To Örebro University

When acute pain persists, it is said to become chronic after 3 months. Considerable interest has focused on why acute pain appears to transition to chronic pain in some cases, but not all, especially when it becomes disabling. We examine our current understanding of the processes involved in the progression from an acute injury to disabling chronic pain. Rather than viewing this progression as a time dependent transition with specific static risk factors, we consider whether it might be more helpful to understand this evolution in terms of unique individual pathways. While brief self-report screening questionnaires assessing risk factors may enable us to stratify patients into risk levels, they do not provide information on the unique context and factors contributing to the disabling pain for each person. It is proposed that a 2-step process combining screening and individual assessment of those at high risk will enhance the prospect of both early identification and individually relevant interventions before more lasting changes emerge. Rather than being concerned with arbitrary time limits, it is argued that by aiming to understand the unique developmental pathway for those individuals identified as high risk, early, preventive interventions will be both viable and effective. Even so, there are barriers to the implementation of early assessment and matched treatments, and these remain a challenge for future research.

BACKGROUND & OBJECTIVE: Psychologically informed care has been proposed to improve treatment outcomes for chronic pain and aligns with a person-centered approach. Yet implementation lags behind, and studies suggest that a lack of competency leads to poor results. It is unclear what training clinicians require to deliver this care. We examine how we might improve psychologically informed care guided by the needs of the patient and in congruence with the scientific literature with a particular focus on how competencies might be upgraded and implementation enhanced.

METHODS: We selectively review the literature for psychologically informed care for pain. The patient's view on what is needed is contrasted with the competencies necessary to meet these needs and how treatment should be evaluated.

RESULTS: Patient needs and corresponding competencies are delineated. A number of multi-professional skills and competencies are required to provide psychologically informed care. Single-subject methodologies can determine whether the care has the desired effect for the individual patient and facilitate effectiveness. We argue that becoming a competent "pain clinician" requires a new approach to education that transcends current professional boundaries.

CONCLUSIONS: Providing person-centered care guided by the needs of the patient and in line with the scientific literature shows great potential but requires multiple competencies. We propose that training the pain clinician of the future should focus on psychologically informed care and the competencies required to meet the individual's needs. Single-subject methodology allows for continual evaluation of this care.

BACKGROUND: Psychological treatments for common mental disorders are increasingly being delivered remotely via the internet. Evidence suggests that internet-delivered cognitive behavioural therapy (iCBT) is superior to waitlist. However, the benefits are unclear of using this treatment modality as an add-on to treatment as usual (TAU) in regular healthcare.

METHODS: The literature was systematically searched up to August 2021 for randomized trials of internet-delivered psychological treatments using TAU as the comparator. Eligible participants were diagnosed with depressive, anxiety, obsessive-compulsive, or trauma- and stress-related disorders. Outcomes of interest were symptoms, functioning, quality of life, healthcare utilization, and negative effects. Results were synthesized using random-effects meta-analyses. Quality of evidence was assessed using GRADE.

RESULTS: The included studies evaluated iCBT for adults with depression (k = 9), depressive or anxiety disorders (k = 4), and post-traumatic stress disorder (k = 2) and were conducted in primary care or similar settings. For depression, low-certainty evidence suggested beneficial short-term effects on symptoms (g = -0.23; 95 % CI: = -0.37, -0.09), response rate (OR = 2.46; 1.31, 4.64), and remission (OR = 1.70; 1.19, 2.42;). The certainty of evidence was very low for long-term effects, other outcomes, and other disorders.

LIMITATIONS: TAU varied across studies and was often insufficiently described.

CONCLUSIONS: iCBT as a complement to usual care for adult with depression may result in a small incremental effect, which potentially could be clinically important. Studies are lacking for several common disorders and for children, adolescents, and the elderly. More robust studies of long-term effects are also needed, to better inform clinical decision-making.

Objective: The aim of this study was to investigate physiotherapists' validating and invalidating communication, before and after brief Cognitive Functional Therapy (CFT) training that included a session on validation skills. Associations between validation/invalidation and the characteristics of the interviews and physiotherapists were also explored.

Methods: Eighteen physiotherapists treating patients with low back pain participated in the study. The study had a within-group design in which validation and invalidation for physiotherapists were rated before and after training using a reliable observational scale. We also collected data on interview length and physiotherapists' and patients' speech percentages.

Results: The physiotherapists' validating responses increased and invalidating responses decreased from pre- to post-training. The within-group effect size was large for validating responses and medium for invalidating responses. The interview length increased from pre- to post-training (large effect size). However, the reason for this was related to factors other than validation and invalidation. The results indicate that increased validation is associated with an increase in physiotherapists' speech percentage.

Conclusions: The results of this study show changes invalidating and invalidating communication among physiotherapists from pre- to post-CFT training. The study also found associations between specific interview characteristics and validating communication. Future studies with larger samples and control groups are needed.

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.

BACKGROUND: Sexual communication is a common target in psychological treatments for vulvodynia, and associations with sexual function and distress, as well as pain intensity, have been demonstrated. However, structured observations of the communication patterns of couples with vulvodynia are lacking, as these are needed to guide treatment efforts.

AIM: To explore (1) the sexual communication patterns in couples with vulvodynia in terms of observed communication quality (operationalized as validating and invalidating responses), self-reported sexual assertiveness, and self-disclosure and (2) associations between sexual communication quality and pain intensity.

METHODS: In a case-control design with within- and between-group comparisons, 62 couples engaged in videotaped discussions about their sexual relationship. Trained coders assessed the discussions by rating sexual communication (validation and invalidation) according to a structured behavioral coding scheme. Group differences in sexual communication quality were examined with parametric and nonparametric tests. Dyadic associations among observed communication quality, self-rated sexual assertiveness, and self-disclosure were examined within the actor-partner interdependence model. Multiple regression was used to test the predictive value of partners' validation/invalidation on the pain intensity of the women with vulvodynia.

OUTCOMES: Observed communication quality (ie, validation and invalidation), self-reported sexual assertiveness, self-disclosure, and pain intensity.

RESULTS: Partners of women with vulvodynia were more invalidating toward their partners than those of women without pain. There were no significant differences in validating/invalidating communication between women in the 2 groups or in validation between partners. Partners' validating communication were significantly associated with women's lower pain intensity. The sexual communication patterns differed between couples with and without vulvodynia, and the associations between validating/invalidating responses and sexual assertiveness were stronger in the vulvodynia group than in the group without pain. Results on validation/invalidation and self-disclosure were inconclusive.

CLINICAL IMPLICATIONS: The results indicate a need to direct treatment interventions toward couples' sexual communication quality (ie, levels of validation and invalidation).

STRENGTHS AND LIMITATIONS: Strengths include systematic behavioral coding and dyadic analyses. Limitations include the cross-sectional design and self-selection of participants.

CONCLUSION: This study demonstrated sexual communication patterns specific to couples with vulvodynia, and we conclude that validation and invalidation are important components of the sexual communication of couples with vulvodynia as they relate to sexual assertiveness, women's self-disclosure, and pain intensity.

BACKGROUND: The Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) was developed to identify psychological and functioning-related risk factors among individuals with musculoskeletal pain at risk of work disability. This study aimed to examine whether the short version of the ÖMPSQ (ÖMPSQ-SF) can be used for this purpose, using registry-based outcomes.

METHODS: The ÖMPSQ-SF was completed by the members of the Northern Finland Birth Cohort 1966 at the age of 46 years (baseline). These data were enriched with national registers, including information on sick leaves and disability pensions (indicators of work disability). The associations between the ÖMPSQ-SF categories (low-, medium- and high risk) and work disability over a 2-year follow-up were analysed using negative binomial regression and binary logistic regression models. We made adjustments for sex, baseline education level, weight status and smoking.

RESULTS: Overall, 4063 participants provided full data. Of these, 90% belonged to the low-risk, 7% to the medium-risk and 3% to the high-risk group. Compared to the low-risk group, the high-risk group had a 7.5 [Wald 95% confidence interval (CI) 6.2-9.0] times higher number of sick leave days and 16.1 (95% CI 7.1-36.8) times higher odds of disability pension after adjustments in the 2-year follow-up.

CONCLUSIONS: Our study suggests that the ÖMPSQ-SF could be used for predicting registry-based work disability at midlife. Those allocated to the high-risk group seemed to have a particularly great need of early interventions to support their work ability.

This study explores the subjective experiences of dyspareunia among queer women in Sweden. Ten semi-structured, in-depth interviews were conducted with five participants who were all interviewed on two separate occasions. Interviews were analysed using thematic analysis. Dyspareunia was described as affecting the participants' sexual activities, intimate relationships, and identity constructs. Reported struggles involved feelings of sadness, guilt, frustration, and fear of pain. Dyspareunia was described as threatening the participants' queer identities through its effect on their ability to be sexual in idealised ways. However, queer experiences and communities were also found to be associated with advantages in pain management, such as well-developed sexual communication skills, anatomic similarity to their partner, access to non-heteronormative sexual scripts and a focus on nurturing desire. Queer related advantages in pain management are proposed to buffer to some extent against pain interference with sexual function and desire. Findings indicate that it is important to consider the unique relational and social context of queer women to understand their experiences of dyspareunia. More research is needed on the role of differences of normativities, context and communication in dyspareunia.

Background: Recent low back pain guidelines recommend a BPS approach to the management of disabling low back pain. However, the most effective way of teaching physiotherapists to implement these approaches remains unknown. The present qualitative study aimed to explore physiotherapists' conceptions of learning and integrating Cognitive Functional Therapy (CFT) into clinical practice in Finnish primary health care.

Methods: We interviewed 22 physiotherapists, who participated in four to six days of CFT workshops. A phenomenographic approach was used to explore the variation in the physiotherapists' conceptions of this process.

Results: Four themes emerged from the data: 1) membership of work community; 2) learning journey; 3) transition to new working methods; and 4) professional role as a physiotherapist. These themes varied in four categories of description: recognizing difference of the new approach, toward integrating the new approach, waking up to explore, commitment to new approach and expanding application of new approach. The critical aspects between the categories that enabled the integration of CFT into clinical practice were ability to overcome resistance and to change views, being shaken and ability to critically reflect on one's work, support from the work community and becoming convinced, creativity, multidisciplinary collaboration and continuous learning.

Conclusion: The participants' responses to the training varied greatly, suggesting that for some, the training was insufficient to support adequate changes in their practice behavior; whereas for others, the training was a life changing experience.

Vulvodynia is common and has an immense impact on affected women and their partners. Psychological factors have been found to contribute to pain maintenance and exacerbation, and treatments addressing psychological factors have yielded positive results. This study employed a replicated single-case experimental design to examine a cognitive behavioral therapy (CBT) group treatment with partner involvement in vulvodynia. Repeated measures of pain intensity related to pain-inflicting behaviors were collected weekly throughout baseline and treatment phases. Associated outcomes were measured pre-, post- and at two follow-up assessments. Participants were 18-45-year-old women, in a stable sexual relationship with a man, experiencing vulvodynia. Five women completed the treatment consisting of 10 group sessions and 3 couple sessions. Data were analyzed through visual inspection and supplementary nonparametric calculations. The study showed promising results of the CBT treatment in alleviating pain intensity in connection to specific pain-inflicting behavior since three out of five participants showed improvements. For the participants who improved, sexual function, pain catastrophizing, avoidance, and endurance behavior changed during treatment and were maintained at follow-ups. These results warrant further study of the CBT treatment, in larger, and controlled formats.