Understanding Work Ability in Employees with Pain and Stress-Related Ill-Health: An Explorative Network Analysis of Individual Characteristics and Psychosocial Work Environment.

PURPOSE: There is a wide range of individual and work environment factors that influence work ability among workers with pain and stress-related ill-health. The multiple interactions and overlap between these factors are insufficiently understood, and a network approach could mitigate limitations of previous research. This pilot study aimed to explore interactions between individual characteristics and psychosocial work environment and potential links to long-term work ability. METHODS: Prospective data from a prevention project was used. Individuals (N = 147) with pain and/or stress-related ill-health (95% women) at public sector workplaces filled out baseline questionnaires about a collection of individual and work environment factors, which were used for constructing undirected networks. The model was run in three subsamples of workplaces. Finally, a separate model was established with work ability at 6-month follow-up as outcome variable. A shortest pathway analysis was calculated to identify mediators of work ability. RESULTS: Symptom catastrophizing and perceived stress were the most influential factors in all network models. Symptom catastrophizing and pain-disability risk were found to mediate the relation between perceived stress and long-term work ability. Further, demand-control-support factors were interrelated, and patterns of interaction differed between different types of workplaces. CONCLUSION: The findings support the importance of individual factors, specifically symptom catastrophizing in an individual's coping with pain or stress-problems and its influence on long-term work ability. Catastrophizing might play a role in stress-related disorders which should be further investigated. Individual and work environment factors interact and vary across context, which needs to be taken into consideration to prevent pain and stress-related ill-health at work.

When Matching Fails: Understanding the Process of Matching Pain-Disability Treatment to Risk Profile.

PURPOSE: A previous study (Bergbom et al. in J Occup Rehabil, 2013) showed that matching people at risk for pain-related disability to an intervention aimed at targeting their psychological problem profile did not, as hypothesized, improve the effect of the intervention. Methodological issues were suggested to explain the lack of differential effect. It was questioned whether the profiles used to allocate people to treatment were adequate. The aim of this study was to investigate if the risk profiles used to determine matching were sufficiently stable and valid by comparing the original profiles with profiles constructed using other methods. METHODS: Ninety-five people suffering musculoskeletal problems were screened, profiled, and matched to workplace based early interventions according to profiles. We studied stability and validity of their psychological risk profiles by investigating their concordance at different time points. People were originally assigned to profiles at inclusion, using a brief screening questionnaire. Then, they were profiled just before treatment start, using the same items. Finally, they were profiled again at treatment start, using extensive questionnaires. Concordance among the three sets of profiles was investigated. RESULTS: Profiles at inclusion were unstable until treatment start. People moved from profiles with more severe elevations in psychological variables, to a profile with moderate elevations. Concordance between the two means of profiling at treatment start was better; the brief screening and the extensive questionnaires assigned people to similar profiles. CONCLUSIONS: Risk level may be determined with brief instruments at an early stage of problem development. However, profiles and targets for interventions should be determined immediately prior to treatment start, preferably using full questionnaires.

Early psychologically informed interventions for workers at risk for pain-related disability: does matching treatment to profile improve outcome?

PURPOSE: This randomized controlled trial had two main aims. The first aim was to investigate the effect of early preventive, psychologically informed, interventions for pain-related disability. The second aim was explore whether people who are matched to an intervention specifically targeting their psychological risk profile had better outcomes than people who were not matched to interventions. METHODS: A total of 105 participants were recruited from their workplace, screened for psychological risk factors and classified as being at risk for long-term pain-related disability. They were subgrouped into one of three groups based on their psychological profile. Three behaviorally oriented psychological interventions were developed to target each of the three risk profiles. Half of the participants were assigned a matched intervention developed to target their specific profile, and half were assigned an unmatched intervention. After treatment, repeated measure ANOVAs and v2 tests were used to determine if treatments had an effect on primary and secondary outcomes including perceived disability, sick leave, fear and avoidance, pain catastrophizing and distress, and if matched participants had better outcomes than did unmatched. RESULTS: Treatments had effects on all outcome variables (effect sizes d ranging between 0.23 and 0.66), but matched participants did not have better outcomes than unmatched. CONCLUSIONS: Early, preventive interventions have an impact on a number of outcome variables but it is difficult to realize a matching procedure. More in-depth research of the process of matching is needed.

Both early and late changes in psychological variables relate to treatment outcome for musculoskeletal pain patients at risk for disability.

We know little about why some people get better after psychological treatments for pain disability, whereas other people do not. In order to understand differences in treatment response, we need to explore processes of change during treatment. It has been suggested that people with pain complaints who change early in treatment have better outcomes. Therefore, we aimed to investigate whether changes in psychological variables at different time points are related to outcome, and whether early or late changes are better predictors of outcome. We used the fear avoidance model as a theoretical framework. We followed 64 patients weekly over 6-7 weeks and then determined outcome. Our findings indicate that people who decrease in catastrophizing and function early in treatment as well as in depressive symptoms, worry, fear avoidance beliefs and function late in treatment have better outcomes. Early decreases in function, and late decreases in depressive symptoms and worry uniquely predict improvements in disability. While early and late changes covaried concurrently, there were no significant sequential relationships between early and late changes. Changes in the proposed process variables in the fear avoidance model, early as well as late in treatment, thus add valuable information to the explanation of outcome.

Relationship among pain catastrophizing, depressed mood, and outcomes across physical therapy treatments.

BACKGROUND: Pain catastrophizing and emotional distress can act as prognostic factors for pain and disability. Research on how these variables interact within individuals and over time is in an early stage. Understanding various patterns of prognostic factors and how these factors change during treatment is important for developing treatments targeting important factors. OBJECTIVE: The primary aim of this study was to investigate relationships between pain catastrophizing and depressed mood in people seeking primary care for musculoskeletal pain. An additional aim was to relate these patterns of prognostic factors to outcomes during a 6-month period. DESIGN: The design was prospective; data were obtained at baseline and at follow-up. METHODS: Forty-two physical therapists taking part in an educational program recruited, from their clinical practices in primary care, consecutive patients who were currently experiencing a pain problem. Patients received various physical therapy interventions between baseline and follow-up. RESULTS: On the basis of patterns of scoring for pain catastrophizing and depressed mood, 4 subgroups of participants were found. Belonging to a subgroup with elevated levels of either pain catastrophizing or depressed mood at baseline was related to the absence of improvement and elevated levels of disability after physical therapy interventions. Furthermore, elevated levels of both variables were related to the highest levels of disability. LIMITATIONS: The analyses relied on self-report. Neither treatment content nor pain-related fear was measured. The sample was a mixture of participants reporting acute pain and subacute pain. CONCLUSIONS: The results stress the importance of assessing and targeting prognostic factors. Moreover, the results suggest the need to tailor treatments to match patterns of prognostic factors and the need to target depressed mood and pain catastrophizing in physical therapy interventions.

The role of depression and catastrophizing in musculoskeletal pain.

Many patients with musculoskeletal pain also suffer from a depressed mood. Catastrophizing is one process that may link depression and pain since it is a key concept in models of both problems. Earlier research has suggested that catastrophizing measures something above and beyond depression. This study tests the idea that if depressed mood and catastrophizing are separate entities then when one is absent the other should still contribute to poor outcome, and, when both are present there should be an additional adverse effect. To this end, a prospective design, with a built-in replication from two clinical samples of patients with sub-acute pain (one from Sweden, N=373; one from Australasia, N=259), was employed. Participants were classified as to having high/low scores on measures of depression and catastrophizing. Subsequently, these classifications were studied in relation to outcome variables cross-sectionally and at follow-up. Results showed a small to moderate correlation between catastrophizing and depression and that there are individuals with one, but not the other problem. Further, having one or the other of the entities was associated with current pain problems and outcome, while having both increased the associations substantially. The replication showed very similar results Our data demonstrate that pain catastrophizing and heightened depressed mood have an additive and adverse effect on the impact of pain, relative to either alone. It suggests that each should be assessed in the clinic and that future research should focus on treatments specifically designed to tackle both depressed mood and catastrophizing.

Understanding the link between depression and pain.

Background and aims Patients seeking care for a pain problem very often also report symptoms of depression.In fact, depression is associated with the development of chronic pain as well as poor treatment results. Yet, the mechanisms by which depression and pain impact upon one another are not clear. This paper provides a critical review of the literature with the aim of shedding light on the relationship between pain and depression. Further, we introduce the Örebro Behavioral Emotion Regulation Model which may stimulate understanding in addition to research. Method Data bases (MedLine and PsychINFO) were searched as well as reference lists to locate relevant articles, especially previous reviews, published since 2000. We located 244 articles including 6 reviews. Results We found that while depression is strongly linked to pain, there is little understanding of how this link works or how it might be utilized in clinical settings. It is not clear whether one of the symptoms precedes the other, but when both are present prognosis is significantly affected. Clinicians often fail to assess both depression and pain resulting in probable "under" treatment of one or both problems. There is little evidence that treating the pain will result in the disappearance of the depression. Indeed, early improvements in depression are associated with overall treatment gains for patients with musculoskeletal pain. Therefore, treatment outcomes might be substantially enhanced by addressing both the pain and the depression. Moreover, directly addressing the depression early in treatment may be especially valuable. While pharmacological treatments of depression are often pursued for pain patients, the results for depression, pain and function are not impressive. Although there are effective cognitive-behavioral techniques for depression, these have not been properly evaluated in patients with co-morbid pain and depression. We found two likely mechanisms that can help to explain the link between depression and pain. First, catastrophizing plays a central role in models of both pain and depression and hence might form an important link between them. Second, emotion regulation is important in both depression and pain since they both can be viewed as significant emotional stressors. We offer a model which focuses on the recurrent nature of pain and depression. It hypothesizes that flare-ups trigger catastrophic worry which in turn strains the individual's emotion regulation system. Successful behavioral emotion regulation is said to result in coping while negative behavioral emotion regulation results in spiraling negative affect, pain and mood related disability and, in the long term, a consequent relapse. Implications Since both pain and depression are closely linked and are both involved in the development of long-term problems, it is important for clinicians to assess them as early as possible. Moreover, both symptoms should be monitored and addressed in treatment to maximize outcome results. Because pharmacological treatment has limited effects, cognitive-behavioral therapy is an alternative. Behavioral emotion regulation may be an important mechanism linking depression and pain. Conclusions It is concluded that pain and depression impact on each other and play an important role in the development and maintenance of chronic problems. Future studies of treatments for co-morbid depression and pain are urgently required. The purposed Örebro Behavioral Emotion Regulation Model provides much needed guidance for investigating the psychological mechanisms involved.