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Mechanisms explaining the relationship between pain-related injustice appraisals and functional outcomes in youth with chronic pain have yet to be examined. In studies of adults, greater pain-related injustice is associated with worse depressive symptoms and greater pain through greater anger. No study to date has examined anger expression as a mediator in the relationships between pain-related injustice appraisals and physical and psychosocial functioning in youth with chronic pain. The current sample consisted of 385 youth with varied pain conditions (75% female, 88% White, Mage=14.4 years) presenting to a university-affiliated pain clinic. Patients completed self-report measures assessing anger expression (anger-out and anger-in), pain-related injustice, pain intensity, functional disability, and emotional, social, and school functioning. Bootstrapped mediation analyses indicated that only anger-out (indirect effect= -.12, 95% CI: -.21, -.05) mediated the relationship between pain-related injustice and emotional functioning, whereas both anger-out (indirect effect= -.17, 95% CI: -.27, -.09) and anger-in (indirect effect= -.13, 95% CI: -.09, -.001) mediated the relationship between pain-related injustice and social functioning. Neither mode of anger expression mediated the relationship between pain-related injustice and pain intensity, functional disability, or school functioning. Collectively, these findings implicate anger as one mechanism by which pain-related injustice impacts psychosocial outcomes for youth with chronic pain. Perspective: Anger expression plays a mediating role in the relationship between pain-related injustice appraisals and psychosocial outcomes for youth with chronic pain. Anger represents one target for clinical care to decrease the deleterious impact of pain-related injustice on emotional and social functioning.

Pain appraisals are closely tied to pain and functional outcomes. Pain-related injustice and pain catastrophizing appraisals have both been identified as important cognitive-emotional factors in the pain experience of youth. Although pain-related injustice and catastrophizing have been linked to worse pain outcomes – as primary predictors and intermediary variables – little is known about whether they operate as independent or parallel mediators of the relationship between pain and functioning in youth. We tested pain-related injustice and catastrophizing appraisals as candidate mediators of the relationship between baseline pain intensity and 3-month functional outcomes in adolescents. Youth with chronic pain (N = 89, 76% female, 89% White, average age = 15 years) completed measures assessing pain intensity, pain-related injustice, and catastrophizing at baseline, as well as measures assessing functional disability and overall quality of life 3 months later. Multiple mediation analyses indicated that injustice mediated the relationship between pain intensity and 3 month quality of life. Exploratory analyses of specific quality of life domains indicated that injustice mediated the relationship between pain intensity and 3 month emotional functioning, whereas catastrophizing mediated the relationship between pain intensity and 3 month social functioning. The findings suggest these pain-related appraisals play different intermediary roles in the relationships among pain and future psychosocial outcomes. Perspective Pain-related injustice and catastrophizing appraisals play different intermediary roles in the relationships among pain and future psychosocial outcomes in youth with chronic pain. Treatments targeting pain-related injustice appraisals in pediatric populations are needed to complement existing treatments for catastrophizing.

A central concern raised by many patients attending a pediatric chronic pain interdisciplinary clinic is physical functioning decline, fatigue, and diminished endurance. However, most studies examining treatment effects of pain programs on physical outcomes have relied on self- and/or parent-reported measures without confirming the results using objective indices, and predictors of objective indices of physical function in this population have rarely been examined. The purpose of the present study was to evaluate changes in objective physical functioning and to investigate psychosocial predictors of physical functioning over time in a sample of pediatric patients who completed an intensive outpatient pain program (IOP). Participants (N=55; Mage=14.92 years; 12.7% male, 87.3% female; 83.6% White, 5.6% African-American/Black; 9.1% Latinx) completed baseline measures assessing pain levels (Brief Pain Inventory), anxiety/depressive symptoms (Hospital Anxiety and Depression Scale), pain catastrophizing (Coping Strategies Questionnaire), and kinesiophobia (Tampa Scale for Kinesiophobia). Participants completed the FitKids Treadmill Test ("FitKids") assessing physical endurance and the high-level mobility assessment tool (HiMAT) assessing physical ability pre- and post-IOP completion. Paired samples t-tests indicated significant improvement in Total Time to Exhaustion (TTE) on FitKids (p .138). Participation in an IOP led to significant improvement in physical endurance and ability. Depressive symptoms were negatively associated with endurance at baseline but not after program completion. Depressive symptoms may influence pre-treatment objective physical endurance and should be assessed in pediatric chronic pain patients beginning rehabilitation.

Chronic pain is prevalent in children/adolescents and contributes to high rates of healthcare utilization. Research suggests injustice perceptions about pain are important in adult patients and a possible treatment focus. We conducted a preliminary evaluation of the psychometric properties of the Injustice Experiences Questionnaire (IEQ) and the relationship between injustice perceptions, pain, and functioning in chronic pain patients (N = 139, mean age = 15 years, 72% female) presenting to a pediatric pain clinic. Patients completed measures assessing pain intensity, injustice perceptions about pain, catastrophizing, overall functional disability, emotional functioning, social functioning, and school functioning. The IEQ showed good reliability and validity. Higher levels of perceived injustice were associated with higher levels of pain intensity, catastrophizing, and functional disability, and with poorer emotional, social, and school functioning. Additionally, perceived injustice remained significantly associated with pain intensity, functional disability, emotional functioning, social functioning, and school functioning after accounting for relevant demographic and clinical factors. This is the first study to suggest that injustice perceptions are important in the experience of pediatric chronic pain patients. Future studies should more thoroughly examine the psychometric properties of the IEQ in children/adolescents and elucidate the causal nature of these relationships, which will inform treatment efforts to improve pediatric pain care. Perspective This initial investigation suggests that injustice perceptions about pain can be reliably and validly measured and are tied to important clinical outcomes in children/adolescents. Future studies that replicate and extend these preliminary results are necessary to determine the extent to which injustice perceptions are an important target for intervention.

Pediatric surgeries and postoperative pain interventions with opioids pose risks for functional recovery and analgesic dependence. Prehabilitation, optimizing of physical functioning prior to surgery, is a possibly efficacious intervention with minimal adverse effects not yet assessed among children. Little is known about typical physical activity patterns of children undergoing orthopedic surgeries, or whether measurement with commercial accelerometry is feasible. This pilot study aimed to determine the feasibility of actigraphy assessment in children undergoing posterior spinal fusion (PSF) and assess the variability of their pre-operative activity. Children and adolescents undergoing PSF (n=15) wore a Fitbit Flex for approximately two weeks between their preoperative clinic appointment and surgery date, with no instructed change to activity level. Daily step counts were obtained from the Fitbit account for each participant. Of 15 participants, two dropped out (surgery or postoperative visit canceled). Overall, 73% of data was obtained from the pre-surgical period. The median number of data points per day was 11 [IQR:4-13]. The median average steps per day was 5,423 [IQR:4222-8060], the median maximum was 11,513 [IQR:6862-16142] and the median difference between highest and lowest step counts was 10,680 [IQR:4,886-15,662]. Four participants had consistently lower counts, defined as ≥50% of the recorded day total th percentile of the population average (4,222 steps). No participants had consistently higher counts preoperatively, defined as ≥50% of the recorded day total >75 th percentile of the population average (8,060 steps). Results demonstrate that assessing children's physical activity preoperatively is feasible and provides a description of the typical patterns of physical activity among children undergoing posterior spinal fusion. These findings support the possibility for implementation of prehabilitation in children. Prehabilitation can help prevent poor post-surgical outcomes among adults undergoing orthopedic surgeries and holds promise for possible preventative intervention for children to reduce risks associated with surgeries and opioid use.

Depression, pain catastrophizing, and anxiety commonly co-occur with chronic pain. However, the degree to which improvement in these psychological comorbidities predicts subsequent pain outcomes and, in particular, the relative effects of these 3 psychological factors with respect to each other is only partially known. Longitudinal analysis of 250 primary care patients with chronic musculoskeletal pain enrolled in the Stepped Care to Optimize Pain care Effectiveness (SCOPE) trial was examined, using data gathered at baseline, and at 3 and 12 months. Mixed effects model repeated measures analyses were used to determine if changes in depression, pain catastrophizing, and anxiety predicted a subsequent reduction in pain intensity or interference and pain-related disability. Defining a clinically significant change as twice the standard error of measurement for each predictor, we found that a 2-standard error of measurement improvement in depression, pain catastrophizing, and anxiety resulted in, respectively, an effect size decrease in pain intensity or interference of .45, .33, and .12; a 14%, 12%, and 6% reduction in the number of pain-specific disability days; and a 43%, 30%, and 28% decreased likelihood of high disability (defined as ≥10 pain-specific disability days in the past 4 weeks). In summary, improvements in 3 common psychological comorbidities predicted better pain outcomes. Perspective Because depression, pain catastrophizing, and anxiety commonly accompany chronic pain and might adversely affect pain outcomes, treatment of these modifiable psychological factors is warranted to optimize the effectiveness of pain-specific therapies.