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  • 1.
    Abbott, Allan
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Schröder, Karin
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Nilsen, Per
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Effectiveness of implementing a best practice primary healthcare model for low back pain (BetterBack) compared with current routine care in the Swedish context: an internal pilot study informed protocol for an effectiveness-implementation hybrid type 2 trial2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 4, article id e019906Article in journal (Refereed)
    Abstract [en]

    Introduction Low back pain (LBP) is a major health problem commonly requiring healthcare. In Sweden, there is a call from healthcare practitioners (HCPs) for the development, implementation and evaluation of a best practice primary healthcare model for LBP.

    Aims (1) To improve and understand the mechanisms underlying changes in HCP confidence, attitudes and beliefs for providing best practice coherent primary healthcare for patients with LBP; (2) to improve and understand the mechanisms underlying illness beliefs, self-care enablement, pain, disability and quality of life in patients with LBP; and (3) to evaluate a multifaceted and sustained implementation strategy and the cost-effectiveness of the BetterBack☺ model of care (MOC) for LBP from the perspective of the Swedish primary healthcare context.

    Methods This study is an effectiveness-implementation hybrid type 2 trial testing the hypothesised superiority of the BetterBack☺ MOC compared with current routine care. The trial involves simultaneous testing of MOC effects at the HCP, patient and implementation process levels. This involves a prospective cohort study investigating implementation at the HCP level and a patient-blinded, pragmatic, cluster, randomised controlled trial with longitudinal follow-up at 3, 6 and 12 months post baseline for effectiveness at the patient level. A parallel process and economic analysis from a healthcare sector perspective will also be performed. Patients will be allocated to routine care (control group) or the BetterBack☺ MOC (intervention group) according to a stepped cluster dogleg structure with two assessments in routine care. Experimental conditions will be compared and causal mediation analysis investigated. Qualitative HCP and patient experiences of the BetterBack☺ MOC will also be investigated.

    Dissemination The findings will be published in peer-reviewed journals and presented at national and international conferences. Further national dissemination and implementation in Sweden and associated national quality register data collection are potential future developments of the project.

  • 2. Andersson, A
    et al.
    Ekberg, Kerstin
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, National Centre for Work and Rehabilitation.
    Enthoven, Paul
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Division of Physiotherapy.
    Kjellman, Görel
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Östergötlands Läns Landsting, Local Health Care Services in the West of Östergötland, Unit of Research and Development in Local Health Care, County of Östergötland.
    Ockander, Marlene
    Linköping University, Department of Department of Health and Society.
    Skargren, Elisabeth
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Division of Physiotherapy.
    Åkerlind, Ingemar
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, General Practice. Östergötlands Läns Landsting, Local Health Care Services in the West of Östergötland, Unit of Research and Development in Local Health Care, County of Östergötland.
    Öberg, Birgitta
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Östergötlands Läns Landsting, Centre for Public Health Sciences, Centre for Public Health Sciences.
    Vad är en god arbetslivsinriktad rehabilitering? Slutsatser baserade på en litteratursammanställning2003Report (Other academic)
  • 3.
    Engström, Sven
    et al.
    Linköping University, Department of Medicine and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences.
    Magnusson, Henrik
    Linköping University, Department of Medicine and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences.
    Enthoven, Paul
    Linköping University, Department of Medicine and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
    Walter, Lars
    FHVC landstinget i Östergötland.
    Thorell, Kristine
    Blekinge kompentenscentrum.
    Halling, Anders
    Allmänmedicin, Lunds universitet.
    Borgquist, Lars
    Linköping University, Department of Medicine and Health Sciences. Linköping University, Department of Medicine and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences.
    Social status påverkar kostnader för läkemedel och vård: Vårdval bör ta hänsyn till socioekonomiska faktorer, visar registerstudie2009In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 106, no 48, p. 3248-3253Article in journal (Other academic)
  • 4.
    Enthoven, Paul
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Division of Physiotherapy.
    Back Pain in Primary Care: a prospective cohort study of clinical outcome and health care consumption2002In: Humans in a Complex Environment,2002, 2002, p. 227-227Conference paper (Refereed)
  • 5.
    Enthoven, Paul
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Back pain: long-term course and predictive factors2005Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background. Better knowledge of the long-term course in patients treated in primary care for back pain (clinical course) and in patients that do not receive specific treatment after seeking care (clinical natural course) is needed to enable health professionals and their patients to understand the likely course of back pain and to make clinical decisions about treatment alternatives.

    Aims. To increase and deepen the knowledge of the course of back pain during 2½ and 5 years, and of predictive factors for health condition and sick-leave at 1-year and 5-year follow-ups for patients with low back pain. In addition specific emphasis was on assessing the influence of type of outcome measure, timepoint of assessment of the outcome measure, timepoint of assessment of the predictive factors (baseline, after treatment or after four weeks) and inclusion of different combinations of predictive factors. Furthermore to assess the ability of physiotherapists to predict which patients will return for additional care if they do not receive specific treatment.

    Material and Methods. The thesis is based on two cohorts of patients between 18 to 60 years of age seeking primary care for back pain. Exclusion criteria were having received active treatment for the current back pain within the previous month, other disease, recent accident, pregnancy, and inability to understand Swedish. In one cohort 254 patients previously treated in primary care filled out a 5-year follow-up questionnaire. Also in the other cohort almost the same questionnaire was used, including a package of well-known measures of pain, disability, recurrence rate, healthcare consumption, sick-leave, and questions regarding demographic data. The other cohort including 56 patients was used to describe the clinical natural course with 2½-year follow-up. Patients filled out questionnaires at baseline, after 4 weeks, at 6 months and at 1- and 2½ year follow-ups. Besides physical measures were assessed at baseline and after four weeks. The physiotherapist predicted whether the patient would or would not return for additional care. Main outcome measures for describing the course of back pain were pain and disability, and secondary measures were recurrence rate and health care consumption. Logistic regression was used to identify predictive factors for disability and sick-leave. Prediction models for the two outcome variables at the I-year and 5-year follow-up were created to assess whether the models were influenced by difference in outcome measure, timepoint of measuring the outcome, timepoint of assessment of potential predictive factors (baseline or after treatment), and different combinations of potential predictive factors included in the models. Potential predictive factors included were "standard" factors age, gender, sick-leave, pain frequency, disability, well-being, expectations of treatment, similar problems the previous 5 years, duration of the current episode, more than one localization, and physical activity-related and work-related independent variables. Linear regression was used to assess the predictive value of physical measures, assessed at baseline and at 4-week follow-up, for health condition at 1-year follow-up.

    Results. About half the patients treated in primary care reported pain and disability at the land 5-year follow-up. Around two third of the patients reported recurrence or continuous pain, and approximately one third of the patients reported additional healthcare consumption during the previous 6 months at the 1-year and 5-year follow-up. These proportions were similar for the clinical natural course cohort at the 1-year and 2½-year follow-up. Predictive factors for disability and sick-leave were only partly the same. Disability appeared to be an important predictive factor for future disability. Sick-leave and dissatisfaction with the workplace appeared to be important predictive factors for future sick-leave. Predictive factors for outcome at 1-year  and 5-year follow-up were only partly the same. Health state related variables and duration of the current episode seemed to be stronger predictive factors for outcome at 1-year follow-up than for outcome at 5-year follow-up, whereas being a woman, and physical activity-related and work-related factors were stronger predictive factors for outcome at 5-year follow-up. Health state related variables assessed after treatment appeared to be stronger predictive factors for future disability or sick-leave compared with corresponding variables at baseline. Several confidence intervals were wide and the results must be interpreted with caution. Three out of four physical measures assessed at 4-week follow-up seemed to be predictive factors for health condition after one year. None of these four measures assessed at baseline had predictive value. The physiotherapists showed ability to predict which patients would or would not return for additional care.

    Conclusions. A substantial proportion of patients seeking primary care for back pain continued to report back pain several years after seeking care. Future research should focus on prevention, as well as on management of patients with long-term back pain. Both selfreported measures related to health state, physical activity and work, as well as physical measures and prediction by health professionals seem helpful to identify patients at risk of worse future health condition and sick-leave. Further exploration of the predictive value of disability and sick-leave showed that future disability was predicted by disability only, and future sick-leave was predicted by both sick-leave and disability. In clinical practice, selfreported measures and physical measures can be assessed for various reasons. To improve the ability to predict future outcome, information obtained at a later timepoint than baseline should be used instead of information obtained at the first visit. Assessment of physical measures at baseline was useless for prediction purposes. Future studies should include other factors, such as psychosocial predictive factors found in other studies, to further improve the ability to predict future health condition and sick-leave. Another promising area of research is further exploration of the ability of health care professionals to predict outcomes, and on what grounds they base their predictions.

    List of papers
    1. Clinical course in patients seeking primary care for back or neck pain: a prospective 5-year follow-up of outcome and health care consumption with subgroup analysis
    Open this publication in new window or tab >>Clinical course in patients seeking primary care for back or neck pain: a prospective 5-year follow-up of outcome and health care consumption with subgroup analysis
    2004 (English)In: Spine, ISSN 0362-2436, E-ISSN 1528-1159, Vol. 29, no 21, p. 2458-2465Article in journal (Refereed) Published
    Abstract [en]

    Study Design. Prospective follow-up.

    Objective. To describe the 5-year clinical course in a cohort of patients treated for back or neck pain in primary care and compare results with the 1-year outcome both for the whole group and for subgroups.

    Summary of Background Data. A randomized study showed a decrease in perceived pain and disability after treatment by chiropractic or physiotherapy, but many reported recurrence or continual pain at the 1-year follow-up. Knowledge of the clinical course over longer follow-up periods is limited.

    Methods. A 5-year follow-up questionnaire was sent to 314 individuals. Main outcome measures were pain intensity, Oswestry score, and general health. Recurrence, health care consumption, and other measures were described.

    Results. Fifty-two percent of respondents reported pain (visual analog scale, >10 mm) and back-related disability (Oswestry, >10%) at the 5-year follow-up. This was similar to 1-year results, and 84% of these were the same individuals. Sixty-three percent reported recurrence or continual pain, and 32% reported health care consumption at the 5-year follow-up.

    Conclusions. In a cohort of individuals of working age seeking primary care for nonspecific back or neck pain, it can be expected that about half of the population will report pain and disability at the 5-year follow-up. A significant proportion will report recurrence or continual pain and health care consumption. Pain and disability were associated with recurrence or continual pain and health care consumption. Further analysis is needed to identify additional predictors for 5-year outcome, taking into account 1-year follow-up results. Since many patients will have recurrence or continual pain, health policies and clinical decision models for long-term outcome must allow for these aspects.

    Keywords
    back pain, neck pain, primary care, disability, recurrence, health care consumption
    National Category
    Social Sciences
    Identifiers
    urn:nbn:se:liu:diva-22473 (URN)10.1097/01.brs.0000143025.84471.79 (DOI)1716 (Local ID)1716 (Archive number)1716 (OAI)
    Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved
    2. Back pain in primary care: a prospective cohort study of clinical outcome and healthcare consumption
    Open this publication in new window or tab >>Back pain in primary care: a prospective cohort study of clinical outcome and healthcare consumption
    2003 (English)In: Advances in Physiotherapy, ISSN 1403-8196, E-ISSN 1651-1948, Vol. 5, no 3, p. 98-108Article in journal (Refereed) Published
    Abstract [en]

    The aim was to describe the clinical course without active treatment in patients with low back and neck pain visiting primary care. A prospective consecutive study was done with follow-ups weekly for 6 weeks and at 3, 6, 12 and 30 months. Main outcome measures were proportion of patients who were free of pain and back-related disability and proportion of patients found to have received additional healthcare at 3-, 6-, 12- and 30-month follow-ups. The physiotherapist predicted additional treatment. Eighty consecutive patients were included. 39 low back pain and 17 neck pain patients underwent 30 months of follow-up. The results on a group level were consistent from about 4 weeks. In the low back pain group, 41% reported no pain and no disability after 30 months, within 3 months 33% and within 30 months 64% had received additional healthcare. In the neck pain group, 12% reported no pain and no disability after 30 months, within 3 months 59% and within 30 months 71% had received additional healthcare. A higher proportion of the patients, predicted with a high probability to seek additional care also reported additional care. It can be expected that half the back pain patients being cared for in primary care will continue to suffer from problems 30 months later. The slope of recovery is most prominent during the first 4 weeks, and a worse outcome is in the neck pain patients. Further healthcare is not equal to self-reported back pain problems at baseline. The 4-week evaluation can be used to predict groups with future healthcare utilization up until 30 months. Further studies including larger cohorts are needed to confirm the results.

    National Category
    Social Sciences
    Identifiers
    urn:nbn:se:liu:diva-26265 (URN)10.1080/14038190310004862 (DOI)10775 (Local ID)10775 (Archive number)10775 (OAI)
    Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
    3. Predictive factors for 1-year and 5-year outcome for disability in a working population of patients with low back pain treated in primary care
    Open this publication in new window or tab >>Predictive factors for 1-year and 5-year outcome for disability in a working population of patients with low back pain treated in primary care
    2006 (English)In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 122, no 1-2, p. 137-144Article in journal (Refereed) Published
    Abstract [en]

    Many patients seeking primary care for low back pain continue to report disability several years after their initial visit. The aims of this study were to assess the independent predictive value of a number of potential predictive factors for disability at the 1-year and 5-year follow-ups, and to examine whether prediction models were improved by replacing baseline health-state-related variables with corresponding variables after treatment. A further aim was to describe possible differences between those on sick leave, early retirement or disability pension, and those who were not. Baseline factors were age, gender, self-reported physical-activity-related and work-related factors, expectations of treatment, similar problems previously, duration of episode, more than one localization, sick leave, pain frequency, disability, and well-being. The study sample comprised 148 participants in a previous randomized trial who were eligible for sick-leave benefits. Multiple logistic regression was used to identify predictive factors. At the 5-year follow-up, 37% (n = 19/52) of the patients with disability were on sick leave or were receiving early retirement or disability pension. For those without disability the corresponding figure was 9% (n = 8/92). Being a woman, duration of the current episode, similar problems during the previous 5 years, exercise level before the current episode, pain frequency at baseline, and disability after treatment emerged as predictive factors for disability at the 5-year follow-up. Replacing baseline health-state-related measures with corresponding measures after the treatment period, and adding physical-activity-related and possibly work-related factors might improve the likelihood of predicting future disability.

    National Category
    Social Sciences
    Identifiers
    urn:nbn:se:liu:diva-33458 (URN)10.1016/j.pain.2006.01.022 (DOI)19479 (Local ID)19479 (Archive number)19479 (OAI)
    Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2017-12-13Bibliographically approved
    4. Course of back pain in primary care: a prospective study of physical measures
    Open this publication in new window or tab >>Course of back pain in primary care: a prospective study of physical measures
    2003 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 35, no 4, p. 168-173Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVE: To describe physical measures used in patients with back pain when no specific treatment is given, to examine associations between change over time in these measures and changes in pain and back-related disability, and to study the value of physical measures at baseline and at a 4-week follow-up to predict outcome at 12 months.

    DESIGN: A prospective consecutive study.

    SUBJECTS: Forty-four patients presenting with low back pain in primary care.

    METHODS: The patients underwent a physical examination at baseline and at 4 weeks. Follow-up was carried out using questionnaires until 12 months. Linear regression was used to identify predictors.

    RESULTS: Most measures had improved significantly at the 4-week follow-up. Thoracolumbar rotation, isometric endurance back extensors, and fingertip-to-floor distance at 4 weeks were significant predictors for pain intensity and back-related disability at the 12-month follow-up. Eighteen out of 44 patients reported an increase in pain after the assessment of the physical measures at baseline. This group of patients improved more in physical measures between baseline and the 4-week follow-up.

    CONCLUSION: Physical measures assessed at the 4-week follow-up, but not at baseline, could provide important additional information for identifying those patients at risk for worse outcome in pain or back-related disability at 12 months.

    National Category
    Social Sciences
    Identifiers
    urn:nbn:se:liu:diva-26264 (URN)10.1080/16501970306124 (DOI)10774 (Local ID)10774 (Archive number)10774 (OAI)
    Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2017-12-13Bibliographically approved
  • 6.
    Enthoven, Paul
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Department of Health and Society, Division of Physiotherapy.
    Ryggbesvär -långtidsförlopp samt prediktiva faktorer2006In: Incitament, ISSN 1103-503X, Vol. 1, p. 67-70Article in journal (Other (popular science, discussion, etc.))
  • 7.
    Enthoven, Paul
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Molander, Peter
    Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Stålnacke, Britt-Marie
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Department of Clinical Sciences, Karolinska Institutet and Department of Rehabilitation Medicine, Danderyd Hospital, Stockholm, Sweden.
    Stenberg, Gunilla
    Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Do pain characteristics guide selection for multimodal pain rehabilitation?2017In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 49, p. 161-169Article in journal (Refereed)
    Abstract [en]

    Objective: To determine whether self-reported painmeasures are associated with selection for multimodalor multidisciplinary rehabilitation (MMR) andwhether this selection is influenced by sex.Design: Cross-sectional cohort study.Subjects: A total of 1,226 women and 464 men withchronic pain conditions from 2 university hospitals.Methods: Drawing from the Swedish Quality Registryfor Pain Rehabilitation (SQRP), data on pain, psychologicalsymptoms, function, health, and activity/participation were collected. Multiple logistic regressionwas used to investigate association of painmeasures with selection for MMR (no/yes) aftermultidisciplinary assessment. Covariates were: age,educational level, anxiety, depression, working status,and several pain measures.Results: High pain intensity in the previous week(odds ratio (OR) 0.92; 95% confidence interval (CI)0.86–0.99) and high pain severity (MultidimensionalPain Inventory) (OR 0.83; 95% CI 0.74–0.95)were negatively associated with selection for MMR,whereas higher number of pain quadrants was positivelyassociated with selection for MMR. Similarresults were obtained for women, but none of themeasures was predictive for men.Conclusion: This practice-based study showed thathigher scores on self-reported pain were not associatedwith selection for MMR, and in women therewas a negative association for higher pain intensityand pain severity. Thus, other factors than pain determinewhether patients are selected for MMR.

  • 8.
    Enthoven, Paul
    et al.
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Skargren, Elisabeth
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Carstensen, John
    Linköping University, Department of Department of Health and Society, Tema Health and Society. Linköping University, Faculty of Health Sciences.
    Öberg, Birgitta
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Predictive factors for 1-year and 5-year outcome for disability in a working population of patients with low back pain treated in primary care2006In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 122, no 1-2, p. 137-144Article in journal (Refereed)
    Abstract [en]

    Many patients seeking primary care for low back pain continue to report disability several years after their initial visit. The aims of this study were to assess the independent predictive value of a number of potential predictive factors for disability at the 1-year and 5-year follow-ups, and to examine whether prediction models were improved by replacing baseline health-state-related variables with corresponding variables after treatment. A further aim was to describe possible differences between those on sick leave, early retirement or disability pension, and those who were not. Baseline factors were age, gender, self-reported physical-activity-related and work-related factors, expectations of treatment, similar problems previously, duration of episode, more than one localization, sick leave, pain frequency, disability, and well-being. The study sample comprised 148 participants in a previous randomized trial who were eligible for sick-leave benefits. Multiple logistic regression was used to identify predictive factors. At the 5-year follow-up, 37% (n = 19/52) of the patients with disability were on sick leave or were receiving early retirement or disability pension. For those without disability the corresponding figure was 9% (n = 8/92). Being a woman, duration of the current episode, similar problems during the previous 5 years, exercise level before the current episode, pain frequency at baseline, and disability after treatment emerged as predictive factors for disability at the 5-year follow-up. Replacing baseline health-state-related measures with corresponding measures after the treatment period, and adding physical-activity-related and possibly work-related factors might improve the likelihood of predicting future disability.

  • 9.
    Enthoven, Paul
    et al.
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Skargren, Elisabeth
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Kjellman, Görel
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Öberg, Birgitta
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Course of back pain in primary care: a prospective study of physical measures2003In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 35, no 4, p. 168-173Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe physical measures used in patients with back pain when no specific treatment is given, to examine associations between change over time in these measures and changes in pain and back-related disability, and to study the value of physical measures at baseline and at a 4-week follow-up to predict outcome at 12 months.

    DESIGN: A prospective consecutive study.

    SUBJECTS: Forty-four patients presenting with low back pain in primary care.

    METHODS: The patients underwent a physical examination at baseline and at 4 weeks. Follow-up was carried out using questionnaires until 12 months. Linear regression was used to identify predictors.

    RESULTS: Most measures had improved significantly at the 4-week follow-up. Thoracolumbar rotation, isometric endurance back extensors, and fingertip-to-floor distance at 4 weeks were significant predictors for pain intensity and back-related disability at the 12-month follow-up. Eighteen out of 44 patients reported an increase in pain after the assessment of the physical measures at baseline. This group of patients improved more in physical measures between baseline and the 4-week follow-up.

    CONCLUSION: Physical measures assessed at the 4-week follow-up, but not at baseline, could provide important additional information for identifying those patients at risk for worse outcome in pain or back-related disability at 12 months.

  • 10.
    Enthoven, Paul
    et al.
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Skargren, Elisabeth
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Öberg, Birgitta
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Clinical course in patients seeking primary care for back or neck pain: a prospective 5-year follow-up of outcome and health care consumption with subgroup analysis2004In: Spine, ISSN 0362-2436, E-ISSN 1528-1159, Vol. 29, no 21, p. 2458-2465Article in journal (Refereed)
    Abstract [en]

    Study Design. Prospective follow-up.

    Objective. To describe the 5-year clinical course in a cohort of patients treated for back or neck pain in primary care and compare results with the 1-year outcome both for the whole group and for subgroups.

    Summary of Background Data. A randomized study showed a decrease in perceived pain and disability after treatment by chiropractic or physiotherapy, but many reported recurrence or continual pain at the 1-year follow-up. Knowledge of the clinical course over longer follow-up periods is limited.

    Methods. A 5-year follow-up questionnaire was sent to 314 individuals. Main outcome measures were pain intensity, Oswestry score, and general health. Recurrence, health care consumption, and other measures were described.

    Results. Fifty-two percent of respondents reported pain (visual analog scale, >10 mm) and back-related disability (Oswestry, >10%) at the 5-year follow-up. This was similar to 1-year results, and 84% of these were the same individuals. Sixty-three percent reported recurrence or continual pain, and 32% reported health care consumption at the 5-year follow-up.

    Conclusions. In a cohort of individuals of working age seeking primary care for nonspecific back or neck pain, it can be expected that about half of the population will report pain and disability at the 5-year follow-up. A significant proportion will report recurrence or continual pain and health care consumption. Pain and disability were associated with recurrence or continual pain and health care consumption. Further analysis is needed to identify additional predictors for 5-year outcome, taking into account 1-year follow-up results. Since many patients will have recurrence or continual pain, health policies and clinical decision models for long-term outcome must allow for these aspects.

  • 11.
    Gerdle, Björn
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Molander, Peter
    Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Stenberg, Gunilla
    Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden.
    Stålnacke, Britt-Marie
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. 5 Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden.
    Weak outcome predictors of multimodal rehabilitation at one-year follow-up in patients with chronic pain-a practice based evidence study from two SQRP centres.2016In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 17, no 1, article id 490Article in journal (Refereed)
    Abstract [en]

    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.

  • 12.
    Landén Ludvigsson, Maria
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Primary Health Care in Motala.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
    Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care2012In: Physiotherapy, ISSN 0031-9406, E-ISSN 1873-1465, Vol. 98, no 2, p. 131-137Article in journal (Refereed)
    Abstract [en]

    Objectives To evaluate primary physiotherapist assessment and management of patients with musculoskeletal disorders in primary care, and to compare patient satisfaction with primary assessment by a physiotherapist or a general practitioner (GP). less thanbrgreater than less thanbrgreater thanDesign An observational, retrospective cohort study reviewing medical records, and a separate consecutive non-randomised study of patient satisfaction. less thanbrgreater than less thanbrgreater thanSetting Primary healthcare centre. less thanbrgreater than less thanbrgreater thanParticipants Four hundred and thirty-two patients with musculoskeletal disorders, primarily assessed by a physiotherapist. Fifty-one of these patients primarily assessed by a physiotherapist and 42 patients assessed by a GP answered a patient satisfaction questionnaire. less thanbrgreater than less thanbrgreater thanInterventions Primary assessment and management of patients with musculoskeletal disorders. less thanbrgreater than less thanbrgreater thanMain outcome measures Data from medical records within 3-month after the visit, and patient satisfaction questionnaire. less thanbrgreater than less thanbrgreater thanResults Eighty-five percent (367/432) of patients did not need to see a GP. Serious pathologies were found among the 6% (26/432) of patients who were referred to a GP by a physiotherapist, but no serious pathologies were found among the 9% (39/432) of patients who subsequently returned for a GP appointment for the same disorder. Patients assessed by a physiotherapist were more satisfied with the information received about their disorder and self-care than patients assessed by a GP. Patients also had higher confidence in the ability of physiotherapists to assess their disorder (P andlt; 0.002). less thanbrgreater than less thanbrgreater thanConclusion Physiotherapists can be considered primary assessors of patients with musculoskeletal disorders in primary care as few patients needed additional assessment by a GP, patients with confirmed serious pathologies were identified by the physiotherapists, and patients were satisfied with assessment by a physiotherapist.

  • 13.
    Lindbäck, Yvonne
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Primary Health Care in Central County.
    Tropp, Hans
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Spinal Surgery. Linköping University, Center for Medical Image Science and Visualization (CMIV).
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Abbott, Allan
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Bond University, Queensland, Australia.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    PREPARE: presurgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial2018In: The spine journal, ISSN 1529-9430, E-ISSN 1878-1632, Vol. 18, no 8, p. 1347-1355Article in journal (Refereed)
    Abstract [en]

    Background Context

    Surgery because of disc herniation or spinal stenosis results mostly in large improvement in the short-term, but mild to moderate improvements for pain and disability at long-term follow-up. Prehabilitation has been defined as augmenting functional capacity before surgery, which may have beneficial effect on outcome after surgery.

    Purpose

    The aim was to study if presurgery physiotherapy improves function, pain, and health in patients with degenerative lumbar spine disorder scheduled for surgery.

    Study Design

    A single-blinded, two-arm, randomized controlled trial (RCT).

    Patient Sample

    A total of 197 patients were consecutively included at a spine clinic. The inclusion criteria were patients scheduled for surgery because of disc herniation, spinal stenosis, spondylolisthesis, or degenerative disc disease (DDD), 25–80 years of age.

    Outcome Measures

    Primary outcome was Oswestry Disability Index (ODI). Secondary outcomes were pain intensity, anxiety, depression, self-efficacy, fear avoidance, physical activity, and treatment effect.

    Methods

    Patients were randomized to either presurgery physiotherapy or standardized information, with follow-up after the presurgery intervention as well as 3 and 12 months post surgery. The study was funded by regional research funds for US$77,342. No conflict of interest is declared.

    Results

    The presurgery physiotherapy group had better ODI, visual analog scale (VAS) back pain, EuroQol-5D (EQ-5D), EQ-VAS, Fear Avoidance Belief Questionnaire-Physical Activity (FABQ-PA), Self-Efficacy Scale (SES), and Hospital Anxiety and Depression Scale (HADS) depression scores and activity level compared with the waiting-list group after the presurgery intervention. The improvements were small, but larger than the study-specific minimal clinical important change (MCIC) in VAS back and leg pain, EQ-5D, and FABQ-PA, and almost in line with MCIC in ODI and Physical Component Summary (PCS) in the physiotherapy group. Post surgery, the only difference between the groups was higher activity level in the physiotherapy group compared with the waiting-list group.

    Conclusions

    Presurgery physiotherapy decreases pain, risk of avoidance behavior, and worsening of psychological well-being, and improves quality of life and physical activity levels before surgery compared with waiting-list controls. These results were maintained only for activity levelspost surgery. Still, presurgery selection, content, dosage of exercises, and importance of being active in a presurgery physiotherapy intervention is of interest to study further to improve long-term outcome.

    The full text will be freely available from 2018-12-17 11:55
  • 14.
    Lindbäck, Yvonne
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Primary Health Care in Central County.
    Tropp, Hans
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Abbott, Allan
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Faculty of Health Science and Medicine, Bond University, Australia.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    PREPARE: Pre-surgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial protocol2016In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 17, no 270Article in journal (Refereed)
    Abstract [en]

    Background: Current guidelines for the management of patients with specific low back pain pathology suggest non-surgical intervention as first-line treatment, but there is insufficient evidence to make recommendations of the content in the non-surgical intervention. Opinions regarding the dose of non-surgical intervention that should be trialled prior to decision making about surgery intervention vary. The aim of the present study is to investigate if physiotherapy administrated before surgery improves function, pain and health in patients with degenerative lumbar spine disorder scheduled for surgery. The patients are followed over two years. A secondary aim is to study what factors predict short and long term outcomes. Methods: This study is a single blinded, 2-arm, randomized controlled trial with follow-up after the completion of pre-surgery intervention as well as 3, 12 and 24 months post-surgery. The study will recruit men and women, 25 to 80 years of age, scheduled for surgery due to; disc herniation, spinal stenosis, spondylolisthesis or degenerative disc disease. A total of 202 patients will be randomly allocated to a pre-surgery physiotherapy intervention or a waiting list group for 9 weeks. The waiting-list group will receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. The pre-surgery physiotherapy group will receive physiotherapy 2 times per week, consisting of a stratified classification treatment, based on assessment findings. One of the following treatments will be selected; a) Specific exercises and mobilization, b) Motor control exercises or c) Traction. The pre-surgery physiotherapy group will also be prescribed a tailor-made general supervised exercise program. The physiotherapist will use a behavioral approach aimed at reducing patient fear avoidance and increasing activity levels. They will also receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. Primary outcome measure is Oswestry Disability Index. Secondary outcome measures are the visual analogue scale for back and leg pain, pain drawing, health related quality of life, Hospital anxiety and depression scale, Fear avoidance beliefs questionnaire, Self-efficacy scale and Work Ability Index. Discussion: The study findings will help improve the treatment of patients with degenerative lumbar spine disorder scheduled for surgery.

  • 15.
    Lindbäck, Yvonne
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Primary Health Care in Central County.
    Tropp, Hans
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Spinal Surgery.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Abbott, Allan
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Bond University, Australia.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Altered somatosensory profile according to quantitative sensory testing in patients with degenerative lumbar spine disorders scheduled for surgery2017In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 18, article id 264Article in journal (Refereed)
    Abstract [en]

    Background: Somatosensory profiling in affected and non-affected body regions can strengthen our insight regarding the underlying pain mechanisms, which can be valuable in treatment decision making and to improve outcomes, in patients with degenerative lumbar spine disorders pre-surgery. The aim was to describe somatosensory profiles in patients with degenerative lumbar spine disorders, to identify the proportion with altered somatosensory profile, and to analyze demographic characteristics, self-reported function, pain, and health pre- and 3 months post-surgery. Methods: In this prospective cohort study in a Spine Clinic, 105 patients scheduled for surgery for spinal stenosis, disc herniation, degenerative disc disease, or spondylolisthesis were consecutively recruited. Exclusion criteria were; indication for acute surgery or previous surgery at the same spinal level or severe grade of pathology. Quantitative sensory testing (QST) and self-reported function, pain, and health was measured pre- and 3 months post-surgery. The somatosensory profile included cold detection threshold, warmth detection threshold, cold pain threshold, heat pain threshold and pressure pain threshold in affected and non-affected body regions. Results: On a group level, the patients somatosensory profiles were within the 95% confidence interval (CI) from normative reference data means. On an individual level, an altered somatosensory profile was defined as having two or more body regions (including a non-affected region) with QST values outside of normal ranges for reference data. The 23 patients (22%) with altered somatosensory profiles, with mostly loss of function, were older (P = 0.031), more often female (P = 0.005), had higher back and leg pain (P = 0.016, 0.020), lower mental health component summary score (SF 36 MCS) (P = 0.004) and larger pain distribution (P = 0.047), compared to others in the cohort. Post-surgery there was a tendency to worse pain, function and health in the group with altered somatosensory profile pre-surgery. Conclusions: On a group level, patients with degenerative lumbar spine disorders scheduled for surgery were within normal range for the QST measurements compared to reference values. On an individual level, an altered somatosensory profile outside of normal range in both affected and non-affected body regions occurred in 22% of patients, which may indicate disturbed somatosensory function. Those patients had mostly loss of sensory function and had worse self-reported outcome pre-surgery, compared to the rest of the cohort. Future prospective studies are needed to further examine whether these dimensions can be useful in predicting post-surgery outcome and guide need of additional treatments.

  • 16.
    Lindbäck, Yvonne
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Tropp, Hans
    Linköping University, Department of Clinical and Experimental Medicine, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Spinal Surgery.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Abbott, Allan
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Faculty of Health Science and Medicine, Bond University, Gold Coast, Australia.
    Öberg, Birgitta
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
    Association between pain sensitivity in the hand and outcomes after surgery in patients with lumbar disc herniation or spinal stenosis.2017In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 26, no 10, p. 2581-2588Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To investigate the association between pain sensitivity in the hand pre-surgery, and patient-reported outcomes (PROs) in function, pain and health pre- and post-surgery in patients with disc herniation or spinal stenosis.

    METHODS: This is a prospective cohort study with 82 patients. Associations between pressure-, cold- and heat pain threshold (PPT, CPT, HPT) in the hand pre-surgery and Oswestry, VAS pain, EQ-5D, HADS, and Self-Efficacy Scale, pre- and three months post-surgery; were investigated with linear regression.

    RESULTS: Patients with disc herniation more sensitive to pressure pain pre-surgery showed lower function and self-efficacy, and higher anxiety and depression pre-surgery, and lower function, and self-efficacy, and higher pain post-surgery. Results for cold pain were similar. In patients with spinal stenosis few associations with PROs were found and none for HPT and PROs.

    CONCLUSIONS: Altered pain response in pressure- and cold pain in the hand, as a sign of widespread pain pre-surgery had associations with higher pain, lower function and self-efficacy post-surgery in patients with disc herniation.

  • 17.
    Pietilä Holmner, Elisabeth
    et al.
    Umea Univ, Sweden.
    Stålnacke, Britt-Marie
    Umea Univ, Sweden.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Stenberg, Gunilla
    Umea Univ, Sweden.
    ”The acceptance” of living with chronic pain – an ongoing process: A qualitative study of patient experiences of multimodal rehabilitation in primary care2018In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 50, no 1, p. 73-79Article in journal (Refereed)
    Abstract [en]

    Objective: To explore patient experiences of participating in multimodal pain rehabilitation in primary care. Subjects: Twelve former patients (7 women and 5 men) in multimodal rehabilitation in primary care were interviewed about their experiences of multimodal rehabilitation. Methods: The interviews were analysed using qualitative content analysis. Results: Analysis resulted in 4 categories: (i) from discredited towards obtaining redress; (ii) from uncertainty towards knowledge; (iii) from loneliness towards togetherness; and (iv) "acceptance of pain": an ongoing process. The results show that having obtained redress, to obtain knowledge about chronic pain, and to experience fellowship with others with the same condition were helpful in the acceptance process. However, there were patients who found it difficult to reconcile themselves with a life with chronic pain after multimodal rehabilitation. To find what was "wrong" and to have a medical diagnosis and cure were important. Conclusion: Patients in primary care multimodal rehabilitation experience a complex, ongoing process of accepting chronic pain. Four important categories were described. These findings will help others to understand the experience and perspective of patients with chronic pain who engage in multimodal rehabilitation.

  • 18.
    Sandberg, Klas
    et al.
    Linköping University, Department of Medical and Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in East Östergötland, Department of Rehabilitation in Norrköping. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in East Östergötland, Department of Internal Medicine in Norrköping.
    Kleist, Marie
    Linköping University, Department of Medical and Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in East Östergötland, Department of Rehabilitation in Norrköping. Linköping University, Faculty of Medicine and Health Sciences.
    Falk, Lars
    Linköping University, Department of Clinical and Experimental Medicine, Division of Neuro and Inflammation Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. Region Östergötland, Heart and Medicine Center, Department of Dermatology and Venerology.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Effects of Twice-Weekly Intense Aerobic Exercise inQ1 Early Subacute Stroke: A Randomized Controlled Trial2016In: Archives of Physical Medicine and Rehabilitation, ISSN 0003-9993, E-ISSN 1532-821X, Vol. 97, no 8, p. 1244-1253Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE:

    To examine the effects of 12 weeks of twice-weekly intensive aerobic exercise on physical function and quality of life after subacute stroke.

    DESIGN:

    Randomized controlled trial.

    SETTING:

    Ambulatory care.

    PARTICIPANTS:

    Patients (N=56; 28 women) aged ≥50 years who had a mild stroke (98% ischemic) and were discharged to independent living and enrolled 20 days (median) after stroke onset.

    INTERVENTIONS:

    Sixty minutes of group aerobic exercise, including 2 sets of 8 minutes of exercise with intensity up to exertion level 14 or 15 of 20 on the Borg rating of perceived exertion scale, twice weekly for 12 weeks (n=29). The nonintervention group (n=27) received no organized rehabilitation or scheduled physical exercise.

    MAIN OUTCOME MEASURES:

    Primary outcome measures included aerobic capacity on the standard ergometer exercise stress test (peak work rate) and walking distance on the 6-minute walk test (6MWT). Secondary outcome measures included maximum walking speed for 10m, balance on the timed Up and Go (TUG) test and single leg stance (SLS), health-related quality of life on the European Quality of Life Scale (EQ-5D), and participation and recovery after stroke on the Stroke Impact Scale (SIS) version 2.0 domains 8 and 9. Participants were evaluated pre- and postintervention. Patient-reported measures were also evaluated at 6-month follow-up.

    RESULTS:

    The following improved significantly more in the intervention group (pre- to postintervention): peak work rate (group × time interaction, P=.006), 6MWT (P=.011), maximum walking speed for 10m (P<.001), TUG test (P<.001), SLS right and left (eyes open) (P<.001 and P=.022, respectively), and SLS right (eyes closed) (P=.019). Aerobic exercise was associated with improved EQ-5D scores (visual analog scale, P=.008) and perceived recovery (SIS domain 9, P=.002). These patient-reported improvements persisted at 6-month follow-up.

    CONCLUSIONS:

    Intensive aerobic exercise twice weekly early in subacute mild stroke improved aerobic capacity, walking, balance, health-related quality of life, and patient-reported recovery.

  • 19.
    Stenberg, Gunilla
    et al.
    Umeå University, Sweden.
    Pietila Holmner, Elisabeth
    Umeå University, Sweden.
    Stalnacke, Britt-Marie
    Umeå University, Sweden.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Healthcare professional experiences with patients who participate in multimodal pain rehabilitation in primary care - a qualitative study2016In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 38, no 20-21, p. 2085-2094Article in journal (Refereed)
    Abstract [en]

    Purpose: Exploring healthcare professional experiences of Multimodal rehabilitation (MMR) in primary care. Methods: Fourteen healthcare professionals (11 women, 3 men) were individually interviewed about their work with MMR in primary care. Interviews covered experiences of assessing patients and work with patients in the programme. Transcribed interviews were analysed by qualitative content analysis. Results: The analysis resulted in four categories: select patients for success; a multilevel challenge; ethical dilemmas and considering what is a good result. MMR work was experienced as useful and efficient, but also challenging because of patient complexity. Preconceptions about who is a suitable patient for MMR influenced the selection of patients (e.g. gender, different culture). Interviewees were conflicted about not to being able to offer MMR to patients who were not going to return to work. They thought that there were more factors to evaluate MMR than by the proportion that return to work. Conclusions: Healthcare professionals perceive MMR as a helpful method for treating chronic pain patients. At the same time, they thought that only including patients who would return to work conflicted with their ethical views on equal healthcare for all patients. Preconceptions can influence selection for, and work with, MMR.

  • 20.
    Stenberg, Gunilla
    et al.
    Umeå universitet, Umeå, Sweden.
    Stålnacke, Britt-Marie
    Umeå universitet, Umeå, Sweden.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Implementing multimodal pain rehabilitation in primary care - a health care professional perspective.2017In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 39, no 21, p. 2173-2181Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To explore professional perspectives on how to start and work with multimodal pain rehabilitation within primary healthcare.

    METHODS: Fourteen healthcare professionals (11 women, 3 men) were individually interviewed about their experiences of starting and working with multimodal pain. Interviews were transcribed and analyzed by qualitative content analysis. This study was part of a larger project, which aimed at evaluating multimodal pain rehabilitation in primary care.

    RESULTS: The analysis resulted in six categories. Two categories were about management engagement: putting the focus on rehabilitation and creating appropriate conditions. Three were about professional engagement: importance of driving spirits, creating a program - a process, and good teamwork - not a coincidence. The last category was about professional gain from multimodal rehabilitation (MMR): team work is enriching.

    CONCLUSIONS: To enable implementation of MMR in primary care, managers on all organizational levels must take responsibility for allowing rehabilitation to be a priority. A driving spirit among the professionals facilitates the start, but the entire team is important when processing a program. Creating good teamwork requires hard work, e.g., negotiations for consensus about rehabilitation, and assumption of responsibility by each team member. Collaboration between professionals was perceived to strengthen and enhance knowledge about the patients. Implications for rehabilitation Much can be gained from conducting multimodal pain rehabilitation in primary care. Front line managers and those at other organizational levels must prioritize and create appropriate conditions to facilitate multimodal pain rehabilitation in primary care. Creation of an effective multimodal rehabilitation team requires that each team member takes responsibility, drops the focus on individual rehabilitation, seek member consensus about the content of the rehabilitation, and confer equal worth to each team member. The process of creating a program can be facilitated, especially at the beginning, if the team is supported by speciality pain clinics or more experienced teams.

  • 21.
    Svanberg, Mikael
    et al.
    Psychosomat Medical Clin, Västerås, Sweden; University of Örebro, Sweden.
    Stålnacke, Britt-Marie
    Umeå University, Sweden; Danderyd Hospital, Sweden.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Brodda-Jansen, Gunilla
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center. Danderyd Hospital, Sweden; Institute Psychophysiol Behav Med, Sweden.
    Boersma, Katja
    University of Örebro, Sweden.
    IMPACT OF EMOTIONAL DISTRESS AND PAIN-RELATED FEAR ON PATIENTS WITH CHRONIC PAIN: SUBGROUP ANALYSIS OF PATIENTS REFERRED TO MULTIMODAL REHABILITATION2017In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 49, no 4, p. 354-361Article in journal (Refereed)
    Abstract [en]

    Objective: Multimodal rehabilitation programmes (MMRP) for chronic pain could be improved by determining which patients do not benefit fully. General distress and pain-related fear may explain variations in the treatment effects of MMRP. Design: Cohort study with a cross-sectional, prospective part. Patients: Chronic musculoskeletal pain patients referred to 2 hospital-based pain rehabilitation clinics. Methods: The cross-sectional part of this study cluster analyses patients (n = 1,218) with regard to distress and pain-related fear at first consultation in clinical pain rehabilitation and describes differences in external variables between clusters. The prospective part follows the subsample of patients (n = 260) participating in MMRP and describes outcome post-treatment. Results: Four distinct subgroups were found: (i) those with low levels of distress and pain-related fear; (ii) those with high levels of pain-related fear; (iii) those with high levels of distress; and (iv) those with high levels of distress and pain-related fear. These subgroups showed differences in demographics, pain characteristics, quality of life, and acceptance, as well as the degree of MMRP participation and MMRP outcome. Conclusion: Among patients with chronic pain referred to MMRP there are subgroups with different profiles of distress and pain-related fear, which are relevant to understanding the adaptation to pain and MMRP outcome. This knowledge may help us to select patients and tailor treatment for better results.

  • 22.
    Tseli, Elena
    et al.
    Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Sweden.
    Grooten, Wilhelmus Johannes Andreas
    Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Sweden; Functional Area Occupational Therapy and Physiotherapy, Allied Health Professionals Function, Karolinska University Hospital, Stockholm, Sweden.
    Stålnacke, Britt-Marie
    Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden; Department of Clinical Sciences, Department of Rehabilitation Medicine, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.
    Boersma, Katja
    School of Law, Psychology and Social Work, Örebro University, Örebro, Sweden.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Äng, Björn Olov
    Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Sweden; Functional Area Occupational Therapy and Physiotherapy, Allied Health Professionals Function, Karolinska University Hospital, Stockholm, Sweden; School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.
    Predictors of multidisciplinary rehabilitation outcomes in patients with chronic musculoskeletal pain: protocol for a systematic review and meta-analysis2017In: Systematic Reviews, E-ISSN 2046-4053, Vol. 6, no 1, article id 199Article in journal (Refereed)
    Abstract [en]

    Background

    Chronic musculoskeletal pain is a major public health problem. Early prediction for optimal treatment results has received growing attention, but there is presently a lack of evidence regarding what information such proactive management should be based on. This study protocol, therefore, presents our planned systematic review and meta-analysis on important predictive factors for health and work-related outcomes following multidisciplinary rehabilitation (MDR) in patients with chronic musculoskeletal pain.

    Methods

    We aim to perform a synthesis of the available evidence together with a meta-analysis of published peer-reviewed original research that includes predictive factors preceding MDR. Included are prospective studies of adults with benign, chronic (> 3 months) musculoskeletal pain diagnoses who have taken part in MDR. In the studies, associations between personal and rehabilitation-based factors and the outcomes of interest are reported. Outcome domains are pain, physical functioning including health-related quality of life, and work ability with follow-ups of 6 months or more. We will use a broad, explorative approach to any presented predictive factors (demographicsymptoms-relatedphysicalpsychosocialwork-related, and MDR-related) and these will be analyzed through (a) narrative synthesis for each outcome domain and (b) if sufficient studies are available, a quantitative synthesis in which variance-weighted pooled proportions will be computed using a random effects model for each outcome domain. The strength of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation.

    Discussion

    The strength of this systematic review is that it aims for a meta-analysis of prospective cohort or randomized controlled studies by performing an extensive search of multiple databases, using an explorative study approach to predictive factors, rather than building on single predictor impact on the outcome or on predefined hypotheses. In this way, an overview of factors central to MDR outcome can be made and will help strengthen the evidence base and inform a wide readership including health care practitioners and policymakers.

  • 23.
    Wijkman, Magnus
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in East Östergötland, Department of Internal Medicine in Norrköping.
    Sandberg, Klas
    Region Östergötland, Local Health Care Services in East Östergötland, Department of Internal Medicine in Norrköping. Region Östergötland, Local Health Care Services in East Östergötland, Department of Rehabilitation in Norrköping. Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Kleist, Marie
    Region Östergötland, Local Health Care Services in East Östergötland, Department of Rehabilitation in Norrköping. Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Falk, Lars
    Östergötlands Läns Landsting, Heart and Medicine Center, Department of Dermatology and Venerology. Linköping University, Department of Medical and Health Sciences. Linköping University, Department of Clinical and Experimental Medicine. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care. Enheten för forskningsstöd, Region Östergötland Research and Development Unit in Region Östergötland.
    Enthoven, Paul
    Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
    The exaggerated blood pressure response to exercise in the sub-acute phase after stroke is not affected by aerobic exercise.2018In: The Journal of Clinical Hypertension, ISSN 1524-6175, E-ISSN 1751-7176, Journal of Clinical Hypertension, Vol. 20, p. 56-64Article in journal (Refereed)
    Abstract [en]

    The prevalence of an exaggerated exercise blood pressure (BP) response is unknown in patients with subacute stroke, and it is not known whether an aerobic exercise program modulates this response. The authors randomized 53 patients (27 women) with subacute stroke to 12 weeks of twice-weekly aerobic exercise (n = 29) or to usual care without scheduled physical exercise (n = 24). At baseline, 66% of the patients exhibited an exaggerated exercise BP response (peak systolic BP ≥210 mm Hg in men and ≥190 mm Hg in women) during a symptom-limited ergometer exercise test. At follow-up, patients who had been randomized to the exercise program achieved higher peak work rate, but peak systolic BP remained unaltered. Among patients with a recent stroke, it was common to have an exaggerated systolic BP response during exercise. This response was not altered by participation in a 12-week program of aerobic exercise.

  • 24.
    Öberg, Birgitta
    et al.
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Enthoven, Paul
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Kjellman, Görel
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Skargren, Elisabeth
    Linköping University, Department of Department of Health and Society, Division of Physiotherapy. Linköping University, Faculty of Health Sciences.
    Back pain in primary care: a prospective cohort study of clinical outcome and healthcare consumption2003In: Advances in Physiotherapy, ISSN 1403-8196, E-ISSN 1651-1948, Vol. 5, no 3, p. 98-108Article in journal (Refereed)
    Abstract [en]

    The aim was to describe the clinical course without active treatment in patients with low back and neck pain visiting primary care. A prospective consecutive study was done with follow-ups weekly for 6 weeks and at 3, 6, 12 and 30 months. Main outcome measures were proportion of patients who were free of pain and back-related disability and proportion of patients found to have received additional healthcare at 3-, 6-, 12- and 30-month follow-ups. The physiotherapist predicted additional treatment. Eighty consecutive patients were included. 39 low back pain and 17 neck pain patients underwent 30 months of follow-up. The results on a group level were consistent from about 4 weeks. In the low back pain group, 41% reported no pain and no disability after 30 months, within 3 months 33% and within 30 months 64% had received additional healthcare. In the neck pain group, 12% reported no pain and no disability after 30 months, within 3 months 59% and within 30 months 71% had received additional healthcare. A higher proportion of the patients, predicted with a high probability to seek additional care also reported additional care. It can be expected that half the back pain patients being cared for in primary care will continue to suffer from problems 30 months later. The slope of recovery is most prominent during the first 4 weeks, and a worse outcome is in the neck pain patients. Further healthcare is not equal to self-reported back pain problems at baseline. The 4-week evaluation can be used to predict groups with future healthcare utilization up until 30 months. Further studies including larger cohorts are needed to confirm the results.

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