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Introduction Work absenteeism due to chronic non-malignant pain (CNMP) is a major societal and individual cause of concern that requires effective treatments. Objective We present a protocol for a systematic review and network meta-analysis (NMA) aiming to compare available interventions for return to work (RTW) in adults with CNMP. Methods and analysis PubMed, Embase, PsycINFO, Web of Knowledge and Cochrane Central Register of Controlled Trials databases will be searched till 31 August 2020 for randomised controlled trials (RCTs) examining interventions for RTW outcomes among patients with CNMP. Two independent investigators will search the databases, perform data extraction and assess the methodological quality of the selected RCTs. The primary outcome will be RTW, if possible, full-time or part-time after work absence due to chronic pain from baseline to the last available follow-up. Secondary outcomes will include self-reported workability or work capacity, or self-reported physical functioning and quality of life as measured by any validated scale. Pairwise meta-analysis and NMA will be conducted for each outcome using a random-effects model. For the primary outcomes, we will also obtain the ranking of all competing interventions within each NMA using surface under the cumulative ranking curve. The assumption of coherence (ie, that direct and indirect evidence are in statistical agreement) will be examined using both a local and a global approach. We will also conduct subgroup and meta-regression analyses, whenever feasible, to investigate the unexplained variation in effect size. The comparison-adjusted funnel plot will be used to evaluate small-study effects. The overall quality of evidence will be rated with the Confidence in Network Meta-Analysis tool. Data analysis will be conducted using Stata V.16.0. Ethics and dissemination This systematic review does not require ethical approval since it will not disseminate any private patient data. The results of this study will be disseminated through peer-reviewed publication. PROSPERO registration number CRD42020171429. Funding Agencies|Sinnescentrum, Region Ostergotland, Sweden [SC-2019-00155-41]

Additional file 1: Supplementary Table 1. Description of the sociodemographic characteristics and study measures at both baseline and at the two-year follow-up and characteristics of non-participants at baseline and follow up. Supplementary Table 2. Path model’s parameters for chronic pain (1). Supplementary Table 3. Path model’s parameters for chronic widespread pain (1). Supplementary Table 4. Path model’s parameters for severe chronic pain (1).

Background Chronic pain in later life is a worldwide problem. In younger patients, chronic pain affects life satisfaction negatively; however, it is unknown whether this outcome will extend into old age. Objective This study examines which factors determine life satisfaction in older adults who suffer from chronic pain with respect to socio-demographics, lifestyle behaviors, pain, and comorbidities. Methods This cross-sectional study recruited a random sample of people ≥65 years old living in south-eastern Sweden (N= 6611). A postal survey addressed pain aspects and health experiences. Three domains from the Life Satisfaction Questionnaire (LiSat-11) were used to capture the individual’s estimations of overall satisfaction (LiSat-life), somatic health (LiSat-somhealth), and psychological health (LiSat-psychhealth). Results Respondents with chronic pain (2790, 76.2±7.4 years old) rated lower on life satisfaction than those without chronic pain, with medium effect size (ES) on LiSat-somhealth (r = 0.38, P < 0.001) and small ES on the other two domains (r < 0.3). Among the respondents with chronic pain, severe pain (OR 0.29–0.59) and pain spreading (OR 0.87–0.95) were inversely associated with all three domains of the LiSat-11. Current smoking, alcohol overconsumption, and obesity negatively affected one or more domains of the LiSat-11. Most comorbidities were negatively related to LiSat-somhealth, and some comorbidities affected the other two domains. For example, having tumour or cancer negatively affected both LiSat-life (OR 0.62, 95% CI 0.44–0.88) and LiSat-somhealth (OR 0.42, 95% CI 0.24–0.74). Anxiety or depression disorders had a negative relationship both for LiSat-life (OR 0.54, 95% CI 0.38–0.78) and LiSat-psychhealth (OR 0.10, 95% CI 0.06–0.14). Conclusion Older adults with chronic pain reported lower life satisfaction but the difference from their peers without chronic pain was trivial, except for satisfaction with somatic health. Pain management in old age needs to consider comorbidities and severe pain to improve patients’ life satisfaction., Video abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: http://youtu.be/OnY9rk2jNFU

Introduction Atrial fibrillation (AF) is the most common sustained arrhythmia. Catheter ablation (CA) of AF is an increasingly offered therapeutic approach, primary to relieve AF-related symptoms. Despite the development of new ablation approaches, there is no consensus regarding the most efficient ablation strategy. The objective of this network meta-analysis (NMA) is to compare the efficacy and safety of all different CA approaches for the treatment of patients with paroxysmal (PAF) and non-PAF (non-PAF). Methods and analysis We will perform a systematic search to identify randomised controlled trials of different CA approaches for the treatment of PAF and non-PAF, through the final search date of 1 March 2020. Information sources will include major bibliographic databases (MEDLINE, Web of Science and CENTRAL) and clinical trial registries. Our primary outcomes will be the efficacy (recurrence-free survival) and safety of different CA approaches for the treatment of AF. Secondary outcomes will be all-cause mortality and procedural time. An NMA will be performed to determine the relative effects of different catheter ablation approaches (such as pulmonary vein isolation alone or in combination with ablation lines, ablation of complex fractionated atrial electrograms, etc). In PAF, a separate analysis will be performed including different energy sources (such as radiofrequency, cryogenic and laser energy). Risk of bias assessment and sensitivity analyses will be conducted to assess the robustness of the findings to potential bias. Ethics and dissemination No ethical approval will be needed because data are collected from previous studies. The results will be presented through peer-review journals and conference presentation. PROSPERO registration number CRD42020169494.

Cognitive models of pain propose that catastrophic thinking is negatively associated with chronic pain. However, pain catastrophizing is a complex phenomenon requiring a multivariate examination. This study estimates the effects of mood variables (anxiety and depression) on pain catastrophizing in older adults with chronic pain. A postal survey addressing pain aspects was sent to 6611 people &ge, 65 years old living in south-eastern Sweden. Pain catastrophizing was measured using the pain catastrophizing scale. Anxiety and depression were assessed using two subscales of the general well-being schedule. Data were analysed using a path analysis approach. A total of 2790 respondents (76.2 &plusmn, 7.4 years old) reported chronic pain (&ge, three months). The mediation model accounted for 16.3% of anxiety, 17.1% of depression, and 30.9% of pain catastrophizing variances. Pain intensity, insomnia, number of comorbidities, and lifestyle factors (smoking, alcohol consumption, and weight) significantly affected both pain catastrophizing and mood. Anxiety (standardized path coefficient (bstd) = 0.324, p &lt, 0.001) in comparison to depression (bstd = 0.125, p &lt, 0.001) had a greater effect on pain catastrophizing. Mood mediated the relationship between pain catastrophizing and pain-related factors accounting for lifestyle and sociodemographic factors.

Importance: Antidepressant use is increasing worldwide. Contrasting evidence from meta-analyses is available on their safety. Objective: To grade the evidence across meta-analyses of observational studies assessing the association between antidepressants and adverse health outcomes, using an umbrella review approach. Data Sources: We searched PubMed, Scopus, and PsycINFO, up to April 5, 2019. Evidence Review: Only meta-analyses of observational studies with a cohort or case-control study design were eligible. Two independent reviewers recorded the data and assessed the methodological quality of the selected meta-analyses. Evidence was ranked as convincing, highly suggestive, suggestive, weak, and not significant according to established criteria. Results: Forty-five eligible meta-analyses describing 120 associations including data from 1012 individual effect size estimates were included, after scrutinizing 252 potential articles. Seventy-four of the 120 associations (61.7%) had a nominally statistically significant effect (p≤0.05) using random-effects models. Large heterogeneity (I2>50%) was present (43.3%), while small-study effects (14.2%) and excess significance bias (7.5%) were less common. While convincing meta-analytic evidence emerged from both main and sensitivity analysis for the association between antidepressants and risk of suicide attempt/completion in children/adolescents (9.4%, OR=1.92, 95%CI=1.51-2.44 in adjusted studies, SSRIs only, and in high-quality studies, 3.6% OR=1.88, 95%CI=1.47-2.40), autism spectrum disorders (ASD) with antidepressants before (0.8%, RR=1.48, 95%CI=1.29-1.71 in any antidepressant, adjusted studies, and high-quality studies) and during pregnancy (0.9%, OR=1.84, 95%CI=1.60-2.11 in both high-quality studies and SSRIs only, and 0.1% OR=1.80, 95%CI=1.54-2.10 in European studies), pre-term birth in prospective cohort studies (0.4%, RR=1.87, 95%CI=1.52-2.30), and in studies of mixed antidepressants (0.4%, RR=1.59, 95%CI=1.31-1.93), and low APGAR scores in SSRIs only studies (5.7%, SMD=-0.27, 95%CI -0.37 to -0.16), none of these associations remained at convincing evidence after sensitivity analysis for confounding by indication. Conclusions and Relevance: Most putative adverse health outcomes associated with antidepressants are not supported by convincing evidence, and the few of those supported by convincing evidence are affected by confounding by indication. Antidepressants appear to be overall safe for the treatment of psychiatric disorders. More studies matching for underlying disease are needed to clarify the degree of confounding by indication and other biases. No absolute contraindication to antidepressants emerges from this umbrella review. Registration: PROSPERO registration 2018: CRD42018103462.

Anne Schaller,1 Elena Dragioti,1 Gunilla M Liedberg,2 Britt Larsson1 1Department of Medical and Health Sciences, Division of Community Medicine, Faculty of Health Sciences, Linköping University, Pain and Rehabilitation Centre, County Council of Östergötland, Linköping, 2Department of Social and Welfare Studies, Linköping University, Norrköping, Sweden Background: Patients with head and neck cancer (HNC) have a potentially severe diagnosis and often suffer from tumor-related pain as well as from adverse side effects of treatment such as radiotherapy (RT). Knowledge about quality of life (QoL) during early RT in this group is limited and should be assessed in relation to diagnosis and treatment.Purpose: The purpose of this cross-sectional study was to identify potential factors that may influence QoL in patients with HNC during the early stages of RT (no later than two weeks of ongoing RT). We hypothesized that pain intensity, pain interference, catastrophizing, and mood disturbances are associated with QoL during early RT.Patients and methods: In this study, 54 patients (53% of eligible patients) diagnosed with HNC were consecutively recruited from the regular flow to the Pain and Rehabilitation Center at Linköping University. The patients completed self-reported questionnaires on sociodemographics, pain intensity, pain interference, anxiety, depression, pain catastrophizing, and QoL.Results: The patients in this study scored high for QoL, low for pain intensity, and low for pain interference. The patients reported minor depressive symptoms and anxiety symptoms. Regression analyses showed that pain intensity and depressive symptoms negatively influenced QoL. Conclusion: No later than two weeks of RT, pain intensity and depression negatively influenced QoL in patients with HNC. Early screening for pain and depression in a targeted preventive strategy might maintain QoL during the course of the RT for patients with HNC. This assumption needs to be further investigated. Keywords: pain, quality of life, head and neck cancer, radiotherapy, cross-sectional study

We investigated the time-based associations between workload (physical and mechanical), psychosocial work stressors (demands, control, and support), and the number of anatomical regions with pain (ARP). This population-based study with a two-year follow-up included 11,386 responders (5125 men, 6261 women, mean age: 48.8 years, SD: 18.5) living in south-eastern Sweden. Predictive associations were assessed through generalised linear models, and changes over time were examined using a generalised estimating equation. The results of both models were reported as parameter estimates (B) with 95% confidence interval (CIs). Mean changes in the number of ARP, workload, and psychosocial work stressors were stable over time. High mechanical workload and job demands were likely associated with the number of ARP at the two-year follow-up. In the reverse prospective model, we found that the number of ARP was also associated with high physical and mechanical workload and low job control and support. In the two time-based models of changes, we found a reciprocal association between number of ARP and mechanical workload. Our results add epidemiological evidence to the associations between work conditions and the extent of pain on the body. Components of work conditions, including job demands and mechanical strain, must be considered when organisations and health policy makers plan and employ ergonomic evaluations to minimise workplace hazards in the general population.

Using a meta-analysis, meta-regression, and a meta-epidemiological approach, we conducted a systematic review to examine the influence of interdisciplinary multimodal pain therapy (IMPT) dosage on pain, disability, return to work, quality of life, depression, and anxiety in published randomised controlled trials (RCTs) in patients with non-specific chronic low back pain (CLBP). We considered all RCTs of IMPT from a Cochrane review and searched PubMed for additional RCTs through 30 September 2018. A subgroup random-effects meta-analysis by length, contact, and intensity of treatment was performed followed by a meta-regression analysis. Using random and fixed-effect models and a summary relative odds ratio (ROR), we compared the effect sizes (ES) from short-length, non-daily contact, and low-intensity RCTs with long-length, daily contact, and high-intensity RCTs. Heterogeneity was quantified with the I2 metric. A total of 47 RCTs were selected. Subgroup meta-analysis showed that there were larger ES for pain and disability in RCTs with long-length, non-daily contact, and low intensity of treatment. Larger ES were also observed for quality of life in RCTs with short-length, non-daily contact, and low intensity treatment. However, these findings were not confirmed by the meta-regression analysis. Likewise, the summary RORs were not significant, indicating that the length, contact, and intensity of treatment did not have an overall effect on the investigated outcomes. For the outcomes investigated here, IMPT dosage is not generally associated with better ES, and an optimal dosage was not determined.

Objective: To determine whether the intensity, spread and sensitivity of chronic pain can be predicted using demographic features, socioeconomic conditions and comorbidities. Design: A longitudinal study design was employed. Data was collected at baseline and at 2-year follow-up. Setting: General population in south-eastern Sweden. Subjects: A representative stratified random sample of 34,000 individuals, between 18 and 85 years of age, selected from a sampling frame of 404,661 individuals based on the Swedish Total Population Register. Methods: Eligible individuals were sent postal surveys in 2013 and 2015. The 2 surveys included the same questions about basic demographic data, comorbidities, and chronic pain intensity, spread and sensitivity. Results: Several socio-demographic features and comorbidities at baseline were significant predictors of characteristics of pain (intensity, spread and sensitivity) at the 2-year follow-up. When characteristics of pain at baseline were included in the regression analyses they were relatively strong significant predictors of characteristics of pain after 2 years. After this adjustment there were fewer socio-demographic and comorbidity predictors; the effect estimates for those significant predictors had decreased. Conclusion: Clinical assessment should focus on several characteristics of pain and include a broad medical screening to capture the overall burden of pain in adults from a longitudinal perspective. Funding Agencies|Swedish Pain Foundation; Linkoping University; Medical Research Council of Southeast Sweden

Additional file 3: Figure S2. The relation between psychological well-being, life satisfaction at T0, and pain severity classified according to CPGs at both T0 and T1 for sub-cohort 2: Participants with chronic pain at T0 (CPGs > 0). Notes: CPGs = Chronic pain grades, T0 = baseline, T1 = 2-year follow-up.

Elena Dragioti,1 Britt Larsson,1 Lars Bernfort,2 Lars-Åke Levin,2 Björn Gerdle1 1Department of Medical and Health Sciences, Faculty of Health Sciences, Pain and Rehabilitation Centre, 2Division of Health Care Analysis, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden Background: Several studies have illustrated that multisite pain is more frequent than single pain site, and it is associated with an array of negative consequences. However, there is limited knowledge available about the potential factors associated with multisite pain in the elderly general population. Objective: This cross-sectional study examines whether the number of anatomical pain sites (APSs) is related to sociodemographic and health-related factors in older adults including oldest-old ages using a new method (APSs) to assess the location of pain on the body. Materials and methods: The sample came from the PainS65+ cohort, which included 6,611 older individuals (mean age = 76.0years; standard deviation [SD] = 7.4) residing in southeastern Sweden. All the participants completed and returned a postal survey that measured sociodemographic data, total annual income, pain intensity and frequency, general well-being, and quality of life. The number of pain sites (NPS) was marked on a body manikin of 45 sections, and a total of 23 APSs were then calculated. Univariable and multivariable models of regression analysis were performed. Results: Approximately 39% of the respondents had at least two painful sites. The results of the regression analysis showed an independent association between the APSs and the age group of 75–79years, women, married, high pain intensity and frequency, and low well-being and quality of life, after adjustments for consumption of analgesics and comorbidities. The strongest association was observed for the higher frequency of pain. Conclusion: Our results suggest that APSs are highly prevalent with strong relationships with various sociodemographic and health-related factors and concur well with the notion that multisite pain is a potential indicator of increased pain severity and impaired quality of life in the elderly. Our comprehensive method of calculating the number of sites could be an essential part of the clinical presentation, assessment, and treatment of multisite pain. Keywords: pain spread, multisite pain, quality of life, well-being, elderly

Results of normality tests and bivariate correlations of the classification variables. Table S1. Tests of normality with the use of Kolmogorov-Smirnov and Shapiro-Wilk tests. Figure S1. Q-Q plots of raw data (1st figure) and z scores (2nd figure) of pain intensity. Figure S2. Q-Q plots of raw data (1st figure) and z scores (2nd figure) of spreading of pain. Figure S3. Q-Q plots of raw data (1st figure) and z scores (2nd figure) of anxiety. Figure S4. Q-Q plots of raw data (1st figure) and z scores (2nd figure) of depression. Figure S5. Q-Q plots of raw data (1st figure) and z scores (2nd figure) of pain catastrophizing. Table S2. Bivariate correlations of the classifications variables. (DOCX 227 kb)

Background and aims: Few studies have examined the association between the dosage of multimodal pain therapy (IMPT) and outcome effects. The aim of this study was to examine the influence of dosage of IMPT on pain, disability, return to work, quality of life, depression, and anxiety in randomized controlled trials (RCTs), using a systematic meta-epidemiological approach followed by meta-analysis.Methods: Eligible studies were only RCTs of IMPT versus any type of control arm in patients with chronic low-back pain (CLBP). Effect sizes, in short length, in non-daily contact, and in low-intensity RCTs were compared with long length, daily contact, and high-intensity RCTs using random-effects models and a summary relative odds ratio (ROR) were calculated. Heterogeneity was quantified with the I2metric.Results: A total of 47 RCTs was selected and analyzed. The summary RORs were not significant, indicating that the length, contact hours, and intensity of treatment did not have an overall effect on pain outcomes. Per outcome, only for pain and disability the RORs were significant demonstrating larger effects in RCTs with long length, non-daily contact, and low intensity of treatment. Large heterogeneity was also observed.Conclusions: The dosage of IMPT was not associated with better effects on pain outcomes in patients with non-specific CLBP. A program with a duration greater than five weeks and with non-daily contact and low intensity may be more beneficial for pain and disability. The optimum dosage of IMPT is currently unknown.

E Dragioti,1 B Larsson,1 L Bernfort,2 LÅ Levin,2 B Gerdle1 1Pain and Rehabilitation Medicine, 2Division of Health Care Analysis, Department of Medical and Health Sciences (IMH), Faculty of Health Sciences, Linköping University, Linköping, Sweden Background and objective: There is limited knowledge about the prevalence of pain and its relation to comorbidities, medication, and certain lifestyle factors in older adults. To address this limitation, this cross-sectional study examined the spreading of pain on the body in a sample of 6611 subjects ≥65years old (mean age = 75.0years; standard deviation [SD] = 7.7) living in southeastern Sweden.Methods: Sex, age, comorbidities, medication, nicotine, alcohol intake, and physical activity were analyzed in relation to the following pain categories: local pain (LP) (24.1%), regional pain medium (RP-Medium) (20.3%), regional pain heavy (RP-Heavy) (5.2%), and widespread pain (WSP) (1.7%).Results: RP-Medium, RP-Heavy, and WSP were associated more strongly with women than with men (all p85 age groups compared to the 65–69 age group (bothp