Neurobiological Mechanisms of Stress in Youth With Chronic Widespread Pain

Chronic widespread pain (CWP) is a common chronic pain condition in youth and often associated with significant pain-related and psychosocial impairment. Understanding the neurobiological mechanisms that may underlie pediatric chronic pain and pain-related impairment can inform future treatments to ameliorate patients' suffering, making it a critical area of empirical investigation.

Study Overview

• Status: Recruiting
• Conditions: Stress, Psychological; Chronic Widespread Pain; Stress, Physiological
• Intervention / Treatment: Diagnostic test: functional Magnetic Resonance Imaging (fMRI); Other: Allostatic Load Composite

Detailed Description

Pediatric chronic widespread pain (CWP) is a serious public health problem resulting in high levels of healthcare utilization and disability. Youth with CWP also frequently report exposure to adverse childhood experiences (ACEs; abuse/neglect, violent/conflictual home environment, etc.) and a significant subset continue to experience physical and psychosocial impairment long-term. Certain mind-body interventions such as mindfulness-based stress reduction (MBSR) or meditation may be particularly appropriate for youth with CWP as they have been shown to modulate stress-induced maladaptation of the HPA-axis, autonomic nervous system, cardiovascular system, and brain structure (e.g., hippocampus). However, it is currently unknown if these targets are affected in youth with CWP. Preliminary research indicates that allostatic load (AL), or "wear and tear" on the nervous system due to stress, may contribute to pain chronicity. Similarly, evidence suggests that the hippocampus, a brain structure that is among the most deleteriously affected by stress, plays a role in pain perception. However, no study to-date has examined AL and hippocampal functioning in relation to stress exposure in youth with CWP. Mind-body interventions such as MBSR or meditation are an important and safe therapy option for both pain and stress reduction in youth with CWP and may modulate the negative impact of ACEs, so there is a critical need to know if these mechanisms are engaged in this population. The current study utilizes multifactorial physiological and neuroimaging measurement techniques to enhance our understanding of the potential role of these mechanisms in pain-related impairment and responsiveness to mind-body interventions over time. The aims of this study are to better characterize AL, assessed via a multifactorial composite, and hippocampal functioning via fMRI in pediatric CWP as specific targets for mind-body interventions that can lead to treatment optimization and improved compliance.

• Study Type: Interventional
• Enrollment (Estimated): 70
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Sarah Nelson, PhD; Phone Number: 6173557040; Email: sarah.nelson@childrens.harvard.edu

Study Locations

• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02115
      • Recruiting
      • Boston Children's Hospital
      • Contact: Ayeong Kim
      • Principal Investigator: Sarah Nelson, PhD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 11 years to 17 years (Child)
• Accepts Healthy Volunteers: Yes

Description

Chronic Widespread Pain (CWP) group:

Inclusion Criteria:

• Between ages 11-17 years
• Referred to the Boston Children's Hospital Pain Treatment Service for evaluation of a CWP condition with duration > 3 months
• Right-handed

Exclusion Criteria:

• Inability to speak sufficient English to complete questionnaires
• Severe cognitive impairment
• Prescription steroidal (interference with cortisol measures) or psychotropic medication
• Any other chronic pain diagnosis (e.g., migraines, abdominal pain, CRPS)
• fMRI contraindications (e.g., dental appliances)

Healthy Control (HC) group:

Inclusion Criteria:

• Between ages 11-17 years
• Right-handed

Exclusion Criteria:

• Inability to speak sufficient English to complete questionnaires
• Severe cognitive impairment
• Prescription steroidal (interference with cortisol measures) or psychotropic medication
• Any chronic pain diagnosis
• Presence of documented chronic (> 3 months) medical condition with an identifiable, organic cause (e.g., diabetes, cystic fibrosis)
• fMRI contraindications (e.g., dental appliances)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Other: Study Arm; All participants enrolled in the study will undergo baseline fMRI and baseline and follow-up (4-month post-baseline) assessment of stress physiology (i.e., allostatic load). Treatment as usual information will be gathered for all participants to assess observational intervention response.

Diagnostic test: functional Magnetic Resonance Imaging (fMRI); Participants will undergo a one hour fMRI scan with pain-induction using heat-based QST protocol.; Other: Allostatic Load Composite; All participants will be asked to provide saliva samples to measure cortisol response over time and dehydroepiandrosterone (DHEA) in addition to physiological measurements such as blood pressure/pulse, height/weight, and waist-hip ratio. Measurements will be taken at baseline and 4-month follow-up.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hippocampal Functioning	measured via fMRI	baseline
Change in Morning Cortisol	measured via 2 samples of saliva taken via passive drool over the course of two days. After analysis, morning cortisol will be dichotomously coded with participants receiving a "1" if they score over one standard deviation above the mean. Coding will them be combined to formulate an allostatic load risk ratio, with higher scores indicating greater risk for allostatic load.	baseline and 4-month follow-up
Change in Dehydroepiandrosterone (DHEA)	measured via 2 samples of saliva taken via passive drool over the course of two days. After analysis, DHEA will be dichotomously coded with participants receiving a "1" if they score over one standard deviation above the mean. Coding will them be combined to formulate an allostatic load risk ratio, with higher scores indicating greater risk for allostatic load.	baseline and 4-month follow-up
Change in Flattened Cortisol	measured via 10 samples of saliva taken via passive drool over the course of two days. After analysis, the presence of cortisol will be dichotomously coded with participants receiving a "1" if the change in cortisol levels across the day fell at or below one standard deviation below the mean. Coding will them be combined to formulate an allostatic load risk ratio, with higher scores indicating greater risk for allostatic load.	baseline and 4-month follow-up
Change in Blood Pressure	measured via blood pressure cuff by trained nurse. Results will be coded to capture levels that fall in the "normal", "prehypertension" and "hypertension" range with individuals scoring in the latter two ranges receiving a coding of "1" to be included in the allostatic load risk composite measure. Scoring of blood pressure ranges will be done using ezbmi- calculates deviation from expected BP/BMI by age/gender.	baseline and 4-month follow-up
Change in Body-Mass Index (BMI)	measured via height and weight (in cm and kg) by a trained nurse. Results will be coded to capture individuals that score in the "underweight", "normal", "overweight" and "obese" ranges with individuals falling in all categories but "normal" receiving a coding of "1" to be included in the allostatic load risk ratio. Scoring of BMI ranges will be done using ezbmi- calculates deviation from expected BP/BMI by age/gender.	baseline and 4-month follow-up
Change in Waist-Hip Ratio (WHR)	measured via tape measure around the smallest part of the waist and the widest part of the hips by a trained research coordinator. Results (waist measurement/hip measurement) will be coded dichotomously with individuals scoring a "1" whose WHR falls greater than or equal to one standard deviation above the mean of the sample. This scoring will also be included in the larger allostatic load risk ratio.	baseline and 4-month follow-up
Change in Heart Rate (HR)	measured via pulse taken by a trained nurse. Results will be coded dichotomously with individuals scoring a "1" whose HR falls greater than or equal to one standard deviation above the mean of the sample. This scoring will also be included in the larger allostatic load risk ratio.	baseline and 4-month follow-up

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Pain Intensity	measured via numeric rating scale (range: 0-10). Higher rating indicates more intense pain.	baseline and 4-month follow-up
Change in Functional Disability	measured via self-report Functional Disability Inventory (range: 0-60). Higher rating indicates greater functional disability.	baseline and 4-month follow-up
Change in Sleep	measured via Patient Reported Outcome Measurement Information System (PROMIS) sleep disturbance scale short-form (8a). Raw scores are converted to T-scores (range: 0-100). Higher rating indicates greater impairment in sleep.	baseline and 4-month follow-up

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Treatment Engagement	measured via participant self-report of treatment as usual (e.g., engagement in physical therapy, cognitive-behavioral therapy, acupuncture, etc.). Observational measure without metrics for risk or impairment.	baseline and 4-month follow-up
Change in Adverse Childhood Experiences (ACEs) exposure	measured via Childhood Trust Events Scale (CTES). Items on this measure are coded dichotomously (0 = no; 1 = yes) and will be summed to provide a total metric of ACEs exposure (range: 0-26).	baseline and 4-month follow-up
Change in Psychological Stress	measured via Patient Reported Outcome Measurement Information System (PROMIS) psychological stress scale short-form (8a). Raw scores are converted to T-scores (range: 0-100). Higher rating indicates greater amounts of psychological stress.	baseline and 4-month follow-up
Change in Anxiety	measured via Patient Reported Outcome Measurement Information System (PROMIS) anxiety scale short-form (8a). Raw scores are converted to T-scores (range: 0-100). Higher rating indicates greater amounts of anxiety.	baseline and 4-month follow-up
Change in Depression	measured via Patient Reported Outcome Measurement Information System (PROMIS) depression scale short-form (8a). Raw scores are converted to T-scores (range: 0-100). Higher rating indicates greater amounts of depressive symptoms.	baseline and 4-month follow-up

Collaborators and Investigators

• Sponsor: Boston Children's Hospital
• Collaborators: National Center for Complementary and Integrative Health (NCCIH)
• Investigators: Principal Investigator: Sarah Nelson, Boston Children's Hospital/Harvard Medical School

Study record dates

Study Major Dates

• Study Start (Actual): November 4, 2021
• Primary Completion (Estimated): August 31, 2024
• Study Completion (Estimated): August 31, 2024

Study Registration Dates

• First Submitted: July 21, 2020
• First Submitted That Met QC Criteria: July 23, 2020
• First Posted (Actual): July 28, 2020

Study Record Updates

• Last Update Posted (Actual): October 19, 2023
• Last Update Submitted That Met QC Criteria: October 18, 2023
• Last Verified: October 1, 2023

More Information

Terms related to this study

• Keywords: fMRI; Chronic Widespread Pain; Pediatric Pain; Allostatic Load; Mind-Body Interventions
• Additional Relevant MeSH Terms: Behavioral Symptoms; Pain; Neurologic Manifestations; Chronic Pain; Stress, Psychological
• Other Study ID Numbers: IRB-P00035303; 1K23AT010643-01A1 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES

IPD Plan Description

Dr. Nelson and collaborators acknowledge their willingness to share data and materials with other eligible investigators through academically established means.

Finalized data sets will be available to other researchers who seek to conduct further analysis on any and all variables of the study, in full compliance with HIPAA and institutional IRB oversight. Interested researchers would need the permission of the PI of this study (Nelson). Any data-sharing agreement would include the purpose of the secondary analyses and the credentials of the researchers, and will be in full HIPAA compliance, as the data will be de-identified. This data-sharing agreement will meet the NIH's policy for data sharing.

• IPD Sharing Time Frame: Data will be made available on a case-by-case basis.
• IPD Sharing Supporting Information Type: ANALYTIC_CODE

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No