Measurement error, minimal detectable change, and minimal clinically important difference of the Short Form-36 Health Survey, Hospital Anxiety and Depression Scale, and Pain Numeric Rating Scale in patients with chronic pain.

In both pain research and clinical practice, patient-reported outcome measures are used to assess dimensions of health. Interpreting these instruments requires understanding their measurement error and what magnitude of change has subjective importance for patients. This study estimated the standard error of measurement (SEM), one-year minimal detectable change, and one-year minimal clinically important difference (MCID) for the Short Form-36 Health Survey physical component summary (SF-36 PCS) and mental (SF36 MCS), the Hospital Anxiety and Depression Scale anxiety symptoms (HADS-A) and depression symptoms (HADS-D) subscales, and the Numeric Rating Scale (NRS) for past-week average pain intensity. MCIDs for these instruments have not previously been estimated in a large sample of chronic pain patients participating in interdisciplinary pain rehabilitation. Data were drawn from the Swedish Quality Registry for Pain Rehabilitation (n=8854 patients). MCID was estimated as average change and change difference, based on three different anchors. MCID estimates were 2.62-4.69 for SF-36 PCS, 4.46-6.79 for SF-36 MCS, 0.895-1.48 for NRS, 1.17-2.13 for HADS-A, and 1.48-2.54 for HADS-D. The common assumption of an identical SEM for pre- and post-treatment measurements was not always applicable. When estimating MCID, researchers should select an estimation method and anchor aligned with the study's context and objectives. PERSPECTIVE: This article presents estimates of minimal clinically important difference and minimal detectable change for several commonly used patient-reported outcome measures among patients with chronic pain. These estimates can help clinicians and researchers to determine when a measured health improvement is subjectively important to the patient and greater than measurement error. DATA AVAILABILITY: Data Availability Statement: The data utilized in this study are not available due to ethical considerations and the need for appropriate ethical approval.

Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders (PREVSAM): short term effects of a randomised controlled trial in primary care.

PURPOSE: To evaluate short-term effects of the PREVention of Sickness Absence for Musculoskeletal disorders (PREVSAM) model on sickness absence and patient-reported health outcomes. METHODS: Patients with musculoskeletal disorders were randomised to rehabilitation according to PREVSAM or treatment as usual (TAU) in primary care. Sickness absence and patient-reported health outcomes were evaluated after three months in 254 participants. RESULTS: The proportion of participants remaining in full- or part-time work were 86% in PREVSAM vs 78% in TAU (p = 0.097). The PREVSAM group had approximately four fewer sickness benefit days during three months from baseline (p range 0.078-0.126). No statistically significant difference was found in self-reported sickness absence days (PREVSAM 12.4 vs TAU 14.5; p = 0.634), nor were statistically significant differences between groups found in patient-reported health outcomes. Both groups showed significant improvements from baseline to three months, except for self-efficacy, and only the PREVSAM group showed significantly reduced depression symptoms. CONCLUSIONS: The findings suggest that for sickness absence, the PREVSAM model may have an advantage over TAU, although the difference did not reach statistical significance at the p < 0.05 level, and similar positive effects on patient-reported health outcomes were found in both groups. Long-term effects must be evaluated before firm conclusions can be drawn.

Early identification of at-risk patients and team-based rehabilitation within primary care to prevent sickness absence and long-term problems due to acute/subacute musculoskeletal disorders has been scarcely studied.The PREVSAM model provides a framework for team-based interventions in primary care rehabilitation.The PREVSAM model may be used in the management of acute/subacute musculoskeletal disorders in the prevention of sickness absence.

Do beta-blockers reduce negative intrusive thoughts and anxiety in cancer survivors? - An emulated trial.

BACKGROUND: High rates of negative intrusive thoughts have been reported among cancer patients. Prevalent users of beta-blocker therapy have reported lower levels of cancer related intrusive thoughts than non-user. The aim of this study is to investigate if initiation of beta-blocker therapy reduces the prevalence and severity of intrusive thoughts (co-primary endpoints) and the prevalence of anxiety, depressed mood, and low quality of life (secondary endpoints) in cancer survivors. METHODS: Data on patient-reported outcomes from three cohort studies of Swedish patients diagnosed with colon, prostate or rectal cancer were combined with data on beta-blocker prescriptions retrieved from the Swedish Prescribed Drug Register. Two randomized controlled trials were emulated. Trial 1 had follow-up 1 year after diagnosis, trial 2 had follow-up 2 years after diagnosis, baseline in both trials was 12 months before follow-up. Those who initiated beta-blocker therapy between baseline and follow-up was assigned Active group, those who did not was assigned Control group. All endpoints were analysed using Bayesian ordered logistic regression. RESULTS: Trial 1 consisted of Active group, n = 59, and Control group, n = 3936. Trial 2 consisted of Active group, n = 87, and Control group, n = 3132. The majority of participants were men, 83% in trial 1 and 94% in trial 2. The prevalence and severity of intrusive thoughts were lower in the Active group in trial 1, but no significant differences between groups were found in either trial. The prevalence of depressed mood, worse quality of life and periods of anxiety were higher in the Active group in both trials with significant differences for quality of life in trial 1 and anxiety in trial 2. CONCLUSIONS: The emulated trials demonstrated no evidence of a protective effect of beta-blocker therapy against intrusive thoughts. The Active group had reduced quality of life and elevated anxiety compared to the Control group. TRIAL REGISTRATION: The three cohort studies were registered at isrctn.com/clinicaltrials.gov (ISRCTN06393679, NCT02530593 and NCT01477229).

The Swedish version of the pain self-efficacy questionnaire short form, PSEQ-2SV: Cultural adaptation and psychometric evaluation in a population of patients with musculoskeletal disorders.

OBJECTIVES: Measuring pain self-efficacy is suggested as relevant in patients with musculoskeletal disorders (MSDs) in a primary care setting. However, there is no pain self-efficacy questionnaire (PSEQ) available in Swedish. The aim of this study was to translate and culturally adapt PSEQ-2 to Swedish and evaluate reliability and validity in a population of patients with MSDs. METHODS: A translation and cultural adaptation together with psychometric evaluation of reliability and validity were performed according to guidelines with three groups of participants with MSDs. First, a convenient sample of 25 individuals were interviewed in the translation process. Next, 61 participants completed the test-retest survey via social media or QR codes in waiting rooms in rehabilitation clinics. Finally, to evaluate construct validity questionnaires were obtained from 132 participants with MSDs in an ongoing randomized controlled trial. RESULTS: The Swedish version of PSEQ-2 showed adequate face and content validity. The results of 0.805 on Cohen's weighted kappa indicate that the reliability of PSEQ-2SV in a group of adults with MSDs is on the border between substantial and almost perfect. The point estimate regarding relative rank variance, measuring the individual variation within the group, and relative concentration, the systematic change in how the assessments are concentrated on the scale's categories, shows minor systematic differences and some random differences not neglectable. The construct validity of pre-defined hypotheses was met to some degree. CONCLUSION: The PSEQ-2SV has been accurately linguistically translated and tested for reliability and validity, in a population of MSDs, and is deemed to be able to be used in the clinic and in research. As there were some concerns regarding measurement error and systematic bias, more research could be of value.

Long-term patient-reported back and shoulder function after delayed breast reconstruction with a latissimus dorsi flap: case-control cohort study.

BACKGROUND: Sacrifice of the latissimus dorsi (LD) muscle might entail donor site morbidity when used in delayed breast reconstruction. Previous studies are small, have short follow-up, and demonstrate diverging results. The aims of this study were to evaluate long-term patient-reported effects on shoulder and back function following LD flap harvest, and to investigate predictors for a worse outcome. METHOD: This is a retrospective observational case-control cohort study. Cases were all patients who had undergone an LD flap reconstruction during the years 2007-2017. Controls were patients reconstructed with a deep inferior epigastric perforator (DIEP) flap during the same time period. Participants completed two validated questionnaires; the BREAST-Q reconstruction LD domains and the Western Ontario Shoulder Osteoarthritis Index (WOOS). RESULTS: A total of 135 cases (75 per cent) and 118 controls (60 per cent) responded to the questionnaires. The mean follow-up time was 7 years. Patients reconstructed with a LD flap were significantly less satisfied with their back and shoulder function when compared to the DIEP controls, as measured with BREAST-Q and WOOS. Predictors for a poor patient-reported back and shoulder function included axillary surgery and axillary radiotherapy, especially when combined, as well as higher age at reconstruction. CONCLUSION: Patients who have undergone LD flap for delayed breast reconstruction had a lower satisfaction with back and shoulder function, when compared to patients who had undergone a DIEP reconstruction. Delayed LD reconstruction should be used with care, especially in patients who have undergone axillary surgery and axillary radiotherapy.

Psychosocial resources predict frequent pain differently for men and women: A prospective cohort study.

INTRODUCTION: Psychosocial resources, psychological and social factors like self-efficacy and social support have been suggested as important assets for individuals with chronic pain, but the importance of psychosocial resources for the development of pain is sparsely examined, especially sex and gender differences. The aim of this study was to investigate associations between psychosocial resources and sex on the development of frequent pain in a general population sample, and to deepen the knowledge about sex and gender patterns. METHODS: A sample from the Swedish Health Assets Project, a longitudinal cohort study, included self-reported data from 2263 participants, 53% women, with no frequent pain at baseline. The outcome variable was frequent pain at 18-months follow-up. Psychosocial resources studied were general self-efficacy, instrumental and emotional social support. Log binomial regressions in a generalised linear model were used to calculate risk ratios (RRs), comparing all combinations of men with high psychosocial resources, men with low psychosocial resources, women with high psychosocial resources and women with low psychosocial resources. RESULTS: Women with low psychosocial resources had higher risk of frequent pain at follow-up compared to men with high resources: general self-efficacy RR 1.82, instrumental social support RR 2.33 and emotional social support RR 1.94. Instrumental social support was the most important protective resource for women, emotional social support was the most important one for men. Results were discussed in terms of gender norms. CONCLUSIONS: The psychosocial resources general self-efficacy, instrumental and emotional support predicted the risk of developing frequent pain differently among and between men and women in a general population sample. The results showed the importance of studying sex and gender differences in psychological and not least social predictors for pain.

Components of primary care multimodal rehabilitation and their association with changes in sick leave: An observational study.

BACKGROUND: To address the increase in sick leave for nonspecific chronic pain and mental illness, the Swedish government and the Swedish Association of Local Authorities and Regions entered into an agreement on a "Rehabilitation Guarantee" to carry out multimodal rehabilitation (MMR). OBJECTIVE: To investigate whether components of primary care MMR are associated with changes in sick leave. METHODS: A web-based survey was conducted in conjunction with a retrospective cross-sectional observational study of 53 MMR units. Sick leave data for the years before and after MMR completion was collected for 846 individuals. RESULTS: There was great disparity in how MMR was delivered. The average duration of rehabilitation was 4-8 weeks, and 74% of the MMR teams reported having fewer patients than recommended (≥20/year). Only 58% of the teams met the competence requirements. In-depth competence in pain relief and rehabilitation was reported by 45% of the teams and was significantly associated with fewer sick leave days after MMR (26.53, 95% CI: 3.65; 49.42), as were pain duration (17.83, 95% CI: -9.20; 44.87) and geographic proximity (23.75, 95% CI: -5.25; 52.75) of the health care professionals included in the MMR unit. CONCLUSIONS: In-depth competence and knowledge about the complex health care needs of patients seem essential to MMR teams' success in reducing sickness benefits for patients with nonspecific chronic pain and mental illness. Further research is needed to elucidate the optimal combination of primary care MMR components for increasing the return-to work rate and to determine whether involvement of the Social Insurance Agency or employers could support and further contribute to recuperation and help patients regain their previous work capacity.

Validation and reliability testing of the BREAST-Q expectations questionnaire in Swedish.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT04714463, 19 January 2021 Patient and public contribution: All the data were generated directly from patients.

General self-efficacy and social support in men and women with pain - irregular sex patterns of cross-sectional and longitudinal associations in a general population sample.

BACKGROUND: The study of sex and gender patterns in psychosocial resources is a growing field of interest in pain research with importance for pain rehabilitation and prevention. The aims of this study were first, to estimate cross-sectional differences in psychosocial resources (general self-efficacy and social support) across men and women in a population with frequent musculoskeletal pain (pain in the back or neck/shoulder nearly every day or now and again during the week for the last 12 months) and to compare these differences with a population with no frequent pain. Second, to examine if psychosocial resources at baseline were associated with pain at follow-up among men and women in the frequent pain population. METHODS: This study was based on survey data from the Swedish Health Assets Project, including The General Self-Efficacy Scale and social support questions. Participants (n = 4010, 55% women) were divided into no frequent pain (n = 2855) and frequent pain (n = 1155). General self-efficacy and social support were analyzed (cross-sectional and longitudinal data) with linear and logistic regressions. RESULTS: Men, with and without frequent pain, had higher general self-efficacy than the corresponding groups in women. Women, with and without frequent pain, had stronger emotional social support than the corresponding groups in men. Men with no frequent pain had weaker instrumental social support than women with no frequent pain (OR = 0.64 (95% CI 0.47-0.87)), men with frequent pain did not (OR = 1.32 (95% CI 0.86-2.01)). In the frequent pain population, the interaction between sex and strong (compared to weak) emotional social support was statistically significant (p = 0.040) for no frequent pain at follow-up, with women having OR = 1.81 and men OR = 0.62. Among women, strong emotional social support was associated with no frequent pain at follow-up. Among men, strong emotional social support was associated with frequent pain at follow-up. CONCLUSION: Some of the associations between general self-efficacy, social support and musculosceletal pain showed unexpected sex patterns. Gendered expectations might have relevance for some of the results.

App-based COVID-19 syndromic surveillance and prediction of hospital admissions in COVID Symptom Study Sweden.

The app-based COVID Symptom Study was launched in Sweden in April 2020 to contribute to real-time COVID-19 surveillance. We enrolled 143,531 study participants (≥18 years) who contributed 10.6 million daily symptom reports between April 29, 2020 and February 10, 2021. Here, we include data from 19,161 self-reported PCR tests to create a symptom-based model to estimate the individual probability of symptomatic COVID-19, with an AUC of 0.78 (95% CI 0.74-0.83) in an external dataset. These individual probabilities are employed to estimate daily regional COVID-19 prevalence, which are in turn used together with current hospital data to predict next week COVID-19 hospital admissions. We show that this hospital prediction model demonstrates a lower median absolute percentage error (MdAPE: 25.9%) across the five most populated regions in Sweden during the first pandemic wave than a model based on case notifications (MdAPE: 30.3%). During the second wave, the error rates are similar. When we apply the same model to an English dataset, not including local COVID-19 test data, we observe MdAPEs of 22.3% and 19.0% during the first and second pandemic waves, respectively, highlighting the transferability of the prediction model.

Stress, non-restorative sleep, and physical inactivity as risk factors for chronic pain in young adults: A cohort study.

BACKGROUND: Chronic pain is a common condition which causes patients much suffering and is very costly to society. Factors known to be associated with chronic pain include female gender, acute pain, depression, and anxiety. This study investigated whether stress, sleep disturbance, and physical inactivity were risk factors for developing chronic pain among young adults, and whether there were any interactions between these. METHODS: This retrospective longitudinal study was based on an existing database from a cohort study on IT use and health, called Health 24 Years. A questionnaire was sent to students aged 19-24 in Sweden for five consecutive years, containing questions on pain, stress, sleep, physical activity, technology use, health, and more. In logistic regressions, stress, sleep, and physical activity at baseline were potential predictors of chronic pain one and four years later. In addition, a new variable including all possible interactions between potential predictors was created to test for effect modification between risk factors. RESULTS: At the one-year follow-up, stress, non-restorative sleep, and physical inactivity showed odds ratios of 1.6 (95% CI: 1.0-2.4), 1.5 (95% CI: 1.0-2.3), and 1.8 (95% CI: 1.1-3.0) respectively after adjusting for confounders, the reference being non-stressed, having restorative sleep and being active. At the four-year follow-up, stress showed an adjusted odds ratio of 1.9 (95% CI: 1.3-2.9), while non-restorative sleep and physical inactivity were statistically insignificant. At the one-year follow-up, the interaction between risk factors were significant. The most clear example of this effect modification was to be inactive and not have -restorative sleep, compared to individuals who were active and had restorative sleep, showing an adjusted odds ratio of 6.9 (95% CI: 2.5-19.2) for developing chronic pain one year after baseline. This in comparison of odds ratios for only inactive respectively only non-restorative sleep being 1.7 (95% CI: 0.6-5.3) respectively 1.6 (95% CI: 0.7-3.5). CONCLUSIONS: Stress, non-restorative sleep, and physical inactivity were risk factors for developing chronic pain one year after baseline, and stress were also a risk factor four years after baseline. These findings suggest that non-restorative sleep and inactivity are risk factors in the short term while stress is a risk factor in both the short and the long term. In addition to the independent effects of non-restorative sleep and inactivity, their combination seems to further increase the odds of chronic pain.

Texture Analysis of Magnetic Resonance Images Enables Phenotyping of Potentially Painful Annular Fissures.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To investigate whether intervertebral disc (IVD) image features, extracted from magnetic resonance (MR) images, can depict the extension and width of annular fissures and associate them to pain. SUMMARY OF BACKGROUND DATA: Annular fissures are suggested to be associated with low back pain (LBP). Magnetic resonance imaging (MRI) is a sensitive method, yet fissures are sometimes unobservable in T2-weighted MR-images, even though fissure information is present in the image. Image features can mathematically be calculated from MR-images and might reveal fissure characteristics. METHODS: Forty four LBP patients who underwent MRI, low-pressure discography (<50 psi), and computed tomography (CT) sequentially in 1 day, were reviewed. After semi-automated segmentation of 126 discs, image features were extracted from the T2-weighted images. The number of image features was reduced with principle component analysis (PCA). CT-discograms were graded and dichotomized regarding extension and width of fissures. IVDs were divided into fissures extending to outer annulus versus short/no fissures. Fissure width was dichotomized into narrow (<10%) versus broad fissures (>10%), and into moderately broad (10%-50%) versus very broad fissures (>50%). Logistic regression was performed to investigate if image features could depict fissure extension to outer annulus and fissure width. As a sub-analysis, the association between image features used to depict fissure characteristics and discography-provoked pain-response were investigated. RESULTS: Fissure extension could be depicted with sensitivity/specificity = 0.97/0.77 and area under curve (AUC) = 0.97. Corresponding results for width depiction were sensitivity/specificity = 0.94/0.39 and 0.85/0.62, and AUC = 0.86 and 0.81 for narrow versus broad and moderately broad versus very broad fissures respectively. Pain prediction with image features used for depicting fissure characteristics showed sensitivity/specificity = 0.90/0.36, 0.88/0.4, 0.93/0.33; AUC = 0.69, 0.75, and 0.73 respectively. CONCLUSION: Standard MR-images contains fissure information associated to pain that can be depicted with image features, enabling non-invasive phenotyping of potentially painful annular fissures.Level of Evidence: 2.

Association between pre-stroke physical activity and mobility and walking ability in the early subacute phase: A registry-based study.

OBJECTIVE: To investigate associations between pre-stroke physical activity and mobility, walking ability, and self-perceived upper extremity function during stroke unit care. DESIGN: A longitudinal, registry-based study with a consecutively collected cohort. SUBJECTS/PATIENTS: A total of 1,092 adults with stroke admitted to 3 Swedish stroke units between 2017 and 2018. METHODS: Logistic mixed effects regression models were performed to investigate associations (adjusted for age and sex). Pre-stroke physical activity was assessed with Saltin-Grimby Physical Activity Level Scale on admission. Mobility, walking ability, and self-perceived upper extremity function were assessed at admission and discharge from the stroke units and compared between pre-stroke physically active (45%) and inactive (55%) groups. RESULTS: All groups of patients showed improvements in mobility (p < 0.001), walking ability (p < 0.001), and upper extremity function (p < 0.001). The chang-es over time tended to differ between the physically inactive and active groups for mobility (p < 0.062) and walking ability (p < 0.056), but the differences were not significant. CONCLUSION: Pre-stroke physically active people show-ed a tendency to be more independent in physical functioning early after stroke. Regardless of pre-stroke physical activity, all patients showed improvements in mobility, walking ability, and self-perceived upper extremity function during inpatient care.

Insomnia Symptoms and Chronic Pain among Patients Participating in a Pain Rehabilitation Program-A Registry Study.

Insomnia and chronic pain are prevalent health complaints. Previous research has shown that they are closely associated, but their interaction and causality are not completely understood. Further research is needed to uncover the extent to which a treatment strategy focusing on one of the conditions affects the other. This study aimed to map the prevalence of insomnia symptoms among patients in interdisciplinary pain rehabilitation program (IPRP) and investigate associations between the degree of insomnia at baseline and the treatment outcome regarding pain intensity, physical function, social function, mental well-being, anxiety, and depression. Of the 8515 patients with chronic pain, aged 15-81 who were registered in the Swedish Quality Registry for Pain Rehabilitation during 2016-2019 and participated in IPRP, 7261 had follow-up data after treatment. Logistic regression analysis was used to investigate associations. The prevalence of clinical insomnia, according to Insomnia Severity Index (ISI), among chronic pain patients in IPRP was 66%, and insomnia symptoms were associated with both country of birth and educational level. After IPRP, the prevalence of clinical insomnia decreased to 47%. There were statistically significant associations between the degree of insomnia symptoms before IPRP and physical function (p < 0.001), social function (p = 0.004) and mental well-being (p < 0.001). A higher degree of insomnia symptoms at baseline was associated with improvement after IPRP. In conclusion, IPRP seem to have beneficial effects on insomnia symptoms in chronic pain patients. Nevertheless, almost half of the patients still suffer from clinical insomnia after IPRP. The possible effect of systematic screening and treatment of insomnia for improving the effect of IPRP on pain is an important area for future research.

Multidimensional health changes after a multimodal pain rehabilitation program: a registry-based study.

INTRODUCTION: Chronic pain is treated with multimodal rehabilitation programs, targeting improvement in several health aspects. These treatments must be evaluated multidimensionally, which is a methodological challenge. OBJECTIVES: This study investigated factors (demographic, pain-related, and individual- vs group-based treatment) predicting successful outcomes after multimodal pain rehabilitation programs. METHODS: Data from 3 outpatient clinics were retrieved from the Swedish Quality Registry for Pain Rehabilitation, for 314 patients (218 women). Outcome variables were dichotomized as binary change (improved or not improved) based on clinical thresholds. Total improvement grouped outcomes into 0 to 2, 3 to 4, and 5 to 6 improved variables. Binary logistic regression analyses investigated the association between the baseline predictors and change variables. RESULTS: Patients improving after treatment ranged from 34% (pain intensity) to 80% (depression) for women and 34% to 76% for men, respectively. Total improvement outcome was consistent (after treatment and 1 year) with 28% of patients improving on 5 to 6 outcomes. The baseline predictor related to most improved outcomes was pain intensity, with positive correlation to improvement in pain intensity (P < 0.001) and negative correlation with improvements in anxiety (P = 0.075) and depression (P = 0.002). Individual-based treatment, compared with group-based treatment, was associated with improvement in pain intensity (P = 0.008). CONCLUSIONS: About a third of patients improved in several outcomes by the end of a multimodal program, with most improvement for depression and least for pain intensity. Generally, patients with more severe health status at baseline improve most directly after treatment, but these findings could not suggest treatment adjustments that would improve overall success rates.

Longitudinal associations between cardiorespiratory fitness and stress-related exhaustion, depression, anxiety and sleep disturbances.

BACKGROUND: In the last few years, so-called "common mental disorders", including adjustment disorder and stress-related exhaustion, have outrivalled musculoskeletal disorders as being the leading cause of long-term sick leave in Sweden. Cardiorespiratory fitness level defined as "the maximal amount of physiological work that an individual can do as measured by oxygen consumption" has in many studies shown to reduce the risk of several life-style related diseases and moreover to improve mood, well-being and physical performance. The aim of the present study was to investigate, longitudinal associations between cardiorespiratory fitness and self-reported physical activity levels and the severity of symptoms connected to stress-related exhaustion, depression, anxiety, and sleep disturbances among women clinically diagnosed with stress-related exhaustion disorder (ED). METHODS: The study was that of a longitudinal cohort study consisting of women (n = 88) diagnosed with stress-related ED in a specialist clinic in Gothenburg, Sweden. Cardiorespiratory fitness was measured with the Åstrand indirect test of maximal oxygen uptake (VO2max) and subjective measures of physical activity levels were rated on 4-graded physical activity scale. To measure and follow symptoms of ED over time the SMBQ-questionnaire (Shirom Melamed Burnout Questionnaire) was used. The Hospital Anxiety and Depression Scale (HADS) was used to measure depression and anxiety. A proxy variable for capturing overall disturbed sleep used to measure sleep. Longitudinal associations for continuous outcome variables and the dichotomous variable sleep were analysed using mixed- effects regression models with random intercepts. Regression coefficients along with the 95% confidence interval (CI) are presented as measures of association. Both exposures and the outcome were measured simultaneously over six waves (T1-T6). RESULTS: The results showed statistically significant associations between level of fitness and reduced symptoms of stress-related exhaustion over time. Best improvements over time were seen in patients having a medium cardiorespiratory fitness level. No associations could be found between cardiorespiratory fitness level over time and anxiety, depression or sleep disturbances. CONCLUSION: Having medium cardiorespiratory fitness was positivity associated with a more sustained reduction in symptoms of ED overtime compared to those having low or high cardiorespiratory fitness levels. The clinical implication following this result is that an individual recommendation based on a medium level of physical activity in line with the recommendations from ACSM (American College of Sports Medicine) is preferable compared to recommendations including more vigorous physical activity in order to restore and sustainably reduce symptoms of exhaustion disorder over time.

Concurrent and lagged effects of psychosocial job stressors on symptoms of burnout.

PURPOSE: Burnout is a mental condition described as being a result of long-term stressors commonly related to psychosocial factors at work. The aim of the present study was to investigate longitudinal relationships between job demands, decision authority, effort and reward, and symptoms of burnout, as well as the joint effects of job demands and decision authority, and of effort and reward. METHODS: The data came from a four-wave longitudinal cohort study of Swedish health care workers. Longitudinal associations were analysed using mixed effects regression models with random intercept. RESULTS: The concurrent analysis showed that demand and decision authority, as well as effort and reward, were associated with symptoms of burnout over time. Evidence of the lagged effects of workplace factors on burnout symptoms was limited to reward. No clear effect modification was found. CONCLUSION: An increase in unfavourable working conditions implied increasing scores on the burnout measure over time. The concurrent effects of job demands, decision authority, effort and reward on symptoms of burnout were seen. The evidence of lagged effects was limited to the low-reward condition. Regularly monitoring these work environment conditions at workplaces can help identify risk situations for burnout and thus be useful in the prevention of work-related mental illness. Lastly, a new approach to defining the risk groups was proposed, which is consistent across different populations and time points.

Predictors of chronic pain intensity, spread, and sensitivity in the general population: A two-year follow-up study from the SWEPAIN cohort.

OBJECTIVE: To determine whether the intensity, spread and sensitivity of chronic pain can be predicted using demographic features, socioeconomic conditions and comorbidities. DESIGN: A longitudinal study design was employed. Data was collected at baseline and at 2-year follow-up. SETTING: General population in south-eastern Sweden. SUBJECTS: A representative stratified random sample of 34,000 individuals, between 18 and 85 years of age, selected from a sampling frame of 404,661 individuals based on the Swedish Total Population Register. METHODS: Eligible individuals were sent postal surveys in 2013 and 2015. The 2 surveys included the same questions about basic demographic data, comorbidities, and chronic pain intensity, spread and sensitivity. RESULTS: Several socio-demographic features and comorbidities at baseline were significant predictors of characteristics of pain (intensity, spread and sensitivity) at the 2-year follow-up. When characteristics of pain at baseline were included in the regression analyses they were relatively strong significant predictors of characteristics of pain after 2 years. After this adjustment there were fewer socio-demogra-phic and comorbidity predictors; the effect estimates for those significant predictors had decreased. CONCLUSION: Clinical assessment should focus on several characteristics of pain and include a broad medical screening to capture the overall burden of pain in adults from a longitudinal perspective.

Factor structure and internal consistency of a Swedish version of the Pain Catastrophizing Scale.

BACKGROUND: Pain catastrophizing is highly relevant to assess in the context of long-standing pain. The Pain Catastrophizing Scale (PCS) is a well-established questionnaire used to measure catastrophizing in individuals with long-standing pain. So far, no Swedish translation has been evaluated in regard to validity and reliability. The aims of this study were to translate the PCS questionnaire from English to Swedish, and to investigate its construct validity (face, content, and structural validity) and reliability (internal consistency). METHODS: We translated the original English version of the PCS to Swedish and collected item responses from 194 persons suffering from primarily long-standing musculoskeletal pain. We used confirmatory factor analysis to evaluate structural validity, and tested the model fit of a one-factor model, an oblique two-factor model, and an oblique three-factor model. We evaluated the measure's reliability in regard to internal consistency calculated with Cronbach's alpha. RESULTS: A three-factor model comprising a four-item rumination factor, a three-item magnification factor, and a six-item helplessness factor provided the best fit to the data. Internal consistency was adequate and Cronbach's α was 0.92 for the entire scale, 0.84 for the rumination subscale; 0.69 for the magnification subscale, and 0.89 for the helplessness subscale. CONCLUSIONS: The results indicated adequacy of a three-factor solution and the questionnaire's internal consistency, and provide initial support for the structural validity and internal consistency of a Swedish version of the PCS. Future studies should replicate the study in larger samples and extend the current evaluation in regard to validity and reliability.