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Interdisciplinary pain rehabilitation (IPR) is a recommended treatment for people with chronic pain. An inadequate description of the content of IPR programs makes it difficult to draw conclusions regarding their effects. The purpose of this study was to describe the perceptions and attitudes of healthcare professionals toward a content description of IPR programs for patients with chronic pain. Individual interviews with healthcare professionals (n = 11) working in IPR teams in Sweden were conducted between February and May 2019. Analysis of the interviews resulted in a theme: interdisciplinary pain rehabilitation is a complex intervention, with three categories: limitations in the description of IPR programs; lack of knowledge about IPR and chronic pain; and facilitating and hindering factors for using the content description of IPR programs. Conclusion: Healthcare professionals perceived that IPR programs could be described through a general content description. A general content description could enhance the quality of IPR programs through a better understanding of their content and a comparison of different IPR programs. Healthcare professionals also expressed the importance of a content description being a guide rather than a steering document.

Huan-Ji Dong,1 Elena Dragioti,1 Marcelo Rivano Fischer,2,3 Björn Gerdle1 1Pain and Rehabilitation Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; 2Department of Health Sciences, Research Group Rehabilitation Medicine, Lund University, Lund, Sweden; 3Department of Neurosurgery and Pain Rehabilitation, Skåne University Hospital, Lund, SwedenCorrespondence: Huan-Ji DongPain and Rehabilitation Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, SE-581 85, SwedenTel +46 730488933Email huanji.dong@liu.seBackground: It is known that chronic pain makes it difficult to lose weight, but it is unknown whether obese patients (body mass index ≥ 30 kg/m2) who experience significant pain relief after interdisciplinary multimodal pain rehabilitation (IMMPR) lose weight.Objective: This study investigated whether obese patients with chronic pain lost weight after completing IMMPR in specialist pain units. The association of pain relief and weight change over time was also examined.Methods: Data from obese patients included in the Swedish Quality Registry for Pain Rehabilitation for specialized pain units were used (N=224), including baseline and 12-month follow-up after IMMPR from 2016 to 2018. Patients reported body weight and height, pain aspects (eg, pain intensity), physical activity behaviours, psychological distress, and health-related quality of life (HRQoL). A reduction of at least 5% of initial weight indicates clinically significant weight loss. Patients were classified into three groups based on the pain relief levels after IMMPR: pain relief of clinical significance (30% or more reduction of pain intensity); pain relief without clinical significance (less than 30% reduction of pain intensity); and no pain relief. Linear mixed regression models were used to examine the weight changes among the groups with different pain relief levels.Results: A significant reduction of pain intensity was found after IMMPR (p < 0.01, effect size Cohen’s d = 0.34). A similar proportion of patients in the three groups with different pain relief levels had clinically significant weight loss (20.2%∼ 24.3%, p = 0.47). Significant improvements were reported regarding physical activity behaviour, psychological distress, and HRQoL, but weight change was not associated with changes of pain intensity.Conclusion: About one-fifth of obese patients achieved significant weight reduction after IMMPR. Obese patients need a tailored pain rehabilitation program incorporating a targeted approach for weight management.Keywords: obesity, weight loss, chronic pain, pain intensity, pain rehabilitation

Background Efforts to identify specific variables that impact most on outcomes from interdisciplinary pain rehabilitation are challenged by the complexity of chronic pain. Methods to manage this complexity are needed. The purpose of the study was to determine the network structure entailed in a set of self-reported variables, examine change, and look at potential predictors of outcome, from a network perspective. Methods In this study we apply network analysis to a large sample of people seeking interdisciplinary pain treatment (N = 2,241). Variables analyzed include pain intensity, pain interference, extent of pain, depression, anxiety, insomnia, and psychological variables from cognitive behavioral models of chronic pain. Results We found that Acceptance, Pain Interference, and Depression were key, “central,” variables in the pretreatment network. Interestingly, there were few changes in the overall network configuration following treatment, specifically with respect to which variables appear most central relative to each other. On the other hand, Catastrophizing, Depression, Anxiety, and Pain Interference each became less central over time. Changes in Life Control, Acceptance, and Anxiety were most strongly related to changes in the remainder of the network as a whole. Finally, no network differences were found between treatment responders and non-responders. Conclusions This study highlights potential future targets for pain treatment. Further application of a network approach to interdisciplinary pain rehabilitation data is recommended. Going forward, it may be better to next do this in a more comprehensive theoretically guided fashion, and ideographically, to detect unique individual differences in potential treatment processes.

There is now a consensus in the literature that future improvements in outcomes obtained from cognitive behavioral therapy (CBT) for chronic pain will require research to identify patient and treatment variables that help explain outcomes. The first aim of this study was to assess whether pre-treatment scores on measures of psychological (in)flexibility, acceptance, committed action, cognitive (de)fusion, and values-based action predict outcomes in a multidisciplinary, multicomponent, group-based CBT program for adults with chronic pain. The second aim was to assess whether change scores on these same measures mediate outcomes in the treatment program. Participants were 232 people attending treatment for chronic pain. Of the psychological flexibility measures, only pre-treatment scores on the psychological inflexibility scale predicted outcomes; higher scores on this measure were associated with worse outcomes. However, change scores on each of the psychological flexibility measures separately mediated outcomes. The efficacy of CBT for chronic pain may be improved with a greater focus on methods that increase psychological flexibility.

Objective Interdisciplinary pain rehabilitation (IPR) usually employs a cognitive–behavioural therapeutic (CBT) approach. However, there is growing support for chronic pain treatments based on acceptance and commitment therapy (ACT). Most studies of ACT and CBT for chronic pain have evaluated their effects after psychological interventions, not after IPR. We compared the results of an ACT-based IPR programme with two CBT-based IPR programmes. Methods We used a retrospective multicentre pretest–posttest design with matched patient groups at three centres. Data were collected from the Swedish Quality Registry for Pain Rehabilitation before and after IPR participation. Participants completed the EQ-5D health-related quality of life questionnaire, the Chronic Pain Acceptance Questionnaire, (CPAQ) and the Hospital Anxiety and Depression Scale (HADS). Analyses were performed to compare the effects of the different interventions. Results Neither EQ-5D nor HADS depression scores were affected by the psychological approach used. The score changes on both CPAQ subscales (activity engagement and pain willingness) indicated significant improvements between admission and discharge at all centres. Conclusions These findings indicate the effectiveness of using psychological approaches to manage chronic pain. Both CBT and ACT had a beneficial effect on most of the assessed health-related parameters.

Background Throughout the world many people have both obesity and chronic pain, comorbidities that decrease Health-Related Quality of Life (HRQoL). It is uncertain whether patients with comorbid obesity can maintain improved HRQoL after Interdisciplinary Multimodal Pain Rehabilitation (IMMPR). Methods Data from 2016, 2017, and 2018 were obtained from a national pain database for Swedish specialized pain clinics and collected at three time points: Pre-IMMPR; Post- IMMPR; and 12-month follow-up (FU-IMMPR). Participants (N = 872) reported body weight, height, pain aspects, and HRQoL (RAND 36-Item Health Survey). Severe obesity (Body Mass Index, BMI amp;gt;= 35 kg/m(2)) was defined according to WHO classifications. We used linear mixed regression models to examine BMI group differences in HRQoL over time. Results More than 25% of patients (224/872) were obese and nearly 30% (63/224) of these were severely obese. All BMI groups improved significantly in both physical and mental composites of HRQoL after IMMPR (Pre- vs. Post-IMMPR, p amp;lt; .001). The improvements were maintained at a 12-month follow-up (Post- vs. FU-IMMPR, p amp;gt; .05). The severe obesity group had the lowest physical health score and least improvement (pre- vs. FU-IMMPR, Cohens d = o.422, small effect size). Severe obesity had negative impact on physical health (beta = -4.39, p amp;lt; .05) after controlling for sociodemographic factors and pain aspects. Conclusion Improvements in HRQoL after IMMPR were achieved and maintained across all weights, including patients with comorbid obesity. Only severe obesity was negatively associated with physical health aspects of HRQoL. Significance Patients with chronic pain and comorbid obesity achieve sustained Health-Related Quality of Life (HRQoL) improvements from Interdisciplinary Multimodal Pain Rehabilitation (IMMPR). This finding suggests that rehabilitation professionals should consider using IMMPR for patients with comorbid obesity even though their improvement may not reach the same level as for non-obese patients. Funding Agencies|Swedish Trade Union Confederation; The Confederation of Swedish Enterprise; County Council of Ostergotland Research; The Council for Negotiation and Co-operation

Introduction The Multidimensional Pain Inventory (MPI) is frequently used in the assessment of chronic pain. Three subgroups have been derived from MPI: adaptive coper (AC), dysfunctional (DYS), and interpersonally distressed (ID). The primary aim of this study was to examine whether outcome of Interdisciplinary Multimodal Pain Rehabilitation Programs (IMMRPs) differed across the MPI subgroups. Methods Patients with chronic pain (N = 34,513), included in the Swedish Quality Registry for Pain Rehabilitation, were classified into MPI subgroups and a subset that participated in IMMRPs (N = 13,419) was used to examine overall treatment outcomes using a previously established Multivariate Improvement Score (MIS) and 2 retrospective patient-evaluated benefits from treatment. Results The subgroups differed on sociodemographic characteristics, pain duration, and spatial spreading of pain. DYS and ID had the best overall outcomes to MIS. AC had the best outcomes according to the 2 retrospective items. Transition into other subgroups following IMMRP was common and most prominent in DYS and least prominent in AC. Conclusion The validity of the MPI subgroups was partially confirmed. DYS and ID had the most severe clinical presentations at baseline and showed most improvement following IMMRP, but overall severity in DYS and ID at post-treatment was still higher than in the AC group. Future studies should examine how processes captured by MPI interact with neurobiological, medical, sociodemographic, and adaptation/coping factors and how these interactions impact severity of chronic pain and treatment outcome. Funding Agencies|Swedish Research CouncilSwedish Research CouncilEuropean Commission [2018-02470]; County Council of ostergotland [LIO-608021]

Introduction The extent to which pain is distributed across the body (spreading of pain) differs largely among patients with chronic pain conditions and widespread pain has been linked to poor quality of life and work disability. A longer duration of pain is expected to be associated with more widespread pain, but studies are surprisingly scarce. Whether spreading of pain is associated with clinical presentation and treatment outcome in patients seen in interdisciplinary multimodal pain rehabilitation programs (IMMRPs) is unclear. The association between spreading of pain and (1) pain duration (2) clinical presentation (eg, pain intensity, pain-related cognitions, psychological distress, activity/participation aspects and quality of life) and (3) treatment outcome were examined. Methods Data from patients included in the Swedish Quality Registry for Pain Rehabilitation were used (n=39,916). A subset of patients that participated in IMMRPs (n=14,666) was used to examine whether spreading of pain at baseline predicted treatment outcome. Spreading of pain was registered using 36 predefined anatomical areas which were summarized and divided into four categories: 1–6 regions with pain (20.6% of patients), 7–12 regions (26.8%), 13–18 regions (22.0%) and 19–36 regions (30.6%). Results More widespread pain was associated with a longer pain duration and a more severe clinical picture at baseline with the strongest associations emerging in relation to health and pain aspects (pain intensity, pain interference and pain duration). Widespread pain was associated with a poorer overall treatment outcome following IMMRPs at both posttreatment and at a 12-month follow-up, but effect sizes were small. Discussion Spreading of pain is an indicator of the duration and severity of chronic pain and to a limited extent to outcomes of IMMRP. Longer pain duration in those with more widespread pain supports the concept of early intervention as clinically important and implies a need to develop and improve rehabilitation for patients with chronic widespread pain.

Aim: Investigate the feasibility of identifying a well-defined treatment group and a comparable reference group in clinical register data. Background: There is insufficient knowledge on how to avert neck/back pain from turning chronic or to impair work ability. The Swedish Government implemented a national multimodal rehabilitation (MMR) programme in primary care intending to promote work ability, reduce sick leave and increase return to work. Since randomised control trial data for effect is lacking, it is important to evaluate existing observational data from clinical settings. Methods: We identified all unique patients with musculoskeletal pain (MSP) diagnoses undergoing the MMR programme in primary care in the Skåne Health care Register (n = 2140) during 2010–2011. A reference cohort in primary care (n = 56 300) with similar MSP diagnoses, same ages and the same level of sick leave before baseline was identified for the same period. The reference cohort received ordinary care and treatment in primary care. The final study group consisted of 603 eligible MMR patients and 2874 eligible reference patients. Socio-economic and health-related baseline data including sick leave one year before up to two years after baseline were compared between groups. Findings: There were significant socio-economic and health differences at baseline between the MMR and the reference patients, with the MMR group having lower income, higher morbidity and more sick leave days. Sick leave days per year decreased significantly in the MMR group (118–102 days, P < 0.001) and in the reference group (50–42 days, P < 0.001) from one year before baseline to two years after. Conclusions: It was not feasible to identify a comparable reference group based on clinical register data. Despite an ambitious attempt to limit selection bias, significant baseline differences in socio-economic and health were present. In absence of randomised trials, effects of MMR cannot be sufficiently evaluated in primary care.

Purpose Value based action is an important process in the psychological flexibility model and is associated with daily functioning in people with chronic pain, but measures of it are not well-developed. The purpose of the present study was to examine the reliability and validity of a Swedish-language version of the Chronic Pain Values Inventory (CPVI) in a large sample of adults seeking treatment for chronic pain. Material and methods A Swedish version of the CPVI was created and administered alongside other measures of psychological flexibility and pain-related functioning in a convenience sample of 232 patients admitted for treatment at the Pain Rehabilitation Unit at Skane University Hospital between February 2014 and December 2015. Internal consistency of the CPVI was assessed as was its relationship to theoretically related facets from the psychological flexibility model. The utility of values-related processes in explaining variance in pain-related functioning was also examined by correlations and hierarchical regression analyses. Results Overall, this Swedish-language version of the CPVI was found to have satisfactory reliability and validity. The CPVI subscales yielded high levels of internal consistency. Evidence of construct validity in relation to other measures from the psychological flexibility model was observed as well as evidence of clinical utility in relation to measures of pain-related functioning. Discussion This brief self-report measure of values-based action seems to yield valid data in Swedish adults suffering from chronic pain. Values based processes appear important within evidence-based treatments for chronic pain, especially Acceptance and Commitment Therapy (ACT), and the CPVI may help assess these, particularly in predictor studies of pain-related functioning and analyses of therapeutic change processes or mechanisms.

Background: Due to the obesity epidemic, pain rehabilitation clinics have had to reconsider how to best serve their patients. To date, little is known about baseline level of physical activity (PA) in patients referred to pain rehabilitation clinics.Objectives: To investigate the PA levels of patients referred to pain rehabilitation clinics and to evaluate the effect of excess weight on PA level.Methods: Data were obtained from the Swedish Quality Registry for Pain Rehabilitation (SQRP) between 2016 and 2017. These data included PA time, Body Mass Index (BMI), sociodemographic factors, chronic pain and psychological aspects (e.g., pain intensity, depressive and anxiety symptoms and insomnia problems). The SQRP collects data on PA using a questionnaire that asks patients to indicate how much time they spend on everyday PA and physical exercise (PE) per week. Insufficient PA was defined as less than 150 minutes per week. We performed logistic regressions as well as orthogonal partial least square regression to estimate the effects of excess weight on PA.Results: Over one-fourth of the patients were classified as obese (BMI ≥30 kg/m 2 , 871/3110, 25.3%) and nearly one-third of these patients were classified as severely obese (BMI ≥35 kg/m 2 , 242/871, 27.8%). Time estimations for PE varied among the BMI groups, but patients in the higher BMI category were more likely to spend less time on everyday PA. After controlling for sociodemographic factors, pain, and psychological aspects, mild obesity (OR 0.65, 95% CI 0.53-0.81) and severe obesity (OR 0.56, 95% CI 0.42-0.74) were associated with less PA. Compared to normal weight peers, mild obese patients had an elevated risk of 65% and severe obese patients had an elevated risk of 96% for insufficient PA. For obese patients, increased pain intensity was positively related to insufficient PA (OR 1.17, 95% CI 1.06-1.29).Conclusion: Having low PA is very common for patients referred to pain rehabilitation clinics, especially for those with comorbid obesity. As a first step to increase PA, obese patients need to be encouraged to increase the intensity and amount of less painful daily PA.

Objectives: To investigate: (i) changes in sick-leave benefits from 1 year prior to multimodal rehabilitation to 1 and 2 years after rehabilitation; (ii) sex differences in sick leave; and (iii) the impact of policy changes on sick leave. Methods: All patients undergoing multimodal rehabilitation registered in a national pain database for 2007-11 (n = 7,297) were linked to the Swedish Social Insurance Agency database. Sick leave was analysed in 3-month periods: T0: 1 year before rehabilitation; T1: before start; T2: 1 year after; and T3: 2 years after rehabilitation. Four sick-leave benefit categories were constructed: no sick leave, part-time sick leave, full-time sick leave, and full-time permanent sick leave. The individual change in sick-leave category at each time-period was analysed. Results: Sick-leave benefits increased from T0 to T1 (p < 0.001) and decreased from T1 to T3 (p < 0.001). Reductions were significant for both men and women from T1 to T3, but men had less sick-leave benefits at T2 and T3. Positive changes in sick-leave benefits at T2 and T3 were found both prior to and after policy changes, with less sick-leave benefits after policy changes at all time-points. Conclusion: Multimodal rehabilitation may positively influence sick-leave benefits for patients with chronic pain, regardless of their sick-leave situation, sex or policy changes.

Purpose: Psychological flexibility is the theoretical model that underpins Acceptance Commitment Therapy (ACT). There is a growing body of evidence indicating that ACT is an effective treatment for chronic pain but one component of the model, committed action, has not been sufficiently researched. The purpose of this study is to validate Swedish-language versions of the full length Committed Action Questionnaire (CAQ; CAQ-18) and the shortened CAQ (CAQ-8), to examine the generality of previous results related to committed action and to further demonstrate the relevance of this construct to the functioning of patients with chronic pain. Method: The study includes preliminary analyses of the reliability and validity of the CAQ. Participants were 462 consecutive referrals to the Pain Rehabilitation Unit at Skåne University Hospital. Results: The Swedish-language versions of the CAQ (CAQ-18 and CAQ-8) demonstrated high levels of internal consistency and satisfactory relationships with various indices of patient functioning and theoretically related concepts. Confirmatory factor analyses showed that the Swedish versions of the CAQ yielded similar two-factor models as found in the original validation studies. Hierarchical regression analyses identified the measures as significant contributors to explained variance in patient functioning. Conclusion: The development, translation and further validation of the CAQ is an important step forward in evaluating the utility of the psychological flexibility model to the treatment of chronic pain. The CAQ can both assist researchers interested in mediators of chronic pain treatment and further enable research on change processes within the psychological flexibility model.

OBJECTIVE: To describe the organization, content and dosage of interdisciplinary pain rehabilitation, and the differences in degree of severity of problems of patients admitted to clinical units reporting to a Swedish national quality pain registry, grouped according to unit size and possible affiliation with a university hospital. METHODS: Reports from 31 out of 39 clinical units in Sweden, on inclusion processes, organization, content and dosage of interdisciplinary pain rehabilitation, and patient-reported data from a Swedish national quality pain registry at assessment for interdisciplinary pain rehabilitation were analysed. RESULTS: the number of patients treated annually at each unit ranged from 3 to 340. In 17 units, teams comprised 5 professionals. Dosage of interdisciplinary pain rehabilitation ranged from 20-180 h per patient in total. Patients at the university-hospital units scored the highest levels of symptoms and lowest levels of health-related quality of life. Units used similar sets of inclusion criteria, and several treatments, such as education, self-training and psychological interventions, were used by most units. CONCLUSION: When interpreting outcome data from registries, aspects other than rehabilitation outcomes must be considered. The interpretation of outcomes from quality registries would be facilitated if data, in addition to assessments and patient-reported outcomes, also includes standardized descriptions of the reporting clinical units. (Less)

Background: The relevance of PTSD symptoms to outcomes of Cognitive Behavioral Therapy (CBT) for chronic pain is unclear. This study examines whether (a) traumatic exposure or the severity of PTSD symptoms at pre‐treatment predict outcomes (pain intensity/interference) (b) participation in this treatment is associated with reduced PTSD symptoms, and (c) any observed changes in PTSD symptoms are mediated by changes in psychological mechanisms that have been shown to be of importance to PTSD and chronic pain. Methods: Participants were 159 chronic pain patients who were consecutively admitted for a multidisciplinary, group‐based CBT program at the Pain Rehabilitation Unit at Skane University Hospital. A self‐report measure of traumatic exposure and PTSD symptoms was administered before and after treatment, and at a 12‐month follow‐up, along with measures of depression, anxiety, pain intensity, pain interference, psychological inflexibility, life control, and kinesiophobia. Results: Traumatic exposure and PTSD symptom severity did not predict pain intensity or interference at 12‐month follow‐up. There were no overall significant changes in PTSD symptom severity at post‐treatment or follow‐up, but 24.6% of the participants showed potential clinically significant change at follow‐up. Psychological inflexibility mediated the changes that occurred in PTSD symptoms during treatment. Conclusions: Neither traumatic exposure nor baseline symptoms of PTSD predicted the treatment outcomes examined here. Despite improvements in both comorbid depression and anxiety, participation in this pain‐focused CBT program was not associated with improvements in comorbid PTSD. To the extent that changes in PTSD symptoms did occur, these were mediated by changes in psychological inflexibility during treatment. Significance: Pain‐focused CBT programs yield clinically meaningful improvements in pain and comorbid symptoms of depression and anxiety, but may have little effect on comorbid PTSD. This raises the issue of whether current pain‐focused CBT programs can be modified to improve outcomes for comorbid conditions, perhaps by better targeting of psychological flexibility, and/or whether separate treatment of PTSD may be associated with improved pain outcomes. (Less)

Objectives: The symptoms of Posttraumatic Stress Disorder (PTSD) and chronic pain are thought to interact to increase the severity and impact of both conditions, but the mechanisms by which they interact remain unclear. This study examines the relationship between PTSD and chronic pain and whether indices of psychological flexibility mediate the relationship between these two conditions. Methods: Standardized self-report measures of PTSD, pain severity, pain interference, depression, and psychological flexibility (pain-related acceptance, committed action, cognitive fusion, and values-based action) were obtained from 315 people seeking treatment for chronic pain who also reported at least one traumatic experience. Results: People seeking treatment for chronic pain reporting symptoms consistent with a current diagnosis of PTSD had significantly higher levels of pain severity, pain interference, depression, and cognitive fusion and lower levels of pain-related acceptance and committed action than those reporting symptoms below diagnostic threshold for PTSD. Pain-related acceptance, committed action, cognitive fusion and depression mediated the relationship between PTSD and pain severity/interference, with pain-related acceptance being the strongest mediator from the psychological flexibility model. Discussion: Processes from the psychological flexibility model were identified as mediators of the relationship between PTSD and chronic pain in people seeking treatment for chronic pain. The psychological flexibility model may be useful as an overarching model to help understand the relationship between PTSD and chronic pain. It is possible that targeting painrelated acceptance, committed action, and cognitive fusion (among other processes) in the treatment of chronic pain may produce corresponding improvements in comorbid symptoms of PTSD when these are present and may reduce impacts of PTSD on outcomes of chronic pain. Conversely, targeting of these processes in the treatment of PTSD may produce similar improvements for symptoms of chronic pain. Further research to evaluate these possibilities is needed.

Purpose: The purpose of this study was to assess the psychometric properties of a Swedish version of the Posttraumatic Diagnostic Scale (PDS); to investigate the prevalence of traumatic experiences, trauma types, and posttraumatic stress disorder (PTSD) in a sample of patients seeking treatment for chronic pain; and to examine how indices of pain-related functioning vary with a history of traumatic exposure and PTSD diagnostic status. Method: Participants were 463 consecutive patients with chronic pain referred for assessment at the Pain Rehabilitation Unit at Skåne University Hospital. Results: The translated version of the PDS demonstrated high levels of internal consistency and a factor structure similar to that reported in previous validation studies using samples identified because of trauma exposure (not chronic pain), both of which provide preliminary support for the validity of this translated version. Based on their responses to the PDS, most patients (71.8%) reported one or more traumatic events with 28.9% fulfilling criteria for a current PTSD diagnosis. The patients with PTSD also reported significantly higher levels of pain interference, kinesiophobia, anxiety, and depression and significantly lower levels of life control, compared to patients exposed to trauma and not fulfilling criteria for PTSD and patients with no history of traumatic exposure. Conclusion: Consistent with previous research, a significant proportion of patients seeking treatment for chronic pain reported a history of traumatic exposure and nearly one third of these met current criteria for PTSD according to a standardized self-report measure. The presence of PTSD was associated with multiple indictors of poorer functioning and greater treatment need and provides further evidence that routine screening of chronic pain patients for PTSD is warranted. Self-report measures like the PDS appear to be valid for use in chronic pain samples and offer a relative low-cost method for screening for PTSD.

OBJECTIVE: To explore the treatment patterns of patients with a diagnosis related to chronic pain (DRCP) initiating pharmacological treatment indicated for neuropathic pain (NeuP: tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants).DESIGN: Retrospective study on administrative registers.SETTING: General population in Western Sweden (one sixth of the country).SUBJECTS: All patients with a DRCP (N = 840,000) in years 2004-2009.OUTCOME MEASURES: Treatment sequence, continuation, switching, and comedication.RESULTS: In total, 22,997 patients with a first NeuP in 2007 or 2008 were identified, out of which 2% also had epilepsy and 39% had a mood disorder. The remaining 13,749 patients were assumed to be treated for neuropathic pain, out of which 16% had a neuropathy diagnosis, 18% had a mixed pain diagnosis, and the remaining 66% had another DRCP. The most common first prescription was amitriptyline (40%) followed by pregabalin (22%) and gabapentin (19%). More than half had discontinued treatment after 3 months, and 60-70% at 6 months. Seven percent received another NeuP drug within 6 months of the discontinuation of their first NeuP treatment, 11% had another analgesic and 22% had a prescription indicating psychiatric comorbidity (selective serotonin reuptake inhibitors or benzodiazepine).CONCLUSIONS: Treatment initiation of currently available drugs indicated for neuropathic pain less frequently lead to long-term treatment in clinical practice compared with clinical trial, and few try more than one drug. We suggest our findings to be indications of a need for better routines in diagnosing patients to ascertain optimal treatment and follow-up. (Less)

Purpose The aims of the present study were to assess: (i) changes in coping by use of Multidimensional Pain Inventory profiles from baseline to follow-up, (ii) associations between Adaptive Coper (AC) profiles at follow-up and improvements in occupational performance (by Canadian Occupational Performance Measure COPM) and (iii) ability to predict AC profiles at follow-up by participants' baseline characteristics. Method Data at baseline, discharge and follow-up from 525 participants in a pain rehabilitation program were analyzed with multivariate statistics. Results AC profiles increased and Dysfunctional (DYS) profiles decreased at follow-up. Clinically relevant improvements on COPM were associated with having an AC profile at follow-up. Being Nordic born, having longer education, an AC profile and higher baseline scores on satisfaction with performance predicted an AC profile at follow-up. Conclusions Pain rehabilitation seems to result in sustainable and favourable coping strategies at follow-up, and improved occupational performance is associated with favourable coping at follow-up. Outcomes need to be measured independently of improved coping strategies and improvements of participant's individual goals such as difficulties to perform their most meaningful occupations. Patients at risk for unfavourable coping strategies may need modified interventions. Implications for Rehabilitation More participants reported a beneficial coping, MPI profile, in a long-term perspective after a pain rehabilitation program. Improvements on occupational performance prioritized as meaningful by each of the participants are related to adequate coping strategies at follow-up. The associations between improved occupational performance and beneficial coping profiles need to be better understood. Patients with worse initial occupational performance may need modified pain rehabilitation interventions to improve their coping strategies.

The aim of this study was to examine whether Multidimensional Pain Inventory (MPI) subscale score changes can be used for monitoring interdisciplinary cognitive behavioural pain rehabilitation programmes, using the Psychological General Well-Being (PGWB) index as an independent variable of rehabilitation outcome. Data from 434 consecutively referred patients disabled by chronic pain were analysed. The intervention was a 4-week interdisciplinary pain rehabilitation group programme (5 h/day), based on biopsychosocial and cognitive behavioural principles. Mean PGWB total scores improved after rehabilitation (P

Patients with fibromyalgia (FM) and chronic widespread pain (CWP) find physical activity troublesome. The purpose was to develop a questionnaire to investigate the experience of physical activity in FM and CWP populations.A questionnaire was developed from a qualitative study. After that, a total of 204 patients with FM or CWP completed the questionnaire. A factor analysis was conducted and the internal consistency was investigated. The relationship between the factors and pain, health status (the Fibromyalgia Impact Questionnaire, FIQ), distress (the Hospital Anxiety and Distress scale, HAD) and leisure time physical activity (the Leisure Time Physical Activity Instrument, LTPAI) was investigated.Five factors were identified: Physical Relaxation (PR), Well-being (WB), Activity Beliefs (AB), Activity-related Symptoms (AS) and Activity Habits (AH). Cronbach's alpha ranged from 0.57 to 0.86. The PR showed a correlation (rho 0.28, p0.01) with the FIQ Pain. The AS showed a correlation (rho 0.25, p0.01) with the FIQ total score, while the AH showed a correlation with the HAD Depression (0.26, p0.01) and with strenuous physical activity (LTPAI) (-0.32, p0.01).A new instrument was developed to study the experience of physical activity in persons with long-lasting pain. Five factors were identified using factor analysis, and three of them showed fair associations with FM symptoms, distress or physical activity.

Cognitive Behavioral Therapy (CBT) is the most frequently delivered psychological intervention for adults with chronic pain. The treatment yields modest effect sizes and the mechanisms of action remain understudied and unclear. Efforts are needed to identify treatment mediators that could be used to refine CBT and improve outcomes. The primary aim of this study is to investigate whether pain-related acceptance, from the psychological flexibility model, mediates changes in outcome over time in a CBT-based treatment program. This includes comparing how this variable relates to three other variables posited as potential mediators in standard CBT: life-control, affective distress, and social support. Participants attended a five-week outpatient multidisciplinary program with self-report data collected at assessment, post-treatment, and at 12-month follow-up. Multilevel structural equation modeling was used to test for mediation in relation to three outcomes: pain interference, pain intensity, and depression. Results indicate that effect sizes for the treatment were within the ranges reported in the CBT for pain literature. Pain-related acceptance was not related to pain intensity, which is in line with past empirical evidence and the treatment objectives in Acceptance and Commitment Therapy (ACT). Otherwise, pain-related acceptance was the strongest mediator across the different indices of outcome. Accumulating results like these suggest that acceptance of pain may be a general mechanism by which CBT-based treatments achieve improvements in functioning. More specific targeting of pain-related acceptance in treatment may lead to further improvements in outcome. Potential mediators of outcome in a CBT-based treatment for adult chronic pain were investigated using multilevel structural equation modeling. The results highlight the role of pain-related acceptance as an important treatment process even when not explicitly targeted during treatment. These data may help clinicians and researchers better understand processes of change and improve the choice and development of treatment methods.

Background: Knowledge of the diversity of occupational problems perceived by people with chronic pain is insufficient. Aims: To describe everyday occupational problems among patients with musculoskeletal pain enrolled in a pain rehabilitation programme, and to compare subgroups based on participant characteristics. Methods: The sample consisted of 152 men and women. Occupational performance was assessed with the Canadian Occupational Performance Measure (COPM). Other data were obtained from forms including sociodemographic variables and pain diagnoses. Major findings: The participants reported 706 prioritized everyday occupational problems categorized as self-care (37%), productivity (32%), and leisure (31%). Household management was the largest sub-category. Working, sitting, and cleaning the house were the specific occupational problems reported most frequently. Women reported significantly more occupations related to productivity and men reported more self-care occupations. Principal conclusion: Patients with pain have a wide range of occupational problems that need to be addressed, along with gender-specific needs.

OBJECTIVES: To investigate how sociodemographic and clinical factors are associated with psychosocial functioning and disability at admission to a musculoskeletal pain rehabilitation program and at 1-year follow-up. DESIGN: A cohort pre-post study. SETTING: A University hospital specialized pain rehabilitation unit. PARTICIPANTS: Five hundred nine participants with musculoskeletal pain (neck disorders, 29%; fibromyalgia, 24%; low back pain, 24%; myalgia, 14%; and other pain diagnoses, 8%). INTERVENTION: A 5-week outpatient, group-based, and goal-oriented comprehensive musculoskeletal interdisciplinary pain rehabilitation program based on cognitive behavioral principles. MAIN OUTCOME MEASURES: The Multidimensional Pain Inventory (MPI), the Disability Rating Index (DRI), and forms including sociodemographic factors (sex, age, ethnicity, marital status, educational level, and vocational situation) and clinical factors (pain duration and pain diagnoses). Data were analyzed with multivariate logistic regression. RESULTS: At admission, factors associated with more positive scores on the MPI were being older than 40 years, being at work, being Nordic born, attainment of a higher educational level, and a diagnosis of fibromyalgia (compared with a neck disorder) (P < .05). Being at work and a diagnosis of fibromyalgia (compared with low back pain) were associated with more positive scores on the DRI (P < .05). On the basis of cut points for clinically important change on the MPI, participants rated themselves as most improved on the Affective Distress (52%), Life Control (49%), and Pain Severity (43%) subscales, and on the DRI index, the improvement rate was 22%. At the 1-year follow-up, neither sociodemographic nor clinical factors were associated with clinically important improvements of the MPI and the DRI, but younger age was related to deteriorations in pain severity. CONCLUSIONS: The lack of an association between sociodemographic and clinical factors and psychosocial functioning and disability at a 1-year follow-up after a musculoskeletal pain rehabilitation program suggests that the program was effective regardless of the participants' initial characteristics, except for age. The changes at the 1-year follow-up indicate that the program influenced the participants' psychosocial functioning more than their perception of disability.

Objectives It is unclear how to address PTSD in the context of chronic pain management. Here we examine the potential benefits of an addition of prolonged exposure (PE) therapy for PTSD for adults attending multidisciplinary CBT for chronic pain. Methods Four adults seeking treatment for chronic pain from a specialized pain rehabilitation service were offered PE for PTSD using a replicated, randomized, single-case experimental phase design, prior to commencing a 5-week multidisciplinary CBT program for chronic pain. Pre-, post-, follow-up, and daily measures allowed examination of PTSD and pain outcomes, potential mediators, and the trajectory of these outcomes and potential mediators during the subsequent pain-focused CBT program. Results Visual inspection of the daily data demonstrated changes in all outcome variables and potential mediators during the PE phase. Changes came at different times and at different rates for the four participants, highlighting the individual nature of putative change mechanisms. Consistent with expectation, PE produced reliable change in the severity of PTSD symptoms and trauma-related beliefs for all four participants, either by the end of the PE phase or the PE follow-up, with these gains maintained by the end of the 5-week pain-focused CBT program. However, few reductions in pain intensity or pain interference were seen either during the PE phase or after. Conclusions Although “disorder specific” approaches have dominated the conceptualising, study, and treatment of conditions like PTSD and chronic pain, such approaches may not be optimal. It may be better instead to approach cases in an individual and process-focused fashion. Ethical committee number 2013/381.