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BACKGROUND: Chronic pain is prevalent among millions of Americans and can negatively impact cognitive processes, mental health, and overall quality of life. Even though pain affects all ethnic and racial groups equally, studies have shown a growing disparity in pain intensity and prevalence of pain conditions among underrepresented minority adult populations across the United States. Hispanics are among the fastest-growing populations in the U.S., yet chronic pain in Hispanic adults and adolescents remains severely understudied. PURPOSE: This study aims to compare pain and related psychosocial factors (pain catastrophizing, anxiety and depression) and Fear of Pain Questionnaire scores (FOPQ) in Hispanic vs. Non-Hispanic White (NHW) youth with chronic pain. Based on prior literature from studies in adults, it was hypothesized that Hispanic youth would report greater pain catastrophizing, anxiety, depression, and higher FOPQ scores when compared to NHW youth. Further, potential differences in relations between anxiety, pain catastrophizing, and physical functioning on depression among Hispanic and NHW youth will be explored. METHODS: Participant data were gathered from the Boston Children’s Hospital Chronic Pain Data Repository. The current study sample included 116 children and adolescents, ages 12-18 years (M = 15.49, SD = 1.71) from Hispanic and NHW backgrounds. Both groups had the same proportion of participants who identified as female (88%), and samples used for analysis were age-and-sex matched. Independent sample t-tests were performed to compare the mean differences in pain catastrophizing, PROMIS anxiety and depression scores, and FOPQ sum score between groups. Bivariate correlations for each group were also compared, and Hayes PROCESS Macro was used to compare the associations between pain catastrophizing, anxiety, and physical functioning on depression, based across patient ethnicities. RESULTS: The results of independent samples t-tests did not reveal any significant differences across groups. However, significant correlations were found. Notably, PROMIS anxiety and depression t-scores were significantly correlated among each independent cohort of Hispanic youth (r = .612, p <.001), non-Hispanic White youth (r = .817, p<.001), and across the full sample (r = .719, p <.001). Pain catastrophizing was also found to be significantly and positively correlated with anxiety (r = .660, p<.001), depression (r = .582, p <.001) and patient FOPQ score (r = .740, p <.001) across both cohorts. From the moderation analysis, the association between pain catastrophizing and depression was found to be statistically significant based on ethnicity of patient [B = .0272, p<.05]. Similarly, ethnicity was found to significantly moderate the association between PROMIS anxiety and depression [B = .0340, p<.05]. CONCLUSIONS: This study is one of the first to explore how pain and psychosocial-related factors compare in an age-and-sex-matched cohort of Hispanic vs. NHW youth with chronic pain. The study is also novel in identifying patient ethnicity as a moderator between anxiety and pain catastrophizing on depression. Obtaining a significant correlation between pain catastrophizing, anxiety, and depression scores for both groups parallels previous findings in adult populations with chronic pain. Contrary to our hypotheses, no mean differences were found in variables associated with pain or psychosocial factors between the two groups, however it is possible that the small sample size used may have obscured group differences. The results highlight the need to increase diversity in research for pediatric populations with chronic pain to help reduce pain disparities among underrepresented minority youth populations.

Chronic pain (CP) is a personal and economic burden that affects more than 30% of the world's population. While being the leading cause of disability, it is complicated to diagnose and manage. The optimal way to treat CP is to identify the pain mechanism or the underlying cause. The substantial overlap of the pain mechanisms (i.e., Nociceptive, Neuropathic, and Nociplastic) usually makes identification unreachable in a clinical setting where finding the dominant mechanism is complicated. Additionally, many specialists regard CP classification as a spectrum or continuum. Despite the importance, a data-driven way to identify co-existing CP mechanisms and quantification is still absent. This work successfully identified the co-existing CP mechanisms within a patient using Unsupervised Learning while quantifying them without the help of diagnosis established by the clinicians. Two different datasets from different cohorts comprised of patient-reported history and questionnaires were used in this work. Unsupervised Learning (k-prototypes) revealed notable overlaps in the data. It was further emphasized by the outcomes of the Semi-supervised Learning algorithms when the same trend was observed with some diagnosis or class information. It became evident that the CP mechanisms overlap and cannot be classified as distinct conditions. Additionally, mixed pain mechanisms do not make an individual cluster or class, and CP should be considered as a continuum. To reduce data dimension and extract hidden features, Autoencoder was used. Using an overlapping clustering technique, the pain mechanisms were identified. The pain mechanisms were also quantified while elucidating overlaps, and the dominant CP mechanism was successfully pointed out with explainable element. The hamming loss of 0.43 and average precision of 0.5 were achieved when considered as a multi-label classification problem. This work is a data-driven validation that there are significant overlaps in CP conditions, and CP should be considered a continuum where all CP mechanisms may co-exist. / Thesis / Master of Applied Science (MASc) / Chronic pain (CP) is a global burden and the primary cause for patients to seek medical attention. Despite continuous efforts in this area, CP remains clinically challenging to manage. The most effective method of treating CP is identifying the underlying cause or mechanism, which is often unattainable. This thesis attempted to identify the CP mechanisms existing in a patient while quantifying them from patient-reported history and questionnaire data. Unsupervised Learning was used to identify clinically meaningful clusters that revealed the three main CP mechanisms, i.e., Nociceptive, Neuropathic, and Nociplastic, achieving acceptable hamming loss (0.43) and average precision (0.5). The results exhibited that the CP mechanisms co-exist and CP should be regarded as a continuum rather than distinct entities. The algorithm successfully indicated the dominant CP mechanism, a goal for optimal CP management and treatment. The results were also validated by a comparative analysis with data from another cohort that demonstrated a similar trend.

Chronic pain is one of the most frequent reasons for a primary health care visit and people with pain identify improved function as an important goal. Self-management support provides an opportunity to improve function for people with chronic pain, but existing evidence suggests negligible changes in function. This thesis includes five manuscripts with overarching objectives of improving the understanding of reductions in function related to pain and evaluating a new self-management program aimed at improving function for people with chronic pain. The first manuscript is a cross-sectional evaluation of factors associated with reduced function in people with chronic pain referred for self-management support in primary health care. The findings suggest number of medications, depressive symptoms, cognitive factors associated with pain, mechanical hyperalgesia, and duration of symptoms explain 63% of the variance in function in people with chronic pain, multiple comorbidities, and barriers to accessing healthcare. The second manuscript is a case-series describing the participation and outcomes of six participants in Chronic pain self-management support with pain science education and exercise (COMMENCE). This study contributes to the literature by detailing the COMMENCE intervention and describing the varied responses of six participants. The third and fourth manuscripts are a protocol for a randomized controlled trial (RCT) and a completed RCT evaluating the effectiveness of COMMENCE in comparison to a wait-list control. The results suggest COMMENCE improves function for people with chronic pain (mean difference = -8.0 points on the Short Musculoskeletal Function Assessment; 95% confidence interval: -14.7 to -1.3). The fifth manuscript is a planned secondary analysis of the RCT described above. This study suggested people with a greater number of comorbidities are likely to have poorer function at the end of COMMENCE after controlling for age, gender, and baseline function. Together, these factors explained 63% of the variance in function. / Thesis / Doctor of Philosophy (PhD) / Chronic pain is associated with suffering, disability, and health care costs. This thesis includes five papers aimed at better understanding reduced function and evaluating a new self-management program for people living with chronic pain. The results of this research suggests people with more medications, longer lasting pain, negative thoughts and emotions related to their pain, and sensitivity to pressure are more likely to have poor functional abilities. A new self-management approach, Chronic pain self-management support with pain science education and exercise (COMMENCE), is described and evaluated. The results suggest people with chronic pain participating in COMMENCE experience greater improvements in function than people on a wait-list for the program. It appears people living with more chronic health conditions are likely to have poorer function at the end of the program. The findings of this thesis may help to inform management of chronic pain in primary healthcare.

Thesis advisor: Lisa Wood Magee / Background: Chronic cancer-related pain is a considerable problem in cancer survivors. The incidence of chronic pain in cancer survivors is nearly double the rate in the general population. Chronic cancer-related pain reduces quality of life and results in higher healthcare utilization. Due to a lack of alternative treatments, the management of chronic cancer-related pain relies on a biomedical model, with opioids being the cornerstone of cancer-related pain management. As concerns about the risks of long-term opioid therapy rise, there is a need to understand the factors that influence chronic cancer-related pain experience. This manuscript dissertation aims to answer the overarching question, “What are the unique factors that inform the chronic cancer-related pain experience in cancer survivors?” Methods: First, an integrative review aimed to examine the evidence of long-term opioid use in cancer-survivors. Next, a qualitative study using descriptive phenomenology was conducted to develop a deeper understanding of the daily lived experience of chronic cancer-related pain. And finally, a prospective cross-section quantitative study was completed to quantify the contribution of unique cancer-specific factors to the chronic cancer-related pain experience in cancer survivors. Results: The integrative review shed light on the biopsychosocial factors associated with the transition to long-term opioid therapy (LTOT), including the role of cancer type, medical comorbidities, mental health diagnoses, and socioeconomic factors. No studies examined pain severity, pain interference, or cancer-specific psychosocial factors in cancer survivors prescribed LTOT. Second, cancer survivors describe living with chronic cancer-related pain as the cost of survival. Yet, their suffering was often invisible to others. The role of opioids in chronic cancer-related pain leads to strained communication with clinicians and the need to self-navigate a treatment plan characterized by ‘trying everything’. And finally, select cancer-specific psychosocial factors explained relatively little variance in the pain experience compared to non-cancer specific factors of multisite pain and pain catastrophizing. Conclusions: The constellation of the finding from this body of work demonstrates unique factors that inform the chronic cancer-related pain experience in cancer survivors, and several areas of overlap with other chronic pain syndromes. / Thesis (PhD) — Boston College, 2022. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Chronic pain remains a prevalent problem across the United States. Chronic pain does not seem to have a function and relief of this symptom remains elusive for many sufferers. Virtual reality has been used as an adjunct therapy to decrease acute pain with promising results, but there is little research on whether virtual reality could be used as a successful intervention for those with chronic pain. Virtual reality has few side effects, so it warrants consideration for the treatment of chronic pain. There is growing evidence that there is potential for virtual reality to produce desired results with patients having chronic pain, but without more research this intervention cannot be confidently recommended (Garrett, Taverner, & McDade 2017). This thesis reviewed published research on the use of virtual reality in those with chronic pain. A total of seven studies that addressed virtual reality and chronic pain were analyzed and integrated into this literature review. All studies used virtual reality as a distraction to improve chronic pain. Three studies included patients with chronic back pain, one study included patients with chronic neck pain, and the remaining three studies addressed other types of chronic pain including chronic postoperative breast cancer pain, chronic neuropathic pain, and chronic generalized pain. All studies reviewed reported improvement of chronic pain symptoms. This literature review provides evidence to support the use of virtual reality for those with chronic pain. More rigorous research with larger sample sizes is needed to increase the generalizability of results to help people suffering with chronic pain from a variety of causes. This literature review used the search terms "chronic pain" and "virtual reality" and the following databases: EBSCOhost, Medline, CINAHL Plus with Full Text, PsycINFO, Academic Search Premiere, and Applied Science & Technology Source.

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Objective: The purpose of the following study was to test the feasibility of using an ecological momentary assessment strategy during participation in water exercise. This assessment strategy was used to collect ratings of pain intensity level, affective status and self-efficacy for engaging in regular exercise prior to, during and following participation in water exercise for women with chronic pain. Design: Participants (N=15) completed six measures assessing physical activity level and reactions to physical activity and exercise participation and participated in elicitation interviews focused on their experiences with chronic pain and physical activity and exercise. Participants reported daily pain intensity levels, affect and self-efficacy each morning by phone and used cellular phones to report momentary ratings immediately following participation in water exercise for 6 weeks. Results: Participant profiles were developed to display patterns of pain intensity, affect and self-efficacy over the course of 6 weeks. Profiles indicated a variety of levels of exercise consistency in participants. Pain intensity, affect and self-efficacy varied over the course of an exercise event and revealed varied patterns across participants. Overall, momentary self-efficacy (M¹= 7.98, SD=1.65; M²= 8.29, SD=1.62; M³=8.45, SD=1.45) and affect mean ratings (M¹= 2.05, SD=1.42; M²= 2.76, SD=1.22; M³=3.02, SD=1.06) increased over the course of the exercise events while pain levels decreased from pre-exercise levels (M¹= 2.67, SD=2.30; M²= 1.85, SD=1.86; M³=1.95, SD=2.05). Elicitation interviews indicated themes related to the importance of enjoyment of exercise, social factors, and impact on pain level and overall physical condition. Final interviews provided information about the reactions of participants to the assessment strategy and offered insight into the acceptance of this approach for future studies of exercise behaviors. Conclusion: Overall, this approach to ecological momentary assessment of variables associated with exercise was acceptable to participants and revealed variable patterns of pain intensity, self-efficacy and affective state in relation to water-exercise engagement. / Ph. D.