"I'm still the person I am. Not the body it has become." An active but challenging life with cervical dystonia.

BACKGROUND: Improvement of activity and participation for the disabled and chronically ill is an important aim of rehabilitation. Cervical dystonia is a neurological movement disorder characterized by involuntary contractions of the neck muscles. Until now, research has identified factors contributing to disability rather than factors which may make it easier to be active and participate in the community. OBJECTIVE: Explore and describe perceived experiences of activity and participation in daily life as experienced by persons with cervical dystonia. METHODS: Sixteen informants participated in this semi-structured interview study. Inductive qualitative content analysis was performed to understand and interpret experiences shared by the informants. RESULTS: Results from the analysis generated two themes "An active life" and "A challenging life" and six sub-themes: Using helpful coping strategies, Accepting a new life situation, Adhering to BT treatment, Facing the negative impact of stress, Experiencing a negative self-image and Suffering from pain and fatigue. CONCLUSIONS: Our results support the importance of actions using a rehabilitation approach that consider both motor and non-motor symptoms. Future studies should compare the effects of physiotherapy taking into account wishes and challenges in patients' everyday life versus traditional physiotherapy addressing mostly the motor disorder.

Reliability, construct validity, and factorial structure of a Swedish version of the medical outcomes study social support survey (MOS-SSS) in patients with chronic pain.

OBJECTIVES: This study aimed to examine the psychometric properties of a Swedish version of the Medical Outcomes Study Social Support Survey (MOS-SSS). METHODS: Standard forward-backward translation was used. A cross-sectional survey was conducted among treatment seeking individuals with chronic pain included in a clinical cohort. Internal consistency was measured with Cronbach's α, test-retest reliability was examined with intraclass correlation, confirmatory factor analyses was used for examining factor structure, and correlations between the MOS-SSS and selected health validity measures were used for testing concurrent validity hypotheses. RESULTS: 182 participants were included in the study. Internal consistency measured with Cronbach's alpha was acceptable for all subscales and for the total support index of the MOS-SSS. Test-retest reliability was moderate - good for the different subscales, and was good for the overall support index. The original four factor model of the MOS-SSS was confirmed, and the concurrent validity hypotheses were also confirmed; however, the associations were weaker than expected. CONCLUSIONS: The Swedish version of the MOS-SSS was found psychometrically sound and offers a systematic assessment of social support in specialized pain care.

Pain in patients with motor neuron disease: Variation of pain and association with disease severity, health-related quality of life and depression - A longitudinal study.

OBJECTIVES: To describe levels of pain over time during disease progression in individual patients and for a total sample of patients with motor neuron disease (MND), respectively, and to examine associations between pain, disease severity, health-related quality of life (HRQOL), and depression. METHODS: A prospective cohort study was conducted on 68 patients with MND, including data collected on five occasions over a period of 2 years. Pain was assessed using the Brief Pain Inventory - Short Form. Depression was assessed using the Amyotrophic Lateral Sclerosis (ALS)-Depression-Inventory (ADI-12). Disability progression was measured using the Amyotrophic Lateral Sclerosis Functional Rating Scale - Revised Version (ALSFRS-R). HRQOL was assessed using the Amyotrophic Lateral Sclerosis Assessment Questionnaire (ALSAQ-5). RESULTS: Participants reported great individual variation over time. The median level of pain was 4 (min 0 and max 10). Higher levels of pain during the last 24 h were associated with higher depression scores (ADI-12), poorer quality of life (ALSAQ-5), and lower reporting of fine and gross motor skills (ALSFRS-R). Baseline pain levels did not predict future values of depression and function. Individuals reporting average pain >3 experienced more hopelessness toward the future and reported higher depression scores compared with participants reporting average pain <3. SIGNIFICANCE OF RESULTS: Great within-individual variation of pain intensity was reported. Pain intensity was associated with depression, function and HRQOL cross-sectionally, but it did not have a strong prognostic value for future depression, function, or HRQOL. Patients with MND should be offered frequent assessment of pain and depressive symptoms in person-centered care, allowing for individualization of treatment.

Scientific approach and attitudes among clinically working physiotherapists in Sweden -a cross sectional survey.

BACKGROUND: Evidence based medicine (EBM) should be an endeavor within all healthcare professions. Knowledge and understanding of science are important prerequisites of EBM. OBJECTIVE: The aim was to examine and compare perspectives on science and perceived inhibiting and facilitating factors for the assimilation and implementation of scientific information among clinically working specialist- and non-specialist physiotherapists in Sweden. METHODS: A cross-sectional survey study was conducted via a web-based questionnaire. Clinically active physiotherapists in Sweden were invited to participate. Attitudes and perspectives were compared between physiotherapists with completed or on-going specialist training, and non-specialists. RESULTS: In total, 1165 physiotherapists responded to the survey (75.5%, (n = 870) women, mean age 44.8 (SD 12.1), whereof 25.5% (n = 319) with completed or ongoing specialist training). The majority of participants had a high interest in science but did not consider a general scientific approach to be applied within physiotherapy. The main perceived inhibiting factor for a clinical practice more based on scientific evidence was lack of time. Specialists had in general higher interest and ability to interpret and evaluate science, and prioritized scientific evidence to a higher extent. CONCLUSION: Among respondents, a scientific approach was considered valuable within physiotherapy but not considered fully applied in practice. The higher interest and perceived ability to interpret science among specialists indicates that further education and specialist training can increase both interest and understanding of science among physiotherapists.

Psychometric Assessment of the Swedish version of the Work Ability Index in Patients with Chronic Pain in Specialized Care.

OBJECTIVE: To evaluate the construct validity and internal consistency of the Work Ability Index (WAI) in patients with chronic pain in secondary and tertiary care. METHODS: Cross-sectional study based on 200 patients with chronic pain (> 3 months), with a final sample of 118 participants, 18-64-years-old. Construct validity was assessed by exploratory factor analysis for the structural validity of the WAI, and by correlating the WAI with EuroQol EQ-5D, Brief Pain Inventory pain severity and interference, Patient Health Questionnaire and Generalized Anxiety Disorder scales. The study also assessed the discriminant validity of the WAI for occupational status, and the validity of the single-item work ability score. Reliability was assessed by internal consistency. RESULTS: A single-factor model of WAI was supported. Internal consistency was good. Moderate correlations were found, except for Brief Pain Inventory pain severity, where the correlation was weak; hence, both convergent and divergent validity of the WAI were supported. The work ability score correlated strongly with the total WAI, and the discriminant validity for both was good. CONCLUSION: In patients with chronic pain in specialized care, the WAI and the work ability score displayed acceptable construct validity and internal consistency, supporting their use in a clinical context and research.

Construct validity of the Mini-BESTest in individuals with chronic pain in specialized pain care.

BACKGROUND: Balance assessment scales are important clinical tests to identify balance impairments. Chronic pain (> 3 months) is associated with impaired dynamic balance; however, very few balance assessment scales are psychometrically evaluated for the population. The purpose of this study was to evaluate the construct validity and internal consistency of the Mini-BESTest for individuals with chronic pain in specialized pain care. METHODS: In this cross-sectional study, 180 individuals with chronic pain (> 3 months) were assessed with the Mini-BESTest and included in the analyses. For construct validity, five alternative factor structures were evaluated using a confirmatory factor analysis. In addition, we tested the a priori hypotheses about convergent validity with the 10-meter walk test, and divergent validity with the Brief Pain Inventory (BPI): pain intensity, the Tampa Scale of Kinesiophobia-11 (TSK-11), and the Pain Catastrophizing Scale (PCS-SW). Internal consistency was evaluated for the model with the best fit. RESULTS: A one-factor model with added covariance via the modification indices showed adequate fit indices. In line with our hypotheses, Mini-BESTest showed convergent validity (rs = > 0.70) with the 10-meter walk test, and divergent validity (rs = < 0.50) with BPI pain intensity, TSK-11, and PCS-SW. Internal consistency for the one-factor model was good (α = 0.92). CONCLUSIONS: Our study supported the construct validity and internal consistency of the Mini-BESTest for measuring balance in individuals with chronic pain, who were referred to specialized pain care. The one-factor model showed an adequate fit. In comparison, models with subscales did not reach convergence, or showed high correlations between subscales, implying that Mini-BESTest is measuring one construct in this sample. We, therefore, propose using the total score, instead of subscale scores, for individuals with chronic pain. However, further studies are necessary to establish the reliability of the Mini-BESTest in the population.

Implementation of tailored exercise programs for MG patients in a gym setting: a pragmatic feasibility case study.

Although supervised aerobic and resistance training in a hospital setting was proven safe and beneficial for well-controlled myasthenia gravis (MG) patients, implementation of similar programs in the community has not been studied. We conducted a pragmatic open-label study at a large gym in Uppsala, Sweden. Seven patients with generalized MG were recruited to participate in an individualized, tailored exercise program, based on individual baseline status and personal goals, with a personal trainer. All patients completed the entire training period. The individually tailored exercise program was implemented safely and effectively, with all patients improving in aerobic capacity, muscle strength, and balance. Our pragmatic open-label case study suggests that well-controlled patients with generalized MG can extend their physical exercise to personal training in the gym. This is an essential step towards reducing the barriers to implementing exercise procols and increasing the availability of these interventions to MG patients.

Psychologically informed health care.

The term "psychologically informed health care" refers to the comprehensive integration of psychological principles into health care. Psychologically informed health care has the potential to lead to a transformation of care, resulting in truly transdisciplinary care. To facilitate its future development, we discuss key characteristics of this approach. These include the direct mode (psychologists assessing and treating patients themselves) and indirect mode (psychologists working through other health care providers) of integrating psychological principles into healthcare; the range of health domains targeted using this approach; transdisciplinary care, transcending traditional disciplinary boundaries; and the positioning of care. We describe a framework for transdisciplinary care, which we refer to as the Framework for Catalytic Collaboration. This framework comprises six dimensions: setting, disciplines, patients/clients, mode of psychological care, primary components of care, and primary targets of care. We also provide four brief illustrations of psychologically informed health care. Finally, we discuss future directions, including the need for professional recognition of the indirect mode, financing of the indirect mode, cross-disciplinary training and trans-disciplinary research.

The term "psychologically informed health care" refers to the use of the theories and techniques of psychology in health care settings. By integrating psychological and other care, a new approach emerges that is of great value to patients. Psychologically informed health care has the potential to change care for the better. Psychologists may assess and treat patients themselves (the direct approach) in close collaboration with other health care providers. Alternatively, psychologists may work through other health care providers, supporting them in the application of psychological principles to healthcare (the indirect approach). To encourage future development, we discuss key characteristics of this approach, provide a framework for care that cuts across disciplines, present four brief practical examples, and finally, we discuss future directions.

Preventing Pain and Stress-Related Ill-Health in Employees: A 6-Months Follow-Up of a Psychosocial Program in a Cluster Randomized Controlled Trial.

Purpose Pain and stress-related ill-health are major causes of long-term disability and sick leave. This study evaluated the effects of a brief psychosocial program, which previously has been tested for an at-risk population of employees. Methods The Effective Communication within the Organization (ECO) program, where supervisors and employees were trained in communication and problem solving, was compared to an active control consisting of psychoeducative lectures (PE) about pain and stress in a cluster randomized controlled trial. First-line supervisors were randomized to ECO or PE, and a total of 191 mainly female employees with self-reported pain and/or stress-related ill-health were included. The hybrid format programs consisted of 2-3 group sessions. Sick leave data was collected from social insurance registers, before and 6-months after the program. Secondary outcomes (work ability, work limitations, pain-disability risk, exhaustion symptoms, perceived stress, perceived health, quality of life, perceived communication and support from supervisors) were assessed at baseline, post intervention, and at 6-months follow-up. Results No effects were observed on primary or secondary outcome variables. Pain symptoms were common (89%), however a lower proportion (30%) were identified as at risk for long-term pain disability, which might explain the lack of evident effects. The Covid-19 pandemic affected participation rates and delivery of intervention. Conclusion In this study, preventive effects of the ECO program were not supported. Altogether, the findings point at the importance of selecting participants for prevention based on screening of psychosocial risk. Further research on workplace communication and support, and impact on employee health is warranted.

U-PAIN cohort study among patients with chronic pain in specialised pain care: a feasibility study.

OBJECTIVES: To examine acceptability of study participation and feasibility of (1) recruitment, (2) data collection and (3) outcome measures for the prospective U-PAIN cohort. DESIGN: Internal feasibility study of a prospective cohort. PARTICIPANTS AND SETTING: 64 patients, >18 years, with chronic pain at a multidisciplinary pain centre at a university hospital in Sweden. OUTCOME MEASURES: Acceptability of study participation was measured with a study-specific 10-item Likert scale. A score <3 was considered feasible, for the two items that assessed respondent burden a higher score indicated lesser participant burden and a score >3 was feasible. Recruitment was assessed by participation rates at baseline and retention at the 1-year follow-up, with threshold values for feasibility at 75% and 80%, respectively. Data collection and outcome measures were examined by completions rates of study procedures (90% was considered feasible), sample scores, internal consistency (α>0.70 was considered feasible), and agreement between self-reported data and data retrieved from medical records on opioid use (ICC or κ>0.60 was considered feasible). RESULTS: Acceptability for study procedures was feasible, but participation rates were low: 25%. The retention rate at 1-year follow-up was 81% for those included in the feasibility study, that is, filling out computerised patient-reported outcome measures, and 65% for those using paper and pencil format. The completion rates for the different data collection methods ranged from 83% to 95%. Agreement between self-reported opioid use and prescribed dose and between opioid use disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and clinical International Classification of Diseases-10 (ICD-10) diagnoses for opioid dependence were almost perfect (κ=0.91 and κ=0.90, respectively). CONCLUSIONS: This feasibility study has helped to explore and improve methods for recruitment, data collection and use of outcome measures for the U-PAIN cohort. Low participation rate and high refusal rate at baseline is a challenge that needs to be further addressed.

"Opioids are opioids" - A phenomenographic analyses of physicians' understanding of what makes the initial prescription of opioids become long-term opioid therapy.

OBJECTIVES: To explore prescribers' understanding of what makes initial prescription of opioids become long-term opioid therapy (opioids >90 days). METHODS: A qualitative research design, phenomenography, was used for this study. Fifteen attending physicians working within primary, secondary and tertiary care in Sweden in the fields of general practice, rehab medicine, orthopedic surgery, neurosurgery, or obstetrics and gynecology were purposively recruited consecutively until categorical saturation was reached. Semi-structured interviews were used for data collection. The transcripts were analyzed and categorized by two researchers. A third researcher checked for consistency between the data and the categories. An outcome space was constructed representing the logical relationship between the categories. RESULTS: The analysis identified six categories: The addictive opioid, The deserving patient, The ignorant prescriber, The lost patient, The compassionate prescriber, and The exposed prescriber. The differences in conceptions among the categories were clarified through three main contributors related to opioid therapy: prescriber's characteristics, patient's characteristics, and the healthcare organization. CONCLUSIONS: Opioids were understood as being addictive with long-term use promoting a downward spiral of tolerance and withdrawal driving the pain, leading to continued prescription. Long-term opioid therapy could be justified for patients who improved in function, and who were perceived as trustworthy. Inadequate follow-up of patients, poor training in pain management and addiction medicine, personal attitudes and beliefs about opioids, a perceived professional obligation to treat patients with pain, and lack of collegial support, were factors understood to promote clinically unindicated long-term opioid therapy.

Behavioral Medicine Physiotherapy in the Context of Return to Work for Chronic Pain: A Single-Case Experimental Design Study.

Effective interventions are needed for return-to-work (RTW) for individuals with chronic pain on long-term sick leave. In this study, a behavioral medicine physiotherapy protocol was systematically replicated and added to workplace components. The intervention was evaluated for fidelity and effects on target activities and work ability. A single-case experimental design was used with five participants. Daily and weekly ratings of personalized target activities at work as well as work ability were carried out throughout the study period of 26-28 weeks. Effects of the behavioral medicine physiotherapy intervention were evaluated for each individual using visual analysis of displayed graphs and quantitative non-overlap methods. Goal achievement for target activities was reviewed. Three participants completed the intervention. The results indicated an effect from the behavioral medicine physiotherapy intervention on task-specific self-efficacy for target activities, but no consistent effect on experience of target activities or work ability. All three participants had increased function in target activities in line with pre-defined goals. Fidelity to the intervention manual was good. Behavioral medicine physiotherapy can be successfully adapted to work disability and was here replicated in an RTW context for individuals with chronic pain. The intervention protocol should be further evaluated in large-scale studies.

Pain, disease severity and associations with individual quality of life in patients with motor neuron diseases.

BACKGROUND: Up to 85% of people with motor neuron disease (MND) report pain, but whether pain has negative impact on quality of life is unclear. The aim was to study associations between pain, disease severity and individual quality of life (IQOL) in patients with MND. METHODS: In this cross sectional study, 61 patients were recruited from four multidisciplinary teams in Sweden, whereof 55 responded to the pain measure (The Brief Pain Inventory - Short form) and were included in the main analyses. Disease severity was measured with the Amyotrophic Lateral Sclerosis Functional Rating Scale - Revised Version, and individual quality of life was measured with a study-specific version of the Schedule for the Evaluation of Individual Quality of Life - Direct Weighting. RESULTS: Forty-one (74%) of the participants who answered BPI-SF (n = 55) reported pain. Thirty-nine (71%) of those reported pain during the past 24 h. The severity of pain was on average moderate, with eight participants (14%) reporting severe pain (PSI ≥ 7). Satisfaction with IQOL for the entire sample was good (scale 1-7, where 1 equals poor quality of life): median 5, interquartile range (IQR) 2.75 and there was no difference in satisfaction with IQOL between those reporting pain/not reporting pain (median 5, IQR 2/median 5, IQR 3.5, Mann-Whitney U = 249, p = 0.452). There was neither any correlation between pain severity and satisfaction with IQOL, nor between disease severity and satisfaction with IQOL. CONCLUSIONS: The results add to the hypothesis that associations between non-motor symptoms such as pain prevalence and pain severity and IQOL in MND are weak. Pain prevalence was high and the results pointed to that some participants experienced high pain severity, which indicate that pain assessments and pain treatments tailored to the specific needs of the MND population should be developed and scientifically evaluated.

Psychometric assessment of the Swedish version of the injustice experience questionnaire among patients with chronic pain.

OBJECTIVES: The use of the Injustice Experience Questionnaire (IEQ) in psychological assessment of individuals with chronic pain is supported by research. The psychometric properties of the Swedish version, the IEQ-S, has not yet been evaluated. Hence, the aim was to investigate structural validity, and concurrent criterion validity of the IEQ-S against the Work Ability Index (WAI), the Pain Catastrophizing Scale (PCS-SW), the Patient Health Questionnaire 9-item depression module (PHQ-9), and the Generalized anxiety disorder 7-item scale (GAD-7). Internal consistency and test-retest reliability were also studied. METHODS: Sixty-five participants, referred to a University hospital, with a pain duration over three months were consecutively sampled. They completed the IEQ-S at admission and again within six weeks. A confirmatory factor analysis was performed for the study of structural validity. Concurrent criterion validity was evaluated using Spearman's correlation coefficient. Internal consistency reliability for the full IEQ-S was calculated using the Cronbach's alpha. Test-retest reliability was calculated using an Intraclass Correlation Coefficient (ICC). RESULTS: The median total score (0-48, where high scores indicate high levels of injustice) at admission (test 1) was 27.0 (n=64), 25th percentile=15.3, 75th percentile=37.8, range=3-48 points. A one-factor model was supported with item-loadings between 0.67-0.92. Spearman's correlation coefficient between the IEQ-S and the WAI (n=56) was rS =-0.46; the PCS-SW (n=63) was rS =0.68, the PHQ-9 (n=64) was rS =0.50 and the GAD-7 (n=64) was rS =0.57, p<0.01. Cronbach's alpha was 0.94 (n=64). The ICC was 0.80 (n=55), with a 95% confidence interval, ranging between 0.69-0.88. CONCLUSIONS: Our study supported structural validity and concurrent criterion validity of the IEQ-S against other measures of psychological constructs and work ability. It also supported the internal consistency reliability of the IEQ-S and the test-retest reliability with a retest interval up to six weeks, was good. These findings support the use of the IEQ-S as an adjunct tool to assess appraisals of injustice in patients with chronic pain who are referred to tertiary care in Sweden. The added value might be identification of those who are at risk for slow or no improvement in their pain condition over time, and sick-leave, but this has to be confirmed in future studies. ETHICAL COMMITTEE NUMBER: EPN Uppsala D-No 2016-376.

Does exercise intensity matter for fatigue during (neo-)adjuvant cancer treatment? The Phys-Can randomized clinical trial.

Exercise during cancer treatment improves cancer-related fatigue (CRF), but the importance of exercise intensity for CRF is unclear. We compared the effects of high- vs low-to-moderate-intensity exercise with or without additional behavior change support (BCS) on CRF in patients undergoing (neo-)adjuvant cancer treatment. This was a multicenter, 2x2 factorial design randomized controlled trial (Clinical Trials NCT02473003) in Sweden. Participants recently diagnosed with breast (n = 457), prostate (n = 97) or colorectal (n = 23) cancer undergoing (neo-)adjuvant treatment were randomized to high intensity (n = 144), low-to-moderate intensity (n = 144), high intensity with BCS (n = 144) or low-to-moderate intensity with BCS (n = 145). The 6-month exercise intervention included supervised resistance training and home-based endurance training. CRF was assessed by Multidimensional Fatigue Inventory (MFI, five subscales score range 4-20), and Functional Assessment of Chronic Illness Therapy-Fatigue scale (FACIT-F, score range 0-52). Multiple linear regression for main factorial effects was performed according to intention-to-treat, with post-intervention CRF as primary endpoint. Overall, 577 participants (mean age 58.7 years) were randomized. Participants randomized to high- vs low-to-moderate-intensity exercise had lower physical fatigue (MFI Physical Fatigue subscale; mean difference -1.05 [95% CI: -1.85, -0.25]), but the difference was not clinically important (ie <2). We found no differences in other CRF dimensions and no effect of additional BCS. There were few minor adverse events. For CRF, patients undergoing (neo-)adjuvant treatment for breast, prostate or colorectal cancer can safely exercise at high- or low-to-moderate intensity, according to their own preferences. Additional BCS does not provide extra benefit for CRF in supervised, well-controlled exercise interventions.

Physical therapists' experiences of learning and delivering a complex behavioral medicine intervention to adolescents with pain.

The objective was to study physical therapists' (PTs') experiences of learning and delivering a complex intervention, a tailored behavioral medicine treatment (BMT) targeting adolescents with pain in primary care.Method: An explorative study with qualitative approach, using content analysis. Three primary care PTs delivering the treatments in a randomized controlled study were interviewed regarding their views on the BMT.Results: The participating PTs considered learning about and delivering the BMT as challenging but rewarding. The biopsychosocial approach, tailoring of the treatment and dialogues with parents were identified as key aspects of the BMT program. The process of formulating a functional behavioral analysis was perceived as strenuous. The supervision of the PTs throughout the study was regarded as crucial and necessary for learning about and providing tailored BMT.Conclusion: Learning about and delivering BMT targeting adolescents with persistent pain is fruitful but laborious and demanding according to three PTs experienced with treatment of pediatric pain in primary care. Extensive education and long periods of supervision seem to be crucial for success and safe delivery according to protocol.

Association between health care utilization and musculoskeletal pain. A 21-year follow-up of a population cohort.

Background and aims Few studies have reported the long-term impact of chronic pain on health care utilization. The primary aim of this study was to investigate if chronic musculoskeletal pain was associated with health care utilization in the general population in a 21-year follow-up of a longitudinal cohort. The secondary aim was to identify and describe factors that characterize different long-term trajectories of health care utilization. Methods A prospective cohort design with a baseline sample of 2,425 subjects (aged 20-74). Data were collected by self-reported questionnaires, and three time points (1995, 2007, and 2016) were included in the present 21-year follow up study. Data on health care utilization were dichotomized at each time point to either high or low health care utilization. High utilization was defined as >5 consultations with at least one health care provider, or ≥1 consultation with at least 3 different health care providers during the last 12 months. Low health care utilization was defined as ≤5 consultations with one health care provider and <3 consultations with different health care providers. The associations between baseline variables and health care utilization in 2016 were analyzed by multiple logistic regression. Five different trajectories for health care utilization were identified by visual analysis, whereof four of clinical relevance were included in the analyses. Results Baseline predictors for high health care utilization at the 21-year follow-up in 2016 were chronic widespread pain (OR: 3.2, CI: 1.9-5.1), chronic regional pain (OR:1.8, CI: 1.2-2.6), female gender (OR: 2.0, CI: 1.4-3.0), and high age (OR: 1.6, CI:0.9-2.9). A stable high health care utilization trajectory group was characterized by high levels of health care utilization, and a high prevalence of chronic pain at baseline and female gender (n = 23). A stable low health care utilization trajectory group (n = 744) was characterized by low health care utilization, and low prevalence of chronic pain at baseline. The two remaining trajectories were: increasing trajectory group (n = 108), characterized by increasing health care utilization, chronic pain at baseline and female gender, and decreasing trajectory group (n = 107) characterized by decreasing health care utilization despite a stable high prevalence of chronic pain over time. Conclusions The results suggest that chronic pain is related to long-term health care utilization in the general population. Stable high health care utilization was identified among a group characterized by female gender and a report of chronic widespread pain. Implications This cohort study revealed that chronic widespread pain predicted high health care utilization over a 21-year follow-up period. The results indicate the importance of early identification of musculoskeletal pain to improve the management of pain in the long run.

Influences of Sex, Education, and Country of Birth on Clinical Presentations and Overall Outcomes of Interdisciplinary Pain Rehabilitation in Chronic Pain Patients: A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP).

This study investigates the effects of sex, education, and country of birth on clinical presentations and outcomes of interdisciplinary multimodal pain rehabilitation programs (IMMRPs). A multivariate improvement score (MIS) and two retrospective estimations of changes in pain and ability to handle life situations were used as the three overall outcomes of IMMRPs. The study population consisted of chronic pain patients within specialist care in the Swedish Quality Registry for Pain Rehabilitation (SQRP) between 2008 and 2016 at baseline (n = 39,916), and for the subset participating in IMMRPs (n = 14,666). A cluster analysis based on sex, education, and country of origin revealed significant differences in the following aspects: best baseline clinical situation was for European women with university educations and the worst baseline clinical situation was for all patients born outside Europe of both sexes and different educations (i.e., moderate-large effect sizes). In addition, European women with university educations also had the most favorable overall outcomes in response to IMMRPs (small effect sizes). These results raise important questions concerning fairness and equality and need to be considered when optimizing assessments and content and delivery of IMMRPs for patients with chronic pain.

"My life is under control with these medications": an interpretative phenomenological analysis of managing chronic pain with opioids.

BACKGROUND: The use of opioids to relieve chronic pain has increased during the last decades, but experiences of chronic opioid therapy (COT) (> 90 days) point at risks and loss of beneficial effects. Still, some patients report benefits from opioid medication, such as being able to stay at work. Guidelines for opioid use in chronic pain do not consider the individual experience of COT, including benefits and risks, making the first person perspective an important scientific component to explore. The aim of this study was to investigate the lived experience of managing chronic pain with opioids in a sample who have severe chronic pain but are able to manage their pain sufficiently to remain at work. METHODS: We used a qualitative research design: interpretative phenomenological analysis. Ten individuals with chronic pain and opioid therapy were purposively sampled in Swedish tertiary care. RESULTS: Three super-ordinate themes emerged from the analyses: Without opioids, the pain becomes the boss; Opioids as a salvation and a curse, and Acknowledgement of the pain and acceptance of opioid therapy enables transition to a novel self. The participants used opioids to regain control over their pain, thus reclaiming their wanted life and self, and sense of control over one's life-world. Using opioids to manage pain was not unproblematic and some of the participants had experienced a downward spiral of escalating pain and uncontrollable opioid use, and stigmatisation. CONCLUSIONS: All participants emphasised the importance of control, regarding both pain and opioid use. To accomplish this, trust between participants and health care providers was essential for satisfactory treatment. Regardless of the potential sociocultural benefits of staying at work, participants had experiences of balancing positive and negative effects of opioid therapy, similar to what previous qualitative research has found. Measurable improvement of function and quality of life, may justify the long-term use of opioids in some cases. However, monitoring of adverse events should be mandatory. This requires close cooperation and a trusting relationship between the patients and their health care provider.

Effects on obstructive sleep apnea severity following a tailored behavioral sleep medicine intervention aimed at increased physical activity and sound eating: an 18-month follow-up of a randomized controlled trial.

STUDY OBJECTIVES: Positive effects have been reported following a behavioral sleep medicine (BSM) intervention targeting physical activity and eating behavior in addition to continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA). Long-term follow-up remains to be explored. The aim was to examine the long-term effects of a tailored BSM intervention addressing physical activity and eating behavior in addition to CPAP treatment in patients with moderate to severe OSA combined with overweight and physical inactivity. Further, the aim was to identify variables at baseline, associated with treatment success regarding OSA severity. METHODS: Sixty participants (body mass index: 34.5 ± 5.0 kg/m²; apnea-hypopnea index [AHI]: 43.7 ± 21.2 events/h) completed the randomized controlled trial with a follow-up at 18 months. The participants were randomized to either a control group treated with CPAP or an experimental group treated with CPAP and a BSM intervention targeting physical activity and eating behavior changes. OSA was categorized as mild (AHI: 5 to <14.9 events/h), moderate (AHI: 15 to <29.9 events/h), or severe (AHI ≥30 events/h). RESULTS: Being in the experimental group was associated with a larger improvement (B = -9.353, P = .029) in AHI at the 18-month follow-up compared with being in the control group when adjusting for baseline AHI and body mass index. Improvement in OSA category occurred more frequently in the experimental group participants (n = 11; 36.7%) compared with the control group (n = 2; 6.7%). Deterioration in OSA category was found in 1 (3.3%) participant in the experimental group and 3 (10%) in the control group. CONCLUSIONS: The importance of a BSM intervention as an adjunct treatment in patients with OSA is emphasized due to its long-term benefits. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Lifestyle changes in obstructive sleep apnea; Identifier: NCT01102920.