To Örebro University

BACKGROUND: In digital health innovations, sustainable implementation should be considered from the initiation of the development to ensure that the solution fits into the existing healthcare system. This study aims at identifying barriers and facilitators for the prospective implementation of a digital behavioral intervention for chronic pain in the Swedish healthcare system, as perceived by key stakeholders.

METHODS: Eight semi-structured individual interviews were conducted with stakeholders (n = 2 IT developers, n = 4 healthcare managers, n = 2 healthcare professionals). Qualitative data were analyzed using a framework analysis following the Consolidated Framework for Implementation Research (CFIR).

RESULTS: A total of 86 facilitators and 38 barriers to prospective implementation were identified across stakeholder interviews. Facilitators included perceived relevance of the digital intervention and organizational readiness. Identified barriers primarily related to insufficient training and supervision, unclear decision-making processes (e.g., specific actions, responsibilities of stakeholders), and the lack of systematic needs assessment to guide implementation planning.

CONCLUSION: Overall, findings indicate a high level of openness toward digital interventions within the implementation context. While implementation context largely demonstrates readiness, successful integration will depend on proactively addressing identified barriers. Awareness of these factors enhances the likelihood of successful and sustainable implementation.

Although associations exist between child maltreatment (CM) and multiple chronic painful conditions, it remains unclear to what extent associations might be attributable to unmeasured confounding. We leveraged the co-twin control approach, which rules out genetic and shared environmental confounding by design, with cross-sectional, national Swedish data from the Study of Twin Adults: Genes and Environment (N = 25,418; Mage = 33.2; SDage = 7.7; 55.7% female) to assess associations between the number of self-reported experiences of CM (ie, experiencing emotional or physical abuse/neglect, sexual abuse, or witnessing family violence before age 18 years) and self-reported endorsement of criteria for chronic widespread pain (CWP), lower back pain (LBP), and irritable bowel syndrome (IBS). In negative binomial generalized estimating equation models adjusting for age and sex at birth, a one-unit increase in CM counts was associated with 37%, 18%, and 34% more endorsement of CWP, LBP, and IBS criteria, respectively (CWP-adjusted incidence rate ratio [aIRR] = 1.37 [95% confidence interval: 1.32-1.42]; LBP aIRR = 1.18 [1.16-1.21]; IBS aIRR = 1.34 [1.29-1.39]). In comparisons of differentially exposed co-twins, associations attenuated only slightly for CWP (aIRR, 1.21 [1.12-1.31]), LBP (aIRR, 1.15 [1.09-1.21]), and IBS (aIRR, 1.24 [1.14-1.35]). Analyses restricted to monozygotic twins to rule out virtually all genetic confounding produced similar results (CWP aIRR, 1.20 [1.05-1.38]; LBP aIRR, 1.10 [1.01-1.21]; IBS aIRR, 1.14 [1.00-1.30]). Altogether, the results suggest that associations between CM and CWP, LBP, and IBS are not entirely attributable to genetic or shared environmental confounding.

Previous research indicates that individuals with chronic widespread pain (CWP) have an excess risk of cardiovascular disease. Given the high global prevalence of CWP, this association may have substantial public health implications. Our objective was to summarise the current evidence on the association between CWP and incident cardiovascular disease in a systematic review and meta-analysis. We searched major databases (MEDLINE, Embase, Web of Science, and Cochrane) and included studies based on predefined eligibility criteria. We identified 18 studies reporting associations between CWP (n = 80,021) and atherosclerotic diseases or cardiovascular mortality (n events = 33,799). In the meta-analysis, we removed studies that analysed identical outcomes in the same population. Individuals with CWP had an almost doubled risk of atherosclerotic diseases, RR 1.94 (95% confidence interval [CI]: 1.56-2.41), and for cardiovascular mortality, the RR was 1.61 (95% CI: 1.24-2.08) in the minimally adjusted models. In the maximally adjusted model, the RR for atherosclerotic diseases was 1.53 (95% CI: 1.27-1.86) vs RR 1.12 (95% CI: 0.93-1.34) for cardiovascular mortality. The heterogeneity was high and potential publication bias was indicated for the mortality analysis. This meta-analysis, although based on relatively few studies with high heterogeneity, shows that CWP is consistently associated with incident atherosclerotic disease. Evidence for an association with cardiovascular mortality is less conclusive. Individuals with CWP may represent an underrecognized high-risk group for atherosclerotic diseases that could benefit from proactive cardiovascular risk assessment and intensified prevention. Further high-quality studies are warranted to confirm the strength and causality of the association.

BACKGROUND: Chronic pain frequently co-occurs with emotional problems, highlighting the need for integrated treatment approaches. Previously, we evaluated a hybrid emotion-focused treatment with positive results. However, there is a dire need for studies evaluating treatments in 'real world' clinical contexts. Therefore, this study evaluated the effectiveness of this treatment in regular clinical care.

METHODS: Using a sequential single-case experimental AB design with randomized baseline lengths (4, 5 or 6 weeks), pain, emotional problems and cognitive behavioural factors were assessed weekly across a 20-week study period. Additional outcome measurements were collected at pre-, post- and 12-month follow-up. Patients from primary and secondary care (final n = 31) with chronic pain and anxiety/depression were recruited, and their psychologists delivered the treatment. Individual effects were evaluated using non-overlap of all pairs and aggregated effects via multilevel shift models. Acceptability, adherence and fidelity were summarized, and responders and non-responders compared using group-level analyses.

RESULTS: Most (87%) demonstrated a treatment response on ≥ 1 outcome, and over half (55%) on ≥ 3 outcomes. One-third were classified as broad responders. Aggregated analysis showed a significant effect on pain interference. The treatment was viewed as credible and acceptable, with greater satisfaction among responders. Non-responders showed more variability in attendance and lower progression through later treatment phases involving exposure.

CONCLUSION: The findings support the feasibility and potential effectiveness of the hybrid emotion-focused treatment for patients in routine clinical care. The treatment benefits most patients to some extent and a smaller subset of patients to a clinically significant extent.

SIGNIFICANCE STATEMENT: This pragmatic trial evaluates effectiveness in a clinically representative patient sample reflecting the complexity of routine care, including pain and psychiatric comorbidity, sociodemographic diversity and health care utilization. The hybrid emotion-focused treatment represents one of several emerging approaches targeting pain-emotion connections. These findings extend results from a prior RCT and highlight the importance of evaluating interventions under real-world clinical conditions.

BACKGROUND: Chronic pain remains a leading cause of patient distress in primary care and effective pain management presents an ongoing challenge in patient-clinician interactions. The prescribing of opioids further contributes to communication and shared decision-making disparities between patients and general practitioners. Gaining greater insight into patients' experiences of opioid treatment is valuable as there still is limited knowledge. Patients' perspectives and expectations can provide important contributions to enhance mutual understanding in clinical encounters.

AIM: To explore how patients experience, and what they expect from, pain management consultations regarding opioid use.

DESIGN AND SETTING: A qualitative study with patients in rural Örebro County, Sweden.

METHOD: Semi-structured interviews were carried out with fifteen chronic pain patients prescribed opioids managed in primary care. The interviews were analyzed using reflexive thematic analysis.

RESULT: Two main themes were generated to capture patients experience and their expectations concerning pain management and opioids. Prescribing Validation gives insights to what expectations patients have and how they perceive prescriptions. Renewals are interpreted as validation of the pain condition, and dismissals as mistrust. The Battle for the Steering Wheel capture how patients, based on the lived experience of chronic pain, expect and seek to assert their own expertise in consultations but often feel frustrated over being unheard.

CONCLUSION: While education about the biopsychosocial nature of pain may provide a necessary foundation for communication around reducing opioid use, validation of patient experience is pivotal for building a trusting alliance.

More than two decades have passed since exposure-based interventions were first applied to four individuals with chronic low back pain reporting pain-related fear. To reflect on the progress made since then, an international Special Interest Meeting gathered experts for two days of active dialogue and discussion focusing on the theoretical foundations of exposure-based interventions and their broader application to bodily symptoms from an interdisciplinary perspective. In a subsequent joint paper, the participants summarized how exposure-based interventions have been applied across clinical settings (psychology, behavioral and rehabilitation medicine), treatment providers (psychologists, physiotherapists, physiatrists), delivery formats (digital and in-person), and treatment adaptations (for different age groups and co-occurring conditions). Beyond chronic pain, emerging applications have also extended to a wider range of bodily symptoms, including chronic neuropathic pain, post-concussion symptoms, tinnitus, female genitopelvic pain, cardiovascular symptoms, and gastrointestinal symptoms. To facilitate implementation in clinical practice, the Consolidated Framework for Implementation Research (CFIR) was used to systematically identify evidence gaps and inform a strategic roadmap for future research. Theoretical models that have shaped the field were examined for their potential to guide future innovation. Continued research is needed to clarify which individuals benefit most within a matched care framework and to identify optimal strategies for implementation in routine practice.

Background: Chronic pain affects up to 20% of the population and often results in significant distress, disability, and reduced quality of life. Despite compelling evidence for behavioural treatments, treatment access remains limited. To improve access, a digital behavioural treatment for chronic pain was developed as part of the multi-phase 'DAHLIA' project. The present study evaluates the effects of this newly developed digital behavioural treatment.

Methods: Data were collected in a single-arm, iterative trial using a replicated single-case experimental design (SCED). In total, 56 participants received treatment (mean age 47, 87% female, varied pain regions). Participants completed twice daily digital diaries and questionnaires at pre-, and post-treatment, and at 3- and 6-months follow-ups. Diary items and questionnaires assessed psychological flexibility and acceptance, pain-related functioning, pain intensity, and general well-being. Daily diary data were examined using a combined p-value approach to conduct a meta-analysis of the SCED data, and questionnaire data were analysed using linear mixed models.

Results: Meta-analyses of daily diary data showed significant improvements in most pain-related items, indicating the utility of treatment in everyday life. Linear mixed model analyses of effects showed significant improvements over time in key outcomes with the largest changes observed in pain acceptance and psychological flexibility and smaller effects in pain-related functioning.

Conclusion: This study provides initial evidence for the newly developed digital behavioural treatment for chronic pain. Findings suggest that the treatment can improve resilience, daily functioning and symptoms and suggest the potential of the treatment as an effective evidence-based treatment for chronic pain.

BACKGROUND: Chronic musculoskeletal pain is reported by one of four adolescents worldwide. Pain-related functioning is negatively affected by pain itself but also related to depressive symptoms. While the association between pain-related functioning and depressive symptoms is established, there is a lack of longitudinal studies that establishes the direction of the association.

OBJECTIVES: The aim was to analyse the temporal association between depressive symptoms and pain-related functioning among adolescents with recurrent musculoskeletal pain. METHODS: This longitudinal sample comprised 604 adolescents in 7th and 8th grade (M = 13.7 years) who reported recurrent musculoskeletal pain at baseline, defined as occurring at least every week over the previous 6 months. The adolescents were followed yearly for two consecutive years (T1, T2 and T3). Temporal associations of self-reported pain-related functioning and depressive symptoms were analysed. Using cross-lagged panel modelling, four models were estimated: Autoregressive; Depressive symptoms predicting pain-related functioning; Pain-related functioning predicting depressive symptoms and a bidirectional model. Pain intensity was entered as a covariate.

RESULTS: The results indicate high stability of depressive symptoms and pain-related functioning over time. While the strength of the prediction was strongest in the autoregressive paths, cross-lagged paths revealed that depressive symptoms at T1 and T2 significantly predicted pain-related functioning at T2 respectively T3. Conversely, pain-related functioning at T1 and T2 did not predict depressive symptoms at T2 respectively T3.

CONCLUSIONS: The model where depressive symptoms predict pain-related functioning provided the best model fit and thus, in this general population sample, depressive symptoms drive pain-related functioning more than vice versa. Screening for, and targeting depressive symptoms, might be essential in affecting the functional consequences of pain.

INTRODUCTION: A sizeable number of adolescents with recurrent pain frequently miss school, yet the trajectories of absenteeism and their correlates remain unclear. We aimed to explore trajectories of school absenteeism due to pain among adolescents with recurrent pain, and predictors and correlates of the trajectories.

METHODS: A prospective cohort design with 3 yearly measurement points between 2016 and 2018 was used. The sample included 873 Swedish upper secondary school adolescents (mean age = 16.5 years; 60.8% girls; 11.7% immigrants) with recurrent pain (headache, abdominal and/or musculoskeletal pain ≥1/wk for 6 months). Predictors were sociodemographic variables, pain characteristics, depressive symptoms, and stressors in the school context. Distal outcomes were perceived future work ability and overall future expectancy.

RESULTS: We identified 3 trajectories of absenteeism through latent class growth analysis: persistently high absenteeism (18.1%), persistently low absenteeism (49.4%), and persistently no absenteeism (32.5%). Pain intensity and school-related stressors independently predicted absenteeism trajectories. Compared with the other trajectories, the persistently high absenteeism subgroup had more negative perceived future work ability and overall future expectancy.

CONCLUSION: A substantial subgroup of adolescents showed a stable pattern of high absenteeism across their upper secondary education, which was associated with overall negative expectancies for the future and specifically future work ability. Therefore, there is a need to identify this subgroup and intervene early in the life course to prevent long-term disadvantages in education, employment, and overall well-being.