medication taking at follow-up. Interestingly, medical complications and mortality were significantly associated with both parent and adolescent-perceived ingestion issues barriers.Barriers to adherence are essential to address in an effort to ameliorate adherence difficulties and potentially reduce the incidence of medical complications.

  View details for DOI 10.1093/jpepsy/jsq025

  View details for Web of Science ID 000282843100014

  View details for PubMedID 20410021

• Development of a Group Intervention to Improve School Functioning in Adolescents with Chronic Pain and Depressive Symptoms: A Study of Feasibility and Preliminary Efficacy JOURNAL OF PEDIATRIC PSYCHOLOGY Logan, D. E., Simons, L. E. 2010; 35 (8): 823-836

  Abstract

  To establish feasibility and preliminary efficacy of "Coping with Pain in School" (CPS), an intervention to improve school functioning in adolescents with chronic pain and depressive symptoms.Forty adolescents and parents participated in this uncontrolled trial. Participants completed measures of pain severity, depression, and school attendance at baseline and one month after participating in a manualized group intervention. Several other indicators of school functioning were explored.CPS was generally acceptable and satisfying to families and feasible to implement but participation was low. Post-treatment analyses suggest that pain, some dimensions of depression, and school attendance improved after treatment. Conclusions CPS is feasible and holds promise in terms of its effects on pain and school attendance. Addressing enrollment challenges, refining the role of depression and its treatment, and further developing treatments with a school-functioning focus for adolescents with chronic pain are key areas for continued research.

  View details for DOI 10.1093/jpepsy/jsq008

  View details for Web of Science ID 000281185300004

  View details for PubMedID 20167628

• Engagement in Multidisciplinary Interventions for Pediatric Chronic Pain: Parental Expectations, Barriers, and Child Outcomes CLINICAL JOURNAL OF PAIN Simons, L. E., Logan, D. E., Chastain, L., Cerullo, M. 2010; 26 (4): 291-299

  Abstract

  To examine the adherence to the recommendations of pain treatment among children and adolescents evaluated for a variety of chronic and recurrent pain conditions.Several measures during initial evaluation and after 3 months were collected to assess satisfaction with initial evaluation, adherence to multidisciplinary recommendations, pain ratings, somatic symptoms, functional limitations, and school attendance.Of the 120 patients who initially enrolled in the study, 70 parents and 57 children participated in 3-month follow-up interviews and reported significantly fewer doctor visits, decreased somatic symptoms, fewer functional limitations, and decreased pain compared with their initial evaluation. Adherence to multidisciplinary recommendations ranged from 46.7% to 100% with the highest level of overall adherence to physical therapy. Factors associated with adherence varied across type of recommendation. For medical recommendations, higher parent-reported patient satisfaction and expectations that medical tests would be beneficial were associated with engagement in medical treatment, whereas parent reports of negative attitude-type barriers and experience with surgery were associated with less frequent engagement in recommended treatment. With regard to physical therapy recommendations, only earlier experience with exercise was associated with better adherence. For psychologic recommendations, familiarity with hypnosis and biofeedback in addition to positive expectations regarding psychologic treatment and biofeedback were all associated with subsequent engagement in psychologic treatment. Lastly, we identified modest associations between functional improvements and adherence to specific recommendations.Results of this study support the importance of examining adherence to multidisciplinary interventions among children and adolescents with chronic pain.

  View details for DOI 10.1097/AJP.0b013e3181cf59fb

  View details for Web of Science ID 000277181500004

  View details for PubMedID 20393263

• The Relation of Social Functioning to School Impairment Among Adolescents With Chronic Pain CLINICAL JOURNAL OF PAIN Simons, L. E., Logan, D. E., Chastain, L., Stein, M. 2010; 26 (1): 16-22

  Abstract

  To further our understanding of social functioning in children with chronic pain, and particularly how social functioning relates to school impairment in this population.This study involved 126 adolescents (12 to 17 y) evaluated at a multidisciplinary pain clinic. Adolescents completed measures assessing social functioning, pain, physical limitations, somatic symptoms, and school impairment.Lower social functioning scores were significantly associated with pain, physical limitations, somatic symptoms, and school impairment. Social functioning mediated the relations between adolescents' pain experience (ie, pain, physical symptoms, physical limitations) and school impairment.These findings highlight the importance of assessing and addressing social functioning in youth with chronic pain. Future research targeting school impairment should include evaluating the potential role that peer difficulties may play.

  View details for Web of Science ID 000273116900003

  View details for PubMedID 20026948

• School Functioning in Adolescents With Chronic Pain: The Role of Depressive Symptoms in School Impairment JOURNAL OF PEDIATRIC PSYCHOLOGY Logan, D. E., Simons, L. E., Kaczynski, K. J. 2009; 34 (8): 882-892

  Abstract

  To explore associations between depressive symptoms and school functioning, including school attendance, academic performance, self-perceived academic competence, and teacher-rated school adjustment among predominantly Caucasian and female adolescent chronic pain patients.A total of 217 clinically referred adolescents (aged 12-17 years) and their parents completed measures of pain characteristics, depression, and school functioning. Additional data were collected from school records and teacher reports.Depressive symptoms strongly correlated with school functioning indicators. In linear regression analyses, higher levels of depressive symptoms predicted more school impairment. A model testing whether depressive symptoms mediated the association between current pain intensity and parent perceptions of the interference of pain on school functioning was supported by the data.Depressive symptoms play a key role in influencing the extent of school impairment in adolescents with chronic pain. Interventions to alleviate depressive symptoms may enhance treatments designed to improve school functioning in this population.

  View details for DOI 10.1093/jpepsy/jsn143

  View details for Web of Science ID 000269207800010

  View details for PubMedID 19181819

• Multidimensional Adherence Classification System: Initial development with adolescent transplant recipients PEDIATRIC TRANSPLANTATION Simons, L. E., Gilleland, J., Blount, R. L., Amaral, S., Berg, A., Mee, L. L. 2009; 13 (5): 590-598

  Abstract

  As transplantation has progressively become a more viable option for children with life-threatening illness, ensuring that adolescents do not lose their new organ secondary to medication non-adherence is paramount. The first step to addressing non-adherence is adequate assessment of this construct. In this investigation, we introduce the MACS. The MACS includes self-report and drug assay levels. Self-report is a subjective measure with a low false-positive rate, but is vulnerable to social desirability. Drug assays are an objective measure of drug ingestion, but values suggestive of non-adherence may be influenced by medical complications and timing. The MACS builds on the strengths of both methods and attempts to contain their weaknesses. The sample in this study consisted of 82 adolescent solid organ transplant recipients. The non-adherence rate using the MACS in this sample was 61%. Initial data to support this system are promising. The occurrence of rejection episodes and mortality were significantly related to membership in the Genuinely Non-adherent category. Beyond providing initial support for the MACS, we discuss the clinical implications of this adherence classification system.

  View details for DOI 10.1111/j.1399-3046.2008.01038.x

  View details for Web of Science ID 000267756100014

  View details for PubMedID 18992064

• Parent and patient perspectives on barriers to medication adherence in adolescent transplant recipients PEDIATRIC TRANSPLANTATION Simons, L. E., McCormick, M. L., Mee, L. L., Blount, R. L. 2009; 13 (3): 338-347

  Abstract

  The aim of this study was to identify barriers to medication adherence in adolescent transplant recipients. Eighty adolescent transplant recipient families reported in an open-ended manner about barriers to medication adherence. These responses were then coded to reflect potentially important themes associated with medication adherence. The themes derived included: forgot/distracted, poor planning/scheduling issues, physical barriers/medication issues, and voluntary resistance/attempts to be normal. Inter-rater reliability for barrier coding was very high (k = 0.91). Patients who were classified as non-adherent reported significantly more overall barriers, more forgot/distracted barriers, and more voluntary resistance/attempts to be normal barriers than those classified as adherent. Non-adherence was also found to be more likely when adolescents, as opposed to parents, were responsible for administering the medication. Further, non-adherence was more likely when taking morning rather than evening doses. These findings are explained with an emphasis on potential remedies that directly address the stated barriers.

  View details for DOI 10.1111/j.1399-3046.2008.00940.x

  View details for Web of Science ID 000264891700014

  View details for PubMedID 18433413

• Pain coping profiles in adolescents with chronic pain PAIN Claar, R. L., Baber, K. F., Simons, L. E., Logan, D. E., Walker, L. S. 2008; 140 (2): 368-375

  Abstract

  This study sought to evaluate the extent to which the pain coping profiles observed by Walker and colleagues in a sample of patients with chronic abdominal pain also were evident in a sample of adolescent patients who presented to a tertiary care clinic for evaluation of a variety of diverse pain conditions. In addition, we aimed to evaluate the relation of these pain coping profiles to patients' emotional and physical functioning. Participants (n=254) were adolescent patients aged 12-17 years. Patients completed the Pain Response Inventory (PRI) as well as measures of pain, somatic symptoms, anxiety and depressive symptoms, and functional disability. Using the PRI classification algorithm developed by Walker and colleagues, we successfully classified all the patients in our sample. We also found that the pain coping profiles successfully differentiated among patients with different levels of symptoms, disability, and emotional distress, further demonstrating the external validity of these profiles. Results have implications for tailoring pain treatment interventions to patients' particular coping profiles.

  View details for DOI 10.1016/j.pain.2008.09.007

  View details for Web of Science ID 000261551700013

  View details for PubMedID 18938032

• The Impact of Adult Behaviors and Vocalizations on Infant Distress during Immunizations JOURNAL OF PEDIATRIC PSYCHOLOGY Blount, R. L., Devine, K. A., Cheng, P. S., Simons, L. E., Hayutin, L. 2008; 33 (10): 1163-1174

  Abstract

  The Child-Adult Medical Procedure Interaction Scale-Infant Version (CAMPIS-IV) was used to examine the influence of adult and infant behaviors on infant distress following injections.In this naturalistic observation study, videotaped interactions of 49 infants, parents, and nurses were coded using the CAMPIS-IV. A series of three lag sequential analyses were used to examine the immediate and delayed effects of each of the CAMPIS-IV criterion behaviors, as well as the effects of the onset of each behavior, on infant distress.Strong support was found for beneficial effects of the infants playing with an object and sucking, and for adults' belly-to-belly contact and nonprocedural talk to infant. Some benefit was found for bouncing, patting, and rocking the infant. Apologizing, empathizing, and reassuring the infant received no support, with some indication of detrimental effects.The CAMPIS-IV was useful for identifying modifiable risk and protective factors for infants undergoing injections.

  View details for DOI 10.1093/jpepsy/jsn030

  View details for Web of Science ID 000260557600011

  View details for PubMedID 18375966

• Evidence-based assessment of coping and stress in pediatric psychology JOURNAL OF PEDIATRIC PSYCHOLOGY Blount, R. L., Simons, L. E., Devine, K. A., Jaaniste, T., Cohen, L. L., Chambers, C. T., Hayutin, L. G. 2008; 33 (9): 1021-1045

  Abstract

  To review selected measures of stress and coping in pediatric populations. Stress and coping are presented within a risk and resiliency framework.The Society of Pediatric Psychology (SPP) surveyed the membership to identify the most frequently used assessment instruments. Twelve measures of coping and three measures of stress were reviewed. These instruments were evaluated using the Stress and Coping workgroup's modification of the criteria developed by the SPP Assessment Task Force (SPP-ATF).One of the three measures of stress and five of the 12 measures of coping were Well-established measures that broaden understanding. Additionally, one of the coping measures was categorized as a Well-established measure that guides treatment. Merits of the individual measures are discussed.Recommendations for future research are provided, including suggestions for the construction and use of measures to inform treatment research.

  View details for DOI 10.1093/jpepsy/jsm071

  View details for Web of Science ID 000259329400012

  View details for PubMedID 17938147

  View details for PubMedCentralID PMC2639500

• Chronic pain in adolescence: Parental responses, adolescent coping, and their impact on adolescents pain behaviors JOURNAL OF PEDIATRIC PSYCHOLOGY Simons, L. E., Claar, R. L., Logan, D. L. 2008; 33 (8): 894-904

  Abstract

  The aim of this study was to examine relations among parental responses, adolescent pain coping, and pain behaviors in adolescents with chronic pain.This study included 217 adolescents (12-17 years) evaluated at a multidisciplinary pain clinic and their parents. Adolescents completed measures assessing their pain, pain coping responses, functional disability, and somatic symptoms. Parents reported on their responses to their adolescent's pain.Passive and active coping interacted with parental protective behavior to predict adolescents' pain behaviors. Contrary to expectations, among adolescents who reported infrequent use of passive or active coping strategies, higher levels of parental protective behavior were associated with higher levels of disability and somatic symptoms. Discussion Among adolescents who report infrequent use of passive and active coping responses, parental protective responses to pain may inadvertently promote greater disability and symptom complaints. Parental responses to pain may be an important target to treat adolescent chronic pain.

  View details for DOI 10.1093/jpepsy/jsn029

  View details for Web of Science ID 000258141300011

  View details for PubMedID 18375447

  View details for PubMedCentralID PMC2493514

• Parental response to children's pain: The moderating impact of children's emotional distress on symptoms and disability PAIN Claar, R. L., Simons, L. E., Logan, D. E. 2008; 138 (1): 172-179

  Abstract

  Parental responses play a central role in the development and maintenance of children's pain behavior. Previous studies examining the impact of parental responses on children's pain have focused mainly on protective or solicitous responses. This study examined the impact of parental responses, including protectiveness, minimization of pain, and encouraging and monitoring responses, on children's functional disability and somatic symptoms. Participants included 327 patients with chronic pain, ages 8-17, who completed measures of pain, disability, somatic symptoms, depression, and anxiety. Patients' parents completed a measure assessing parental responses to their children's pain. Results show that for children with higher levels of emotional distress, maladaptive parental responses to pain (e.g., criticism, discounting of pain, increased attention to pain, and granting of special privileges) were associated with increased disability and somatic symptoms. Results of this study demonstrate the important ways in which parents can influence how their children cope with and manage chronic pain. Children whose parents are overly protective or critical of their pain may experience more impairment or somatic symptoms, particularly those children who are already at risk for difficulties due to higher levels of emotional distress.

  View details for DOI 10.1016/j.pain.2007.12.005

  View details for Web of Science ID 000258746100021

  View details for PubMedID 18221837

• School impairment in adolescents with chronic pain JOURNAL OF PAIN Logan, D. E., Simons, L. E., Stein, M. J., Chastain, L. 2008; 9 (5): 407-416

  Abstract

  The purpose of this study was to assess and describe school functioning among adolescents presenting for evaluation in a tertiary care pediatric chronic pain clinic. Adolescents (n = 220, aged 12-17) and their parents participated in the study, providing self-reported data on school attendance, school performance, and perceived academic competence. Participants' schools provided official attendance records, descriptions of accommodations implemented to address the student's pain problems in the school setting, and teacher ratings of academic competence. Results show that many adolescents with chronic pain miss a significant amount of school, experience a decline in grades, and perceive pain to interfere with their school success. Various indicators of school impairment are highly intercorrelated, suggesting that impairment or success in 1 domain is typically associated with similar patterns in other domains of school functioning. However, as a group, adolescents with pain are viewed by themselves and their teachers as academically competent. Strong correlations emerged between different reporters of school functioning indicators such as attendance, suggesting that reliance on parent or adolescent reporting may be sufficient when assessing these domains. Findings underscore the importance of broadly assessing school functioning in adolescents with chronic pain.This study extends our understanding of school functioning among adolescents with chronic pain. It highlights the need to assess both school attendance and performance in this population as well as how schools respond to pain problems. Devising summary indicators of school impairment can be useful in both clinical and research contexts.

  View details for DOI 10.1016/j.jpain.2007.12.003

  View details for Web of Science ID 000256032500004

  View details for PubMedID 18255341

• Initial development of the pediatric camp outcome measure CHILDRENS HEALTH CARE Simons, L. E., Gilleland, J., McDanel, A. H., Blount, R. L., Campbell, R. 2008; 37 (2): 158-169

  View details for DOI 10.1080/02739610802006593

  View details for Web of Science ID 000256760900005

• Understanding the pathway between the transplant experience and health-related quality of life outcomes in adolescents PEDIATRIC TRANSPLANTATION Simons, L. E., Anglin, G., Warshaw, B. L., Mahle, W. T., Vincent, R. N., Blount, R. L. 2008; 12 (2): 187-193

  Abstract

  Developments in solid organ transplantation have resulted in improved survival for children with advanced kidney, liver, and heart disease; however, concerns have been raised regarding the quality of life of survivors. This study examined HRQOL in adolescent transplant recipients. We examined the influence of demographic, treatment regimen, and family factors on physical and mental health domains of HRQOL. The current single-center investigation involved 68 solid organ transplant recipients and their parents. All families participated in a structured interview to collect information on demographics, characteristics of the adolescents' disease and treatment regimen, family functioning, and HRQOL for parents and adolescents. Using hierarchical regression analyses, predictive models of physical functioning and mental health outcomes for adolescent transplant recipients were developed for parent-proxy and adolescent self-report. Perceived frequency of medication side-effects and family conflict significantly contributed to adolescent physical functioning and mental health outcomes. Taken together, transplant consequences and family environment significantly impact physical and mental health outcomes in adolescent transplant recipients. Our findings demonstrate the need for pharmacological considerations and psychological interventions to address these areas.

  View details for DOI 10.1111/j.1399-3046.2007.00805.x

  View details for Web of Science ID 000253637400012

  View details for PubMedID 18307667

• Decreases in anxiety associated with participation in a camp for children with cardiac defects CARDIOLOGY IN THE YOUNG Simons, L. E., Blount, R. L., Campbell, R., Hubbard, A., Goodwin, B., Devine, K., Benoit, M. 2007; 17 (6): 631-637

  Abstract

  The aim of our study was to examine psychosocial changes associated with participation in a camp for children with cardiac defects. We enrolled 29 children with cardiac defects aged from 8 to 18 years, along with their parents. Both the parents and the children completed measures of expectations for the camp and anxiety. Analyses of repeated measures indicated that levels of anxiety amongst the children decreased significantly at the end of camp when compared to its beginning. Levels of anxiety amongst the children were not statistically different at follow-up. Anxiety amongst the parents concerning the separation from their children also decreased at follow-up when compared to before the camp. Higher levels of anxiety reported by the children prior to the camp were associated with greater anxiety amongst the parents concerning the anticipated separation, more negative parental expectations of the camp, fewer experiences of separation from their children, and lower expectations by the children for the camping experience. Reductions in anxiety amongst the children following the camp were associated with negative parental expectations about the camping experience. The camping environment can provide a naturalistic exposure to new experiences for the child, and a successful separation for the parent, thereby promoting confidence amongst the parents in the ability of their children to function independently.

  View details for DOI 10.1017/S1047951107001485

  View details for Web of Science ID 000251909900009

  View details for PubMedID 17961266

• Social support, coping, and psychological distress in mothers and fathers of pediatric transplant candidates: A pilot study PEDIATRIC TRANSPLANTATION Simons, L., Ingerski, L. M., Janicke, D. M. 2007; 11 (7): 781-787

  Abstract

  Both parents and children report significant psychological difficulties and family disruption prior to transplantation; however, there have been fewer studies examining predictors of distress in both mothers and fathers and across multiple transplant groups. Thirty-four mothers and 22 fathers participated in this pilot study. Parents completed measures during a routine tertiary pretransplant psychological evaluation. Paired sample t-test results indicated that mothers and fathers differed significantly on specific coping strategies employed, with fathers less likely to use engagement strategies than mothers. Correlation analyses demonstrated strong associations between engagement coping strategies and less psychological distress and the reverse with disengagement coping strategies for both mothers and fathers. Social support was associated with less psychological distress for mothers, but was unrelated to distress for fathers. Using regression analyses, for mothers, lack of social support, and disengagement coping predicted poor psychological outcomes. Taken together, these results suggest that assessing specific coping strategies employed by both mothers and fathers is an essential component of the pretransplant evaluation process. This study delineates areas for intervention that impact adjustment in parents of pediatric transplant candidates.

  View details for DOI 10.1111/j.1399-3046.2007.00726.x

  View details for Web of Science ID 000249925000014

  View details for PubMedID 17910657

• A measure of functional impairment in youth with Tourette's syndrome JOURNAL OF PEDIATRIC PSYCHOLOGY Storch, E. A., Lack, C. W., Simons, L. E., Goodman, W. K., Murphy, T. K., Geffken, G. R. 2007; 32 (8): 950-959

  Abstract

  Tourette's Syndrome (TS) during childhood is linked to varied behavioral and psychological difficulties and functional impairment. The current study was undertaken to examine both tic-related impairment and impairment from other psychological problems in 59 youth (mean age 11.4 years, 69% male) with TS.Caretakers completed a checklist about the impact of tics and other psychological difficulties on family, school, and social functioning. In addition, a clinician administered a measure of tic severity to families.Over half of the sample reported one significant problem area due to the presence of tics, with over a third reporting two or more problem areas. Problems were heterogeneous in nature, with no report of a particular problem area in more than 25% of the children. The rate of nontic-related impairment was very high, with 70% of parents reporting at least one problem area.Treating both tic and nontic-related impairments concurrently may improve functioning more so than treating the symptoms separately.

  View details for DOI 10.1093/jpepsy/jsm034

  View details for Web of Science ID 000249698600008

  View details for PubMedID 17522110

• Identifying barriers to medication adherence in adolescent transplant recipients JOURNAL OF PEDIATRIC PSYCHOLOGY Simons, L. E., Blount, R. L. 2007; 32 (7): 831-844

  Abstract

  To create Parent and Adolescent Medication Barriers Scales (PMBS and AMBS) for assessing perceived barriers to medication adherence in adolescent transplant recipients.These scales were developed and initially validated with 78 families. Participants responded to questions concerning perceived barriers to medication adherence. To assess validity, data on contextual factors (e.g., family functioning) and adherence measures were collected.A principal components factor analysis resulted in the following subscales for the PMBS and AMBS: (a) Disease Frustration/Adolescent Issues, (b) Regimen Adaptation/Cognitive Issues, (c) Ingestion Issues, and (d) Parent Reminder (PMBS only). Significant associations were found between barrier scale scores, contextual factors, and adherence.The PMBS and AMBS are brief and psychometrically promising scales for assessing perceived barriers to adherence in adolescent transplant recipients.

  View details for DOI 10.1093/jpepsy/jsm030

  View details for Web of Science ID 000248271000009

  View details for PubMedID 17522111

• Disease-related stress in parents of children who are overweight: relations with parental anxiety and childhood psychosocial functioning. Journal of child health care : for professionals working with children in the hospital and community Ohleyer, V., Freddo, M., Bagner, D. M., Simons, L. E., Geffken, G. R., Silverstein, J. H., Storch, E. A. 2007; 11 (2): 132-42

  Abstract

  The psychometric properties of the Pediatric Inventory for Parents, a measure of chronic disease-related parental stress, were examined in a sample of 72 children and adolescents who are overweight. The correlations between disease-related parental stress and general parenting stress, parental and child anxiety and children's behavioral and psychological maladjustment were examined. The results demonstrated excellent internal consistency and modest correlations with a measure of general parenting stress. Significant and positive relations of medium to large effect sizes between disease-related parenting stress and internalizing and externalizing maladjustment were found. Internalizing and externalizing behavior moderated the relations between disease-related parenting stress and parental distress. Recommendations for use of the Pediatric Inventory for Parents in clinical settings and future research directions are discussed.

  View details for DOI 10.1177/1367493507076065

  View details for PubMedID 17494987