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The present study combined a supervised machine learning framework with an unsupervised method, finite mixture modeling, to identify prognostically meaningful subgroups of diverse chronic pain patients undergoing interdisciplinary treatment. Questionnaire data collected at pre-treatment and 1-year follow up from 11,995 patients from the Swedish Quality Registry for Pain Rehabilitation were used. Indicators measuring pain characteristics, psychological aspects, and social functioning and general health status were used to form subgroups, and pain interference at follow-up was used for the selection and the performance evaluation of models. A nested cross-validation procedure was used for determining the number of classes (inner cross-validation) and the prediction accuracy of the selected model among unseen cases (outer cross-validation). A four-class solution was identified as the optimal model. Identified subgroups were separable on indicators, predictive of long-term outcomes, and related to background characteristics. Results are discussed in relation to previous clustering attempts of patients with diverse chronic pain conditions. Our analytical approach, as the first to combine mixture modeling with supervised, targeted learning, provides a promising framework that can be further extended and optimized for improving accurate prognosis in pain treatment and identifying clinically meaningful subgroups among chronic pain patients.

Patients with chronic pain often experience insomnia symptoms. Pain initiates, maintains, and exacerbates insomnia symptoms, and vice versa, indicating a complex situation with an additional burden for these patients. Hence, the evaluation of insomnia-related interventions for patients with chronic pain is important. This randomized controlled trial examined the effectiveness of internet-based cognitive behavioral therapy for insomnia (ICBT-i) for reducing insomnia severity and other sleep- and pain-related parameters in patients with chronic pain. Participants were recruited from the Swedish Quality Registry for Pain Rehabilitation. We included 54 patients (mean age 49.3, SD 12.3 years) who were randomly assigned to the ICBT-i condition and 24 to an active control condition (applied relaxation). Both treatment conditions were delivered via the internet. The Insomnia Severity Index (ISI), a sleep diary, and a battery of anxiety, depression, and pain-related parameter measurements were assessed at baseline, after treatment, and at a 6-month follow-up (only ISI, anxiety, depression, and pain-related parameters). For the ISI and sleep diary, we also recorded weekly measurements during the 5-week treatment. Negative effects were also monitored and reported. Results showed a significant immediate interaction effect (time by treatment) on the ISI and other sleep parameters, namely, sleep efficiency, sleep onset latency, early morning awakenings, and wake time after sleep onset. Participants in the applied relaxation group reported no significant immediate improvements, but both groups exhibited a time effect for anxiety and depression at the 6-month follow-up. No significant improvements on pain-related parameters were found. At the 6-month follow-up, both the ICBT-i and applied relaxation groups had similar sleep parameters. For both treatment arms, increased stress was the most frequently reported negative effect. In patients with chronic pain, brief ICBT-i leads to a more rapid decline in insomnia symptoms than does applied relaxation. As these results are unique, further research is needed to investigate the effect of ICBT-i on a larger sample size of people with chronic pain. Using both treatments might lead to an even better outcome in patients with comorbid insomnia and chronic pain. ClinicalTrials.gov NCT03425942; https://clinicaltrials.gov/ct2/show/NCT03425942.

Interdisciplinary pain rehabilitation programs (IPRPs) help people with chronic pain improve their health and manage their work; however, the way IPRPs address sick leave could be improved. Although work interventions can be a part of IPRP, it is not well known how and to what extent. This study explores the frequency of work interventions and the characteristics of patients who participate in work interventions as part of IPRP at specialist pain rehabilitation departments in Sweden. In addition, this study explores the association between participation in work interventions and change in patients' self-rated work ability after IPRP. Data from the Swedish quality registry for pain rehabilitation (SQRP), which includes 3809 patients between 2016 and 2018, were analysed with descriptive statistics and regression analyses. The results indicate a high participation rate in work interventions (90%). Some differences were evident concerning characteristics of patients who participated in different work interventions. The return-to-work (RTW) plan, the most frequently used work intervention, had the strongest association with change in self-rated work ability after IPRP. However, the effect sizes were small, and the initial score best explained the change. Furthermore, there were differences between employed and unemployed patients and employment had a positive association with change in self-rated work ability. More research is needed to understand IPRP's mechanisms and work interventions to support patients with chronic pain, reduce sick leave, and manage work. Employment status needs to be considered and interventions should be tailored to match the individual needs.

Tinnitus is the experience of sounds without an appropriate external auditory source. These auditory sensations are intertwined with emotional and attentional processing. Drawing on theories of mental control, we predicted that suppressing an affectively negative sound mimicking the psychoacoustic features of tinnitus would result in decreased persistence in a mentally challenging task (mental arithmetic) that required participants to ignore the same sound, but that receiving a mindfulness exercise would reduce this effect. Normal hearing participants (N = 119) were instructed to suppress an affectively negative sound under cognitive load or were given no such instructions. Next, participants received either a mindfulness induction or an attention control task. Finally, all participants worked with mental arithmetic while exposed to the same sound. The length of time participants could persist in the second task served as the dependent variable. As hypothesized, results indicated that an auditory suppression rationale reduced time of persistence relative to no such rationale, and that a mindfulness induction counteracted this detrimental effect. The study may offer new insights into the mechanisms involved in the development of tinnitus interference. Implications are also discussed in the broader context of attention control strategies and the effects of emotional sound on task performance. The ironic processes of mental control may have an analog in the experience of sounds.

Background For patients with chronic pain, the heterogeneity of clinical presentations makes it difficult to identify patients who would benefit from multimodal rehabilitation programs (MMRP). Yet, there is limited knowledge regarding the predictors of MMRP’s outcomes. This study identifies predictors of outcome of MMRPs at a 12-month follow-up (FU-12) based on data from the Swedish Quality Registry for Pain Rehabilitation (SQRP). Methods Patients with chronic pain from two clinical departments in Sweden completed the SQRP questionnaires—background, pain characteristics, psychological symptoms, function, activity/participation, health and quality of life—on three occasions: 1) during their first visit; 2) immediately after the completion of their MMRP; and 3) 12 months after completing the MMRP ( n  = 227). During the FU-12, the patients also retrospectively reported their global impressions of any changes in their perception of pain and their ability to handle their life situation in general. Results Significant improvements were found for pain, psychological symptoms, activity/participation, health, and quality of life aspects with low/medium strong effects. A general pattern was observed from the analyses of the changes from baseline to FU-12; the largest improvements in outcomes were significantly associated with poor situations according to their respective baseline scores. Although significant regressors of the investigated outcomes were found, the significant predictors were weak and explained a minor part of the variation in outcomes (15–25%). At the FU-12, 53.6% of the patients reported that their pain had decreased and 80.1% reported that their life situation in general had improved. These improvements were associated with high education, low pain intensity, high health level, and work importance (only pain perception). The explained variations were low (9–11%). Conclusions Representing patients in real-world clinical settings, this study confirmed systematic reviews that outcomes of MMRP are associated with broad positive effects. A mix of background and baseline variables influenced the outcomes investigated, but the explained variations in outcomes were low. There is still a need to develop standardized and relatively simple outcomes that can be used to evaluate MMRP in trials, in clinical evaluations at group level, and for individual patients.

Background: Interdisciplinary pain rehabilitation programs (IPRPs) help people with chronic pain improve their health and manage their work; however, the way IPRPs address sick leave could be improved. Although work interventions can be a part of IPRP, it is not well known how and to what extent. Aim: This study explores the frequency of work interventions and the characteristics of patients who participate in work interventions as part of IPRP at specialist pain rehabilitation departments in Sweden. In addition, this study explores the association between participation in work interventions and change in patients' self-rated work ability after IPRP. Methods: Data from the Swedish quality registry for pain rehabilitation (SQRP), which includes 3809 patients between 2016 and 2018, were analysed with descriptive statistics and regression analyses. Results: The results indicate a high participation rate in work interventions (90%). Some differences were evident concerning characteristics of patients who participated in different work interventions. The return-to-work (RTW) plan, the most frequently used work intervention, had the strongest association with change in self-rated work ability after IPRP. However, the effect sizes were small, and the initial score best explained the change. Furthermore, there were differences between employed and unemployed patients and employment had a positive association with change in self-rated work ability. Conclusion: More research is needed to understand IPRP's mechanisms and work interventions to support patients with chronic pain, reduce sick leave, and manage work. Employment status needs to be considered and interventions should be tailored to match the individual needs. Keywords: chronic pain, work interventions, rehabilitation

Although chronic pain is common in patients with Ehlers–Danlos syndrome (EDS) and hypermobility syndromes (HMS), little is known about the clinical characteristics of these groups. The main aim was to compare EDS/HMS with common local and generalized pain conditions with respect to Patient Reported Outcome Measures (PROMs). Data from the Swedish Quality Register for Chronic Pain (SQRP) from 2007 to 2016 (n = 40,518) were used, including patients with EDS/HMS (n = 795), fibromyalgia (n = 5791), spinal pain (n = 6693), and whiplash associated disorders (WAD) (n = 1229). No important differences in the PROMs were found between EDS and HMS. Women were represented in > 90% of EDS/HMS cases and fibromyalgia cases, and in about 64% of the other groups. The EDS/HMS group was significantly younger than the others but had a longer pain duration. The pain intensity in EDS/HMS was like those found in spinal pain and WAD; fibromyalgia had the highest pain intensity. Depressive and anxiety symptoms were very similar in the four groups. Vitality—a proxy for fatigue—was low both in EDS/HMS and fibromyalgia. The physical health was lower in EDS/HMS and fibromyalgia than in the two other groups. Patients with EDS/HMS were younger, more often female, and suffered from pain for the longest time compared with patients who had localized/regional pain conditions. Health-care clinicians must be aware of these issues related to EDS/HMS both when assessing the clinical presentations and planning treatment and rehabilitation interventions.

Hearing problems are among the most common causes of disability worldwide for adults. It is currently classified as one of the top five causes of years lived with disability (YLD), affecting more than half a billion people, and the problem seems to be growing. Between the years 2005 and 2015 the global period prevalence of hearing loss increased with about 26 %. The negative impact of hearing loss on those affected is not limited only to communication problems. A range of other negative effects can be present, such as increased levels of social isolation, problems in the work-place and psychological distress.Even though there are established - and in most of the developed world - accessible ways for people with hearing loss to seek professional care, a substantial number does not seek it. Some authors report a typical wait-time of around 10 years for people to go from noticing a hearing problem to seeking help. One way of addressing this issue might be to make it easy for people to screen for hearing loss over the internet. Another way of using the internet to further help people with hearing loss is to offer treatment for co-morbid psychological distress online.The different studies of the thesis can be summarized in three overall research questions. First, can hearing loss be detected through automated online screening procedures, and what are the characteristics of those who participate (Study I and II)? Second, can psychological acceptance be measured in this population using a new questionnaire (Study III)? Finally, can online administered self-help based on Acceptance and Commitment Therapy [ACT] help persons with hearing loss and psychological distress (Study IV)?In the screening studies (Study I and II) an online speech-innoise hearing test was initially developed and later updated. Screening for hearing problems with this test was feasible, and 16.7 (Study I) -19% (Study II) of the participants were recommended to seek professional care for their potential hearing loss. These participants had more cognitive problems, were more often men than women, and had lower levels of education. There were no differences on measures of depression, anxiety or quality of life. In Study III, we found that it was possible to accurately measure hearing-related acceptance with a new questionnaire and found that this measure was a better predictor of hearing-related disability than measured hearing performance. In Study IV, people with hearing loss and comorbid psychological distress were offered an eight-week long internet-based therapist-guided self-help influenced by ACT. When comparing those who received treatment to those in the wait-list control group, the treatment group had lower levels of perceived hearing disability, increased quality of life and reduced depressive symptoms. In conclusion, hearing screening can be performed online and it is possible to measure hearing-related factors such as cognition in these procedures. Further, lack of hearing-related acceptance can be measured with a questionnaire and this seems to be an important facet of the impact of hearing on health. Further, an internet-based ACT approach can help those with psychological distress and hearing loss.

Objectives For the last decade a host of different projects have been launched to allow persons who are concerned about their hearing status to quickly and at a low cost test their hearing ability. Most often, this is carried out without collecting complementary information that could be correlated with hearing impairment. In this two-part study we first, present the development and validation of a novel Internet-based hearing test, and second, report on the associations between this test and phonological representation, quality of life and self-reported hearing difficulties. Design Cross-sectional study. Setting An opportunity sample of participants was recruited at the Stockholm central station for the first study. All parts of the second study were conducted via the Internet, with testing and self-report forms adapted for online use. Participants The first part of the study was carried out in direct contact with the participants, and participants from the second study were recruited by means of advertisements in newspapers and on webpages. The only exclusion criterion was that participants had to be over 18 years old. Most participants were between 60 and 69 years old. There were almost an equal number of men and women (total n=316). Outcome measures 48 participants failed the Internet-based hearing screening test. The group failing the test reported more problems on the Amsterdam Inventory of Auditory Disability. In addition, they were found to have diminished phonological representational skills. However, no difference in quality of life was found. Conclusions Almost one in five participants was in need of contacting their local hearing clinic. This group had more complaints regarding tinnitus and hyperacusis, rated their own hearing as worse than those who passed, and had a poorer capability of generating accurate phonological representations. This study suggests that it is feasible to screen for hearing status online, and obtain valid data.

Psychological distress and psychiatric symptoms are prevalent among people with hearing loss or other audiological conditions, but psychological interventions for these groups are rare. This article describes the study protocol for a randomized controlled trial for evaluating the effect of a psychological treatment delivered over the Internet for individuals with hearing problems and concurrent psychological distress. Participants who are significantly distressed will be randomized to either an 8-week Internet-delivered acceptance-based cognitive behavioral therapy (i.e., acceptance and commitment therapy [ACT]), or wa it-list control. We aim to include measures of distress associated with hearing difficulties, anxiety, and depression. In addition, we aim to measure acceptance associated with hearing difficulties as well as quality of life. The results of the trial may further our understanding of how to best treat people who present problems with both psychological distress and hearing in using the Internet.