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Kapos FP, Craig KD, Anderson SR, Bernardes SF, Hirsh AT, Karos K, Keogh E, Reynolds Losin EA, McParland JL, Moore DJ, Ashton-James CE. Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives. THE JOURNAL OF PAIN 2024:104608. [PMID: 38897311 DOI: 10.1016/j.jpain.2024.104608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 06/07/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.
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Affiliation(s)
- Flavia P Kapos
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington; Department of Orthopaedic Surgery & Duke Clinical Research Institute, Duke University Schoool of Medicine, Durham, North Carolina.
| | - Kenneth D Craig
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven R Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Sónia F Bernardes
- Centre for Social Research and Intervention, Iscte-Lisbon University Institute, Lisbon, Portugal
| | - Adam T Hirsh
- Department of Psychology, Indiana University Indianapolis, Indianapolis, Indiana
| | - Kai Karos
- Experimental Health Psychology, Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Edmund Keogh
- Department of Psychology & Centre for Pain Research, University of Bath, Bath, United Kingdom
| | | | - Joanna L McParland
- Department of Psychology, Glasgow Caledonian University, Glasgow, United Kingdom
| | - David J Moore
- School of Psychology, Liverpool John Moores University, Liverpool, United Kingdom
| | - Claire E Ashton-James
- Pain Management Research Institute, Kolling Institute, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Household Food Insufficiency and Chronic Pain among Children in the US: A National Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020185. [PMID: 36832314 PMCID: PMC9954897 DOI: 10.3390/children10020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
This study aimed to determine the prevalence of pediatric chronic pain by household food sufficiency status and examine whether food insufficiency would be associated with greater risk for chronic pain. We analyzed data from the 2019-2020 National Survey of Children's Health of 48,410 children (6-17 years) in the United States. Across the sample, 26.1% (95% CI: 25.2-27.0) experienced mild food insufficiency and 5.1% (95% CI: 4.6-5.7) moderate/severe food insufficiency. The prevalence of chronic pain was higher among children with mild (13.7%) and moderate/severe food insufficiency (20.6%) relative to children in food-sufficient households (6.7%, p < 0.001). After adjusting for a priori covariates (individual: age, sex, race/ethnicity, anxiety, depression, other health conditions, adverse childhood events; household: poverty, parent education, physical and mental health; community: region of residence), multivariable logistic regression revealed that children with mild food insufficiency had 1.6 times greater odds of having chronic pain (95% CI: 1.4-1.9, p < 0.0001) and those with moderate/severe food insufficiency, 1.9 higher odds (95% CI: 1.4-2.7, p < 0.0001) relative to food-sufficient children. The dose-response relationship between food insufficiency and childhood chronic pain highlights the importance of further research to identify underlying mechanisms and evaluate the impact of food insufficiency on the onset and persistence of chronic pain across the lifespan.
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Mathur VA, Trost Z, Ezenwa MO, Sturgeon JA, Hood AM. Mechanisms of injustice: what we (do not) know about racialized disparities in pain. Pain 2022; 163:999-1005. [PMID: 34724680 PMCID: PMC9056583 DOI: 10.1097/j.pain.0000000000002528] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/29/2021] [Accepted: 10/21/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Vani A. Mathur
- Department of Psychological and Brain Sciences, Texas A&M University, College Station, TX, United States
| | - Zina Trost
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Miriam O. Ezenwa
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, FL, United States
| | - John A. Sturgeon
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Anna M. Hood
- Division of Psychology and Mental Health, University of Manchester, Manchester, United Kingdom
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Morris MC, Bruehl S, Stone AL, Garber J, Smith C, Palermo TM, Walker LS. Place and Pain: Association Between Neighborhood SES and Quantitative Sensory Testing Responses in Youth With Functional Abdominal Pain. J Pediatr Psychol 2022; 47:446-455. [PMID: 34757421 PMCID: PMC9308448 DOI: 10.1093/jpepsy/jsab113] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/08/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Neighborhood socioeconomic status (SES) is linked to self-reported pain severity and disability but its association with evoked pain responsiveness in individuals with chronic pain remains unclear. The present study examined relations between neighborhood SES, assessed through the area deprivation index (ADI), and static and dynamic pain response indices. It was hypothesized that youth with functional abdominal pain (FAP) living in lower SES neighborhoods would exhibit lower pain threshold, lower pain tolerance, and reduced conditioned pain modulation (CPM) compared to youth living in higher SES neighborhoods. METHODS Participants were 183 youth with FAP and their parents. Youth completed a quantitative sensory testing protocol. Family addresses were used to compute ADI scores. Thermal stimuli for pain threshold and tolerance were delivered to participants' forearms using thermodes. CPM, an index of descending pain inhibition, was determined using a thermode as test stimulus and a hot water bath as conditioning stimulus. RESULTS As hypothesized, youth with FAP living in lower SES neighborhoods exhibited weaker CPM. Contrary to hypotheses, lower neighborhood SES was associated with neither pain thresholds nor with pain tolerance. CONCLUSIONS These findings demonstrated the independent contribution of place of residence-an often neglected component of the biopsychosocial model-to efficiency of descending pain inhibition. Understanding the mechanisms that account for such associations between place and pain could guide the development of public health and policy initiatives designed to mitigate chronic pain risk in underserved and economically marginalized communities.
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Affiliation(s)
- Matthew C Morris
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda L Stone
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Judy Garber
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Craig Smith
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Lynn S Walker
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
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Lloyd JEV, Baumbusch JL, Zou D. Community lives of adolescents across multiple special needs: Discrimination, community belonging, trusted people, leisure activities, and friends. JOURNAL OF COMMUNITY PSYCHOLOGY 2021; 49:1393-1417. [PMID: 33411372 DOI: 10.1002/jcop.22498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 06/12/2023]
Abstract
We sought to gain insights into the community lives, experiences, and activities of adolescents across multiple categories of special needs. Specifically, we: explored the particular aspects of their lives adolescents felt elicited discrimination; determined whether adolescents feel a sense of community belongingness, as well as the categories of people whom adolescents approach when help is needed; and detailed the leisure activities respondents undertake and with which frequency, in addition to the quantity of friendships they have. We performed assorted descriptive analyses of the McCreary Centre Society's 2013 British Columbia Adolescent Health Survey (BCAHS) database. We found tremendous variation in the survey responses of adolescents, both within and between special needs categories, highlighting the importance of such exploratory analyses. This paper provides inductive population-based evidence to inform theories about the community lives of adolescents with special needs, as well as to guide programs and policies targeting such youth.
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Affiliation(s)
- Jennifer E V Lloyd
- School of Nursing, Faculty of Applied Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer L Baumbusch
- School of Nursing, Faculty of Applied Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Danjie Zou
- Department of Educational & Counselling Psychology & Special Education, Faculty of Education, University of British Columbia, Vancouver, British Columbia, Canada
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Testing the intergenerational model of transmission of risk for chronic pain from parents to their children: an empirical investigation of social transmission pathways. Pain 2020; 160:2544-2553. [PMID: 31393280 DOI: 10.1097/j.pain.0000000000001658] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Children of parents with chronic pain have higher rates of pain and internalizing (eg, anxiety and depressive) symptoms than children of parents without chronic pain. Parental modeling of pain behaviour and reinforcement of child pain have been hypothesized to underlie these relationships. These mechanisms were tested in a sample of 72 parents with chronic pain and their children (aged 8-15 years). Standardized measures were completed by parents (pain characteristics, pain interference, and child internalizing) and children (pain catastrophizing, pain over previous 3 months, and internalizing). In a laboratory session, children completed the cold pressor task in the presence of their parent, and parent-child verbalizations were coded. Significant indirect effects of parental pain interference on child self-reported (B = 0.12, 95% confidence interval [CI]: 0.01-0.29) and parent-reported (B = 0.16, 95% CI: 0.03-0.40) internalizing symptoms through child pain catastrophizing were found (parental modeling mechanism), and were not moderated by child chronic pain status. Significant indirect effects were found between parent pain-attending verbalizations and child self-reported (B = 2.58, 95% CI: 1.03-5.31) and parent-reported (B = 2.18, 95% CI: 0.93-4.27) cold pressor task pain intensity and tolerance (B = -1.02, 95% CI: -1.92 to -0.42) through child pain-attending verbalizations (parental reinforcement mechanism). Although further understanding of the temporal relationships between these variables is needed, the current study identifies constructs (eg, parent pain interference, child pain catastrophizing, and parent reinforcement of child pain) that should be further examined as potential targets for prevention and intervention of pain and internalizing symptoms in children of parents with chronic pain.
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Pielech M, Lunde CE, Becker SJ, Vowles KE, Sieberg CB. Comorbid chronic pain and opioid misuse in youth: Knowns, unknowns, and implications for behavioral treatment. AMERICAN PSYCHOLOGIST 2020; 75:811-824. [PMID: 32915025 PMCID: PMC9053101 DOI: 10.1037/amp0000655] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic pain and opioid misuse occur in pediatric populations and can be associated with a range of negative adverse outcomes that may persist into adulthood. While the association between chronic pain, opioid prescribing, and opioid-related adverse consequences is reasonably well established in adults, the relation in pediatric patients is not well understood and the long-term impact of opioid exposure during childhood is yet to be fully revealed. The present review draws from the available literature on chronic and acute pediatric pain prevalence and treatment, opioid misuse, and adolescent substance use to address knowns and unknowns of comorbid pediatric chronic pain and opioid misuse. Additionally, gaps in knowledge regarding the prevalence and etiology of co-occurring chronic pain and opioid misuse in youth are identified. Hypothesized, modifiable risk factors associated with both pediatric pain and opioid misuse are considered. Due to a lack of empirically supported integrated treatments for comorbid chronic pain and opioid misuse in youth, this review examines the evidence base and best practices from both the chronic pain and opioid treatment literature to guide treatment recommendations for these comorbid conditions in youth. Recommendations are then provided to promote screening and mitigate risk of chronic pain and opioid misuse across a range of pediatric settings. Lastly, a comprehensive agenda to prevent and treat chronic pain and opioid misuse in adolescents and young adults is discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Melissa Pielech
- Center for Alcohol and Addiction Studies, Brown University School of Public Health
| | - Claire E. Lunde
- Biobehavioral Pediatric Pain Lab, Department of Psychiatry, Boston Children’s Hospital
- Center for Pain and the Brain (P.A.I.N. Group), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital
- Nuffield Department of Women’s and Reproductive Health, Medical Sciences Division, University of Oxford
| | - Sara J. Becker
- Center for Alcohol and Addiction Studies, Brown University School of Public Health
| | - Kevin E. Vowles
- Centre for Improving Health-Related Quality of Life, School of Psychology, Queen’s University Belfast
| | - Christine B. Sieberg
- Biobehavioral Pediatric Pain Lab, Department of Psychiatry, Boston Children’s Hospital
- Center for Pain and the Brain (P.A.I.N. Group), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital
- Department of Psychiatry, Harvard Medical School
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Wilson AC, Holley AL, Stone A, Fales JL, Palermo TM. Pain, Physical, and Psychosocial Functioning in Adolescents at Risk for Developing Chronic Pain: A Longitudinal Case-Control Stusdy. THE JOURNAL OF PAIN 2019; 21:418-429. [PMID: 31494274 DOI: 10.1016/j.jpain.2019.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 08/08/2019] [Accepted: 08/12/2019] [Indexed: 01/25/2023]
Abstract
This longitudinal case-control study aims to 1) compare symptoms and functioning in otherwise healthy adolescents with versus without a parent with chronic pain (Parent CP+/Parent CP-) 2) test adolescent sex as a moderator of the relation between parent CP group and child functioning, and 3) determine changes in adolescent pain over 1 year. Adolescents (n = 140; ages 11-15) completed tests of pain responsivity and physical function, as well as self-report measures assessing pain characteristics, somatic symptoms, and physical and psychosocial functioning. Self-reported pain and somatic symptoms were reassessed 1 year later. Adolescents in the Parent CP+ group reported greater pain, somatic symptoms, and worse physical health than Parent CP- youth. Parent CP+ youth performed worse on all tests of physical function. Some observed effects were stronger for girls than boys. There were no differences between groups on pain responsivity. Both groups reported increased pain and somatic symptoms from baseline to 1-year follow-up, with the Parent CP+ group reporting the highest level of symptoms at both time points. This study highlights the potential impact of parental pain status on children, particularly daughters, and is the first to document objective physical functioning differences in youth at risk for developing chronic pain. PERSPECTIVE: Adolescents who have a parent with chronic pain demonstrate higher pain and lower physical function than adolescents who have a parent without chronic pain. Group differences in pain and somatic symptoms persist over 1 year. Family based interventions are needed for comprehensive pain prevention and treatment.
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Affiliation(s)
- Anna C Wilson
- Oregon Health & Science University, Department of Pediatrics, Portland, OR.
| | - Amy L Holley
- Oregon Health & Science University, Department of Pediatrics, Portland, OR
| | - Amanda Stone
- Oregon Health & Science University, Department of Pediatrics, Portland, OR; Vanderbilt University Medical Center, Division of Research, Nashville, TN
| | - Jessica L Fales
- Washington State University Vancouver, Department of Psychology, Vancouver, WA
| | - Tonya M Palermo
- Seattle Children's Research Institute, Seattle, WA; University of Washington, Department of Anesthesiology and Pain Medicine, Seattle, WA
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Tran ST, Koven ML, Castro AS, Goya Arce AB, Carter JS. Sociodemographic and Environmental Factors are Associated with Adolescents' Pain and Longitudinal Health Outcomes. THE JOURNAL OF PAIN 2019; 21:170-181. [PMID: 31255798 DOI: 10.1016/j.jpain.2019.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/31/2019] [Accepted: 06/10/2019] [Indexed: 02/04/2023]
Abstract
Research in adult populations indicates that several sociodemographic and environmental variables increase risk for pain and poor outcomes. There is little research exploring the impact of household income, health insurance coverage, barriers to health care, neighborhood and school safety, violence experienced, and neighborhood isolation on pediatric chronic pain. Data from the Add Health Study, a longitudinal examination of a nationally-representative adolescent sample were analyzed. The relationships between demographic variables, risk factors, chronic pain, and long-term health outcomes were examined. Adolescents with chronic pain had lower income, more health care barriers, greater safety concerns, and experienced more violence compared to those without pain. In a model together, female sex, White race/ethnicity, and greater health care barriers, safety concerns, and violence exposure conferred significant risk for chronic pain. Additional analyses revealed nuances in the strength of risk factors between racial/ethnic groups. Systemic health care barriers were significantly associated with chronic pain and may delay symptom alleviation and return to functioning. Considering access to care is necessary in prevention efforts. Among adolescents with chronic pain, greater safety concerns predicted poor mental health outcomes, particularly for White females. The cumulative stress of environmental concerns, such as safety, and managing chronic pain may worsen functioning. PERSPECTIVE: Adolescents with chronic pain had lower income, and more health care barriers, safety concerns, and violence exposure compared to those without chronic pain. Access to care is a significant problem in youth with chronic pain. The relationships between race/ethnicity, risk factors, and health outcomes are complex and require additional research.
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Affiliation(s)
- Susan T Tran
- Department of Psychology, DePaul University, Cook County, Chicago, Illinois.
| | - Marissa L Koven
- Department of Psychology, DePaul University, Cook County, Chicago, Illinois
| | - Ashley S Castro
- Department of Psychology, DePaul University, Cook County, Chicago, Illinois
| | - Ana B Goya Arce
- Department of Psychology, DePaul University, Cook County, Chicago, Illinois
| | - Jocelyn S Carter
- Department of Psychology, DePaul University, Cook County, Chicago, Illinois
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Zeglinski-Spinney A, Wai DC, Phan P, Tsai EC, Stratton A, Kingwell SP, Roffey DM, Wai EK. Increased Prevalence of Chronic Disease in Back Pain Patients Living in Car-dependent Neighbourhoods in Canada: A Cross-sectional Analysis. J Prev Med Public Health 2018; 51:227-233. [PMID: 30286594 PMCID: PMC6182270 DOI: 10.3961/jpmph.18.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/13/2018] [Indexed: 11/30/2022] Open
Abstract
Objectives Chronic diseases, including back pain, result in significant patient morbidity and societal burden. Overall improvement in physical fitness is recommended for prevention and treatment. Walking is a convenient modality for achieving initial gains. Our objective was to determine whether neighbourhood walkability, acting as a surrogate measure of physical fitness, was associated with the presence of chronic disease. Methods We conducted a cross-sectional study of prospectively collected data from a prior randomized cohort study of 227 patients referred for tertiary assessment of chronic back pain in Ottawa, ON, Canada. The Charlson Comorbidity Index (CCI) was calculated from patient-completed questionnaires and medical record review. Using patients’ postal codes, neighbourhood walkability was determined using the Walk Score, which awards points based on the distance to the closest amenities, yielding a score from 0 to 100 (0-50: car-dependent; 50-100: walkable). Results Based on the Walk Score, 134 patients lived in car-dependent neighborhoods and 93 lived in walkable neighborhoods. A multivariate logistic regression model, adjusted for age, gender, rural postal code, body mass index, smoking, median household income, percent employment, pain, and disability, demonstrated an adjusted odds ratio of 2.75 (95% confidence interval, 1.16 to 6.53) times higher prevalence for having a chronic disease for patients living in a car-dependent neighborhood. There was also a significant dose-related association (p=0.01; Mantel-Haenszel chi-square=6.4) between living in car-dependent neighbourhoods and more severe CCI scores. Conclusions Our findings suggest that advocating for improved neighbourhood planning to permit greater walkability may help offset the burden of chronic disease.
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Affiliation(s)
- Amy Zeglinski-Spinney
- Ottawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, ON, Canada
| | - Denise C Wai
- Ottawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, ON, Canada
| | - Philippe Phan
- Ottawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Orthopaedic Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - Eve C Tsai
- Ottawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Neurosurgery, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - Alexandra Stratton
- Ottawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Orthopaedic Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - Stephen P Kingwell
- Ottawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Orthopaedic Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - Darren M Roffey
- Ottawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Eugene K Wai
- Ottawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Orthopaedic Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
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