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.

Introduction:This project aimed to develop a Person-Centred Co-ordinated Care (P3C) pathway for low back pain (LBP). Description:A national working group was formed consisting of representatives from all regional healthcare organisations in Sweden and included all relevant healthcare professions, academia, and patient organisations. A mixed method iterative design and consensus approach was applied in the development of the P3C pathway. Discussion:As a foundation, patient interviews along with a review of literature were conducted investigating the evidence base for healthcare interventions, earlier regional care programs/pathways and guidelines in Sweden as well as patient experiences and challenges with healthcare for LBP. Updated evidence-based clinical recommendations, tools supporting the practical use of the national P3C pathway and national healthcare data registry-based quality outcome indicators were then developed. Thereafter, an open consultation period provided review and feedback for final revisions and consensus. Conclusions:Essential factors for integrating best praxis according to scientific evidence and patient and healthcare professional perspectives were identified to establish a Swedish national P3C pathway for LBP. This provides a novel and innovative example of feasible methodology applicable in the international context. Future research will evaluate potential improvements in healthcare quality outcomes and effectiveness of dissemination and implementation strategies.

Given the lack of robust prognostic models for early identification of individuals at risk of work disability, this study aimed to develop and externally validate three models for prolonged work absence among individuals on sick leave due to musculoskeletal disorders. We developed three multivariable logistic regression models using data from 934 individuals on sick leave for 4–12 weeks due to musculoskeletal disorders, recruited through the Norwegian Labour and Welfare Administration. The models predicted three outcomes: (1) > 90 consecutive sick days, (2) > 180 consecutive sick days, and (3) any new or increased work assessment allowance or disability pension within 12 months. Each model was externally validated in a separate cohort of participants (8–12 weeks of sick leave) from a different geographical region in Norway. We evaluated model performance using discrimination (c-statistic), calibration, and assessed clinical usefulness using decision curve analysis (net benefit). Bootstrapping was used to adjust for overoptimism. All three models showed good predictive performance in the external validation sample, with c-statistics exceeding 0.76. The model predicting > 180 days performed best, demonstrating good calibration and discrimination (c-statistic 0.79 (95

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 randomeffects 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 in validating 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.

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.

Objectives: Male pelvic pain is a common yet poorly understood condition, strongly influencing quality of life of those affected. Research on psychological and sexual factors is lacking, specifically on younger men in family-forming ages. This study aims to explore psychological and sexual factors related to pelvic pain in younger men (<40 years) through a cross-sectional design. Methods: Participants were recruited via social media, and completed a digital survey regarding sexual health and psychological distress (n=2,647). Men with varying levels of pelvic pain were compared on levels of psychological distress and self-reported sexual health. Results: Men with pelvic pain (n=369) reported significantly higher levels of catastrophizing, anxiety and premature ejaculation compared to men without pelvic pain. Furthermore, men with higher pain intensity reported significantly higher levels of catastrophizing, anxiety and depressive symptoms compared to men experiencing lower pain intensity. Hierarchical regression analysis revealed catastrophizing and depressive symptoms as significantly predictors of pain intensity. Conclusions: These findings underscore the role of psychological factors in male pelvic pain, and points to the need for integrating a psychological understanding for further treatment development.

Background The orebro Musculoskeletal Pain Screening Questionnaire (oMPSQ) 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 oMPSQ (oMPSQ-SF) can be used for this purpose, using registry-based outcomes. Methods The oMPSQ-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 oMPSQ-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 oMPSQ-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.

1. Introduction Painful musculoskeletal disorders represent an enormous burden at the individual, organizational, and societal levels.72 In the workplace context, disabling effects of pain are influenced by a wide range of psychosocial factors, including pain beliefs, psychological distress, social support, self-efficacy, and perceptions of organizational support.26,49,52,53,66 Moreover, a patient's ability to return to work (RTW) or maintain employment can be affected by multiple overlapping systems outside of the clinic. Improving occupational outcomes for patients with pain may require that we intervene with these external systems to improve treatment choices, coping, functional and social support, organizational communication, accommodation, and reinforcement.5,53,75 This topical review provides a summary of research and rationale supporting system-level interventions to reduce the lifestyle impacts of pain, with a focus on work disability prevention. Broadly speaking, systems are entities with interrelated and interdependent parts that work together to produce synergistic patterns of behavior.60 In a pain and disability context, systems include workplace, healthcare, personal, and legislative and insurance systems (Fig. 1).37,48 These systems occur at the societal (macro) level, at an organizational or group (meso) level, and at the individual decision-making (micro) level. The contrasting characteristics of these systems are summarized in Table 1. System-level influences can be seen, for example, from national and jurisdictional differences in the prevalence of claims for disability benefits related to back pain,92,93 the length of claims between fault and no-fault systems,14,25 and the influence of compensation rates.2,16Figure 1.: Systems affecting work disability prevention efforts for patients with pain (reprinted with permission from Loisel et al.48). WCB, Workers' Compensation Board. Table 1 - Characteristics of systems influencing pain-related disability. System level Type of systems System governance Role to prevent disability Possible system-level interventions System-level constraints System-level opportunities Macro (societal) Legal and regulatory frameworks Legislative bodies, lobbyists, public, administrators, case law, voters, and union leaders Provide legal standard for job protection, wage replacement, healthcare access, and accommodation Changes to laws and regulations to support and strengthen behavioral strategies to prevent disability Strenuous lobby efforts, low level of public awareness, other priorities, and short electoral cycles Potential for broad and far-reaching changes to standards of care across multiple systems Macro (societal) Disability insurance systems Insurance boards and commissions, legislation, regulations, and market forces Provide wage replacement during recovery period; facilitate RTW planning Screen for long-term disability risk, and improve access to behavioral pain and RTW strategies Lack of integration with healthcare services; emphasis on cost containment may limit new approaches Reduce disability-related costs; can influence practices on a large scale Meso (organizational) Workplace system Managers, shareholders, labor unions, written policies, and market forces Provide fair and reasonable accommodation; identify and address workplace hazards or risks Accommodation, supervisor training, risk reduction, ergonomic improvements, and hiring practices Competing operational demands, efficiency uniformity; time constraints of supervisors Potential to retain skilled workers; reduce disability-related costs, promote workforce diversity Meso (organizational) Local workforce, rehabilitation, and disability programs Funding legislation, agency budgets, needs, and priorities Provide alternative vocational training and employment opportunities Improve communication with employers and clinicians; explore alternate career paths Program reach and financial resources often limited; services unknown to general practitioners Broaden job search beyond current occupation; independent advice and counseling. Meso (organizational) Healthcare systems Managers, shareholders (private), national health service (public) practice and licensing boards, standards of care Provide timely assessment, treatment, and patient education to reduce pain and the functional impacts of pain Integrate work disability concerns into routine care, dissuade low-quality or high-risk treatment, and improve patient education Limited consult time and burgeoning demands on general practitioners; workplace outcomes not a typical functional metric for quality care Access for patient education and counseling; medical determinations for disability insurance; and role in promoting evidence-based treatment RTW, return to work. Policies that affect pain-associated disability include those related to employment, employer compliance, insurance regulation, labor market controls, welfare systems, and healthcare delivery.8 The effectiveness of these policies depends on local organization-specific barriers and successful implementation, especially for people with fluctuating, invisible, and painful health conditions, where substantiating objective evidence may be lacking. A variety of disability protection systems10,36,68 strive to address these issues with provider input and patient/worker participation, but challenges remain, and even best evidence-based pain care can result in poor occupational outcomes if disability prevention efforts are not coordinated across systems. We describe significant system-level influences on pain-related disability further. 2. Employment systems The workplace can be characterized by both organizational culture (values)73 and organizational climate (policies and procedures).23,73 The management of work disability due to pain is influenced by not only organizational culture and climate but also the challenges of diversity (in individual work capability) and the need for flexibility.24 Commonly, clinicians are consulted for 3 types of work-related tasks: (1) authorizing the need for sickness absence; (2) managing the RTW process after an acute illness or injury; and (3) authorizing accommodations to retain employment for those with chronic pain. In all cases, interventions may need to address workplace and individual issues82 and prognostic factors that vary by pain duration.12,40,89 The effective management of pain-associated limitations in the workplace therefore requires consideration of both physical and psychosocial factors as well as overall management planning.76 2.1. Organizational interventions Kristman et al.42 distinguished 4 levels of organizational intervention to reduce pain-associated disability. At the worker level, efforts can be made to provide helpful information and address individual concerns.66,78 At the workforce level, employers can strive for better education and awareness of disability challenges. At the line manager/supervisor level, organizations can instruct supervisors to facilitate appropriate accommodations and communicate effectively with workers. At the employer level, organizations can develop RTW programs, disability prevention and retention policies, and their integration with wellness initiatives. Managerial decision-making and knowledge translation are at the heart of the process, where organizational and individual preferences are vetted.6 Interventions targeting worker-centered risk factors suggest that treatment-related reductions in psychosocial risk factors are important determinants of RTW, independent of reductions in pain.65,83 Return to work rates can be improved by interventions targeting workplace-centered risk factors such as supervisor attitudes and coworker support,77 especially when rehabilitation treatment is provided within the work milieu.15,54 Cognitive-behavioral approaches to work disability are associated with more positive RTW outcomes than usual medical care alone,46 particularly if implemented early,56 but longer absences may require more intensive approaches.32,46 Matching interventions to specific risk profiles27,34,86 and developing community-based programs83 also seem promising. 2.2. Organizational policies Although a strong and detailed disability policy can improve outcomes,61 employers can struggle to manage intermittent work absences that occur with chronic pain, and most policies tend to focus on maintaining medical certifications for lost time, not helping workers address RTW barriers.55 While written procedures are usually available for medically sanctioned illness absence, managers may be unsympathetic towards days off for minor pain complaints and harbor suspicions that short-term absences may not be genuine.38,51,81 2.3. The influence of supervisors Supervisors' capacity to support returning workers is related to individual, communication, organizational, and policy factors,19,45,81 and they play a significant role in successful RTW.47,51,91 Line managers' attitudes, actions, and leadership style can produce positive changes in self-rated health and work ability,50 and middle managers may have an even greater impact on company performance than almost any other part of the organization.90 Successful disability management and reintegration of workers requires a range of supervisor competencies38 including good communication with the absent employee,22,79 although pressure exerted by supervisors for an early RTW can be an added stressor for the employee.1 2.4. Improving psychosocial support within organizations This is an equally important but less well-recognized component to the provision of social support, whether on an individual level, within a working group, or organizational level. Social support (from coworkers and employers/supervisors) is a moderator of job-related stress,59 and social groups in the workplace are important in accommodating or mitigating the impact of disabling health conditions.84 However, the extent and nature of support varies across studies, and the mechanisms are not clear and dependent on the source.11,39,57 Many countries are experiencing rapid changes in the workplace, including new technologies, alternative working arrangements, more widespread telecommuting, changing employment contracts and relationships, and globalization,9,70 and these may present both challenges and opportunities for workers with subacute or chronic pain to receive social and organizational support. Two systematic reviews13,80 have concluded that lower levels of coworker support, but not supervisor support, are associated with longer duration of sickness absence. However, when a broader definition of workplace support is applied, reviewers report a consistent effect of lower levels of workplace support in increasing time until RTW. This finding is consistent with the literature supporting employers' efforts to offer modified duty work, maintain contact with ill workers, and adopt more proactive RTW programs.19 Social support is a significant independent predictor of RTW after long-term absence, with coworker social support as important as manager support or task satisfaction.59 In a recent systematic review of online counseling interventions, a subanalysis showed evidence for peer social support and social networking as elements that led to improved pain and function.7 Understanding social workplace influences on pain coping and work disability continues to be an area ripe for research synthesis and intervention development.74 2.5. Workplace accommodation One of the most important forms of social and material organizational support to workers with pain is the provision of temporary or permanent work accommodation (eg, changes in rotation and workstation reorganization) or graduated RTW (eg, modified hours, duties, or both). Accommodations can be provided to facilitate RTW or provide accommodation to employees with long-term disabilities.29 Thus, accommodation efforts can be positioned along a disability continuum from temporary deficits in work productivity, presenteeism, and absenteeism to long-term disability.17,44 Supervisors, typically involved in determining a suitable work accommodation offers, can also lend legitimacy to a reentering worker's challenges and smooth work-related social interactions.19 Job tenure, performance history, and coworker relationships can also affect whether accommodations are implemented.94 It is important to ensure that supervisors are confident in identifying and developing work accommodations for employees with disabilities and have the authority to secure them.85 2.6. Stakeholder involvement Finally, a more integrated approach, involving all relevant stakeholders is needed for successful implementation, but complex high-risk patients still represent a challenge that may require specialized tertiary care rehabilitation.58 Generally, stakeholder cooperation is effective if the individuals involved exercise trust and establish credibility by following through with formalized programs.43,51 The RTW process requires a coordinated and integrated approach involving all interested parties,61 with shared decision-making,18 particularly within work teams,64 but this level of coordination and communication can be difficult to manage until time off work accumulates to months or years or the level of disability is extreme. The value of implementing an agreed protocol promoting active collaboration between key stakeholders to address identified psychological and workplace factors for delayed RTW has been clearly demonstrated.65 3. The healthcare system Although policy and regulatory issues can overlap significantly in the management of work disabilities, there are distinct features of healthcare systems, which merit comment. Some of these characteristics are listed in Table 1. The lack of work-focused health care is an obstacle to work participation,3,18,67 and healthcare professionals may not regard work issues as falling within their remit.18,31 However, sickness certification is influenced by the professional patient relationship, and there is robust evidence that lack of communication and cooperation from healthcare providers is an obstacle to work participation.19,41,69 Furthermore, some providers rely heavily on biomedical diagnoses and test results to guide sickness certifications rather than to assess individual RTW barriers and working conditions.21 Action at early stages of sickness absence and involvement of the family, where appropriate, have also been recommended, but this has been rarely studied. We recommend that system-level supports for patients with pain (both at home and at work) to prevent disability should be assessed as a part of routine care and follow-up among pain practitioners. Future studies should build on studies examining perspectives beyond the clinician–patient dyad and further consider the role of organizational and system-level factors. Healthcare systems vary considerably within and across countries and jurisdictions, but governance, funding arrangements, and healthcare delivery have been identified as major features of healthcare systems.85 Perhaps the biggest factor is how health care is sanctioned and funded. Fee-for-service systems,30 which generally have higher numbers of contacts, specialist referrals, and diagnostics than capitation systems, in which clinicians receive a fixed salary to provide care for those enrolled have been criticized. However, capitation funding may also have undesirable effects, encouraging clinicians to provide the most time-efficient rather than the most effective care.62,63 Challenges within healthcare systems include not only access to but availability of treatment options, particularly for complex conditions. Systems designed to solve these issues, such as pay-for-performance systems and quality-based contingency payments, may not reward clinicians fairly for all the complexities involved in treating people with pain. A detailed analysis of healthcare system barriers to guideline adherence for low back pain by Traeger and colleagues85 supports more incentives be provided for high-value care. Providing more attention to workplace outcomes and challenges may require not only operational alterations to healthcare systems but also changes to health policy frameworks in governments, workplaces, legislative systems, consumers, and professional bodies. 4. Recent examples of system-level interventions One example of system-level changes to prevent disability is the Individual Placement and Support model to prevent disability that has overwhelming efficacy support to improve employment outcomes for patients with severe mental illness, an effect that is doubled with sufficient policy and stakeholder support.11,28 This approach has recently been adapted to patients with chronic pain in Norway and the United Kingdom with promise,35,71 but implementation will require significant cooperation and coordination of multiple stakeholders. An example from the United States is the Retaining Employment and Talent after Injury/Illness Network program.88 This is a demonstration program by the US Department of Labor to develop and test system-level interventions to help workers stay at or return to the workforce after an illness or injury. The program strives to build stronger linkages between healthcare providers, employers, and government workforce systems. Results of the program are pending, but it provides a relevant example of a national effort to improve systems coordination for work disability prevention. In the United Kingdom, the addition of a vocational advice service to the best current primary care for patients consulting with musculoskeletal pain has led to reduced absence and cost savings,95 and a new workforce of 20,000 First Contact Practitioners33 (typically physiotherapists able to assess, diagnose, manage, and discharge patients with musculoskeletal pain and provide brief vocational advice without the need for an initial general practitioner consultation) is being established.62,63 In addition, as part of a 10-year strategy to improve employment outcomes, Public Health England, as part of healthcare provision, has recommended the introduction of supportive conversations about work.4 Finally, in an Australian study of sick-listed workers with acute, work-related musculoskeletal problems, brief psychological risk factor screening, combined with an agreed-upon protocol for active collaboration between key stakeholders, to address identified psychological and workplace factors for delayed RTW was more effective than usual (stepped) care.65 A key factor in its success was the engagement of insurance case managers, employer representatives, and healthcare providers in the project, which has served as a pathfinder for an integrated approach to injury management and led to policy changes and general implementation of the protocol for the statewide employer (the state health department). The approach adopted in the study was consistent with the implementation model described by Damschroder et al.20 in specifically engaging with the key organizational stakeholders, training for case managers in employing the screening tool, training for the workplace rehabilitation coordinators in implementing the protocol, and close monitoring of the psychologists and physiotherapists to ensure their adherence to the protocol. Such demonstration projects with research evaluations that are built around existing systems may improve feasibility for expansion and application to real-world employment, insurance, and healthcare settings. 5. Conclusion The purpose of this review has been to offer an introduction to the impact of systems on work disability and its management. Overall, we conclude that system-level factors have a substantial influence on treatment efficacy and disability outcomes of pain. Optimal pain management to prevent work disability will require full engagement of healthcare providers, professionals, and organizational leaders and policy makers (Table 2). System-level interventions can add to efficacy trials by locating pain-related challenges in a social context. In our view, there is a real opportunity to improve the management of pain-associated limitations and the facilitation of RTW. Although disability management systems vary across countries and heath jurisdictions, we are optimistic that a specific but integrated focus on psychosocial and occupational obstacles to employment after pain onset can improve relevant outcomes for all interested parties. Table 2 - Conclusions and recommendations. Implications for individual pain management Pain assessment should include questions about workplace and other systems. Assessment of occupational factors requires trust and rapport. Addressing work disability factors may require ancillary support and referral. System-level factors may be primary drivers of pain and behavior change. Review of occupational context may improve pain outcomes. Ability to self-manage pain may depend on environmental and system factors. Implications for working within systems Clinicians can incorporate work outcomes into routine pain treatment protocols. Clinicians can work within organizations to address pain treatment barriers. Communication is a key aspect of work disability prevention. Disability management should be aligned with other workplace injury protection and health promotion programs. Program evaluations and research studies to evaluate innovative pain management can be facilitated through collaborations with organizational systems. Understanding system-level and organizational factors can improve implementation of new pain management and disability prevention strategies. Improving communication between healthcare providers and employment settings is a necessary element for reducing pain-related work disability. Conflict of interest statement The authors have no conflicts of interest to declare.

The objective of this study was to investigate the impact of chronic low back pain (CLBP) on patients’ personal and professional lives, and management strategies applied to treat CLBP.

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.

The present study investigated the association between symptoms of depression in late adolescence and completion of upper secondary school, taking symptoms of ADHD and conduct disorder, and parental education into account. The study is based on the youth@hordaland-survey, conducted in Western Norway in 2012. A total of 9157 adolescents (aged 16–19 years, 53% girls) consented to participation and registry linkage and comprised the sample of the present study. Symptoms of depression, ADHD, and conduct disorder were based on adolescent self-report. Information on parental education, grade point average (GPA), and upper secondary school completion was retrieved from the National Education Database. In the sample, 14.8% had not completed upper secondary education within 5 years. Symptoms of depression were associated with higher odds of failure to graduate within 5 years (adjusted odds ratio (AOR) = 1.50). The association was attenuated but remained significant when adjusting for symptoms of ADHD, conduct disorder, and parental education. Adolescents reporting high levels of both depression and conduct disorder had the highest odds of dropout (AOR = 4.15). GPA partially mediated the association between symptoms of depression and dropout. The results show a consistent, but small association between symptoms of depression in late adolescence and failure to complete upper secondary education within five years. Given the high rate of depressive symptoms in the adolescent population, it is important to identify protective factors that promote school functioning and graduation for adolescents experiencing such symptoms.

Chronic pain and sleep problems frequently co-occur. Pain itself disturbs sleep, but other factors may also contribute to sleep problems in pain patients. This cross-sectional study of 473 patients (69.9% female, mean age 47 years) entering tertiary pain management compared normally sleeping pain patients with those having recurring sleep problems to determine the relationship between pain and sleep. Groups were compared for pain and pain aetiology, pain-related anxiety, childhood adversities, use of sleep and pain medications, self-reported diseases, and sleep disorders. Furthermore, the association of pain-related anxiety (cognitive anxiety, escape/avoidance, fear, and physiological anxiety) with more disturbing sleep problems was investigated in the whole cohort. The main results were that those with sleep problems more often reported multiple health conditions than those sleeping normally (depression 31.6% vs 5.0%; angina pectoris 6.5% vs 0.0%; asthma 19.6% vs 1.7%; low back problems 55.1% vs 23.3%; joint disease other than rheumatoid arthritis 32.3% vs 18.3%). Accumulations of 5 or more childhood adversities were more often present in those with sleep problems. Restless legs symptoms were more common in those with sleep problems than those sleeping normally (33.2% vs 11.7%). Patients having sleep problems reported more use of sleep and pain medications than those sleeping normally. Findings about pain-related anxiety suggest physiological reactions as significant factors for increased sleep disturbances. These factors need to be addressed in the management of the comorbidity of pain and sleep problems, and research to understand mechanisms in these is sorely needed.

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.

OBJECTIVE:Current guidelines recommend management of musculoskeletal pain conditions from a biopsychosocial approach; however, biopsychosocial interventions delivered by physical therapists vary considerably in effectiveness. It is unknown whether the differences are explained by the intervention itself, the training and/or competency of physical therapists delivering the intervention, or fidelity of the intervention. The aim was to investigate and map the training, competency assessments, and fidelity checking of individualized biopsychosocial interventions delivered by physical therapists to treat musculoskeletal pain conditions. METHODS:A scoping review methodology was employed, using Arksey and O'Malley's framework. Seven electronic databases were searched between January and March 2019, with a bridge search completed in January 2020. Full-text peer-reviewed articles, with an individualized biopsychosocial intervention were considered, and 35 studies were included. RESULTS:Reporting overall was sparse and highly variable. There was a broad spectrum of training. More sophisticated training involved workshops combining didactic and experiential learning over longer durations with supervision and feedback. Less sophisticated training was brief, involving lectures or seminars, with no supervision or feedback. Competency assessments and fidelity testing were underperformed. CONCLUSIONS:Training in some interventions might not have facilitated the implementation of skills or techniques to enable the paradigm shift and behavior change required for physical therapists to effectively deliver a biopsychosocial intervention. Lack of competency assessments and fidelity checking could have impacted the methodological quality of biopsychosocial interventions. IMPACT:This study highlighted problematic reporting, training, assessment of competency, and fidelity checking of physical therapist-delivered individualized biopsychosocial interventions. Findings here highlight why previous interventions could have shown small effect sizes and point to areas for improvement in future interventions. These findings can help inform future research and facilitate more widespread implementation of physical therapist-delivered biopsychosocial interventions for people with musculoskeletal pain and thereby improve their quality of life.

Contemporary conceptualizations of pain emphasize its protective function. The meaning assigned to pain drives cognitive, emotional, and behavioral responses. When pain is threatening, and a person lacks control over their pain experience, it can become distressing, self-perpetuating, and disabling. Although the pathway to disability is well established, the pathway to recovery is less researched and understood. This Perspective draws on recent data on the lived experience of people with pain-related fear to discuss both fear and safety learning processes and their implications for recovery for people living with pain. Recovery is here defined as achievement of control over pain, as well as improvement in functional capacity and quality of life. Based on the common-sense model, this Perspective proposes a framework utilizing cognitive functional therapy to promote safety learning. A process is described in which experiential learning combined with "sense making" disrupts a person's unhelpful cognitive representation and behavioral and emotional response to pain, leading them on a journey to recovery. This framework incorporates principles of inhibitory processing that are fundamental to pain-related fear and safety learning.

Background The aim of this investigation was to examine the longitudinal association between change in insomnia status and the development of anxiety and depression in the general population. Methods A survey was mailed to 5000 randomly selected individuals (aged 18–70 years) in two Swedish counties. After 6 months, a follow-up survey was sent to those ( n = 2333) who answered the first questionnaire. The follow-up survey was completed by 1887 individuals (80.9%). The survey consisted of questions indexing insomnia symptomatology, socio-demographic parameters, and the Hospital Anxiety and Depression Scale. Change in insomnia status was assessed by determining insomnia at the two time-points and then calculating a change index reflecting incidence (from non-insomnia to insomnia), remission (from insomnia to non-insomnia), or status quo (no change). Multivariate binary logistic regression analyses were used to examine the aim. Results Incident insomnia was significantly associated with an increased risk for the development of new cases of both anxiety (OR = 0.32, p < .05) and depression (OR = 0.43, p < .05) 6 months later. Incident insomnia emerged also as significantly associated with an elevated risk for the persistence of depression (OR = 0.30, p < .05), but not for anxiety. Conclusions This study extends previous research in that incidence in insomnia was shown to independently increase the risk for the development of anxiety and depression as well as for the maintenance of depression. The findings imply that insomnia may be viewed as a dynamic risk factor for anxiety and depression, which might have implications for preventative work.

Objective: The primary purpose of this study was to investigate the predictive ability of the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) in regard to work productivity (absenteeism and presenteeism) in early adulthood. Methods: A prospective study was performed using data from the Raine Study Generation 2 (Gen2) 22-year follow-up. The ÖMPSQ was completed at baseline, and absenteeism and presenteeism assessed at four intervals over the following 12 months. Results: In early adulthood, the full and short versions of the ÖMPSQ showed some predictive ability for work absenteeism but the Receiver Operator Characteristic demonstrated poor discrimination. There was no evidence of predictive ability for presenteeism. Conclusion: Further work is required to increase the fidelity of screening for risk of reduced work productivity at the population level.