There is growing interest in assistive technology (AT) as a means of enabling participation in everyday activities for persons with dementia and their relatives. Health economic assessment of AT in dementia is of importance due to the consequences of the disease for both patients and relatives and to the high societal costs for dementia care. The aim of this article is to outline a model for assessment of AT interventions for persons with dementia. The model expands existing assessment models as it also includes evaluation of the intervention process. Methodological challenges and possibilities in making health economic assessments, including outcomes and costs, as well as process evaluation, are discussed in the article. © 2007 IOS Press. All rights reserved.

Objective. To compare in a pilot study the effect of two physical therapies, the Mensendieck system (MS) and body awareness therapy (BAT) according to Roxendal, in fibromyalgia patients and to investigate differences in effect between the two interventions. Methods. Twenty female patients were randomized to either MS or BAT in a program lasting 20 weeks. Evaluations were tender point examination and questionnaires, including visual analog scales (pain intensity at worst site, muscular stiffness, evening fatigue, and global health), Fibromyalgia Impact Questionnaire (FIQ), Coping Strategies Questionnaire, Quality of Life Scales, Arthritis Self-Efficacy Scale (ASES), and disability before, immediately after, and at 6 and 18 months followup. Results. The BAT group had improved global health at 18 months followup, but lower results than the MS group. The MS group had improved FIQ, ASES other symptoms, and pain at worst site at 18 months followup. Conclusion. In the present pilot study, MS was associated with more positive changes than BAT.

The aim of the present study was to analyse the effects of gender and age in a population-based sample of clinically healthy subjects on: (1) strength, endurance and perception of fatigue, (2) mean frequency (MNF) of the electromyogram (EMG), and (3) the ability to relax between active contractions (signal amplitude ratio, SAR) of the surface EMG of an isokinetic shoulder forward flexion test. With this aim we have analysed aspects of the validity of MNF as an indicator of fatigue, using peak torque as a criterion variable. The subjects were 27 men and 28 women (age range: 20-60 years), who were obtained by random sample from the official census lists (participation rate: 66%). The peak torque and surface EMG of two portions of the trapezius, deltoid and infraspinatus muscles were recorded throughout 100 repetitive maximal isokinetic shoulder forward flexions. No significant differences in the perception of fatigue and relative endurance levels of peak torque and work were found between males and females. Males were significantly stronger than females and, on average, females produced approximately 60% of the output of the males, 76% after normalisation for body mass. The men had significantly lower MNF endurance levels for three of the investigated muscles. When controlled for age and body mass, the men had a significantly higher MNF of the deltoid muscle than did the females. These differences were only found for the deltoid muscle. Significant correlations existed between the MNF of the four muscles and biomechanical output, indicating criterion validity for the MNF variable with respect to fatigue. There were no significant effects of gender or age on the ability to relax between repetitive contractions (SAR). The higher prevalence of musculoskeletal complaints of the neck-shoulder region in females cannot be explained by a higher intrinsic muscle tension. Age, gender, body mass index and biomechanical output can have significant effects upon MNF. These effects are important considerations in the interpretation of MNF, for instance in ergonomic situations.

The No Lifting Policy has been adopted in Australia to prevent back pain and injuries among nurses. The present study focuses on the intervention of the "No Lift System" (NLS). The purpose of this cross-sectional study was to evaluate the use of transfer equipment, number of injuries, pain/symptoms and absence from work among nurses after the intervention of the NLS (n=201), and compare to nurses at two control hospitals (n=256). A comprehensive questionnaire was used for data collection. The results show that at the hospital where the NLS had been introduced, the nurses used the purchased transfer equipment regularly. They had significantly fewer back injuries, less pain/symptoms and less absence from work due to musculoskeletal pain/symptoms compared with nurses at the control hospitals. The study showed strong evidence for supporting the implementation of the NLS. The positive results shown in the present study can probably be explained by the agreement between the management, the union and the nurses concerning the implementation of the NLS, as well as its comprehensive approach and participatory design.

A prospective dynamic-population-based study was conducted to investigate factors involved in the accident process preceding over-exertion back injuries among nursing personnel. All reported occupational over-exertion back injuries due to accidents among nurses in hospitals included in one network in Melbourne during 13 months were investigated. The assumption was that several factors interact in the accident process causing a back injury, and therefore detailed information was obtained for each injury by interviews with the injured person. Risks in the physical environment were identified using an ergonomic checklist. During the study period 127 nurses who had reported accidents leading to over-exertion back injury were interviewed. Cluster analysis yielded five well-defined clusters and their pattern of contributing factors for the accident process. The most frequent over-exertion back injury occurred during patient transfer in the bed or to/from the bed. Transfer devices were rarely used, most often due to lack of devices. Risks in the environment, most often lack of space, and/or lack of transfer devices often compelled the nurse to work in an awkward position. The nurse often felt rushed/stressed. The clusters showed the complexity of these kinds of accidents, and indicated that the measures for prevention must be of different kinds and at several different levels in the organization. © 2003 Elsevier Ltd. All rights reserved.

Insamling, sortering och återvinning av uttjänta produkter är en snabbt växande industribransch. Det svenska samhällets kretsloppsanpassning har under 1990-talet medfört stora förändringar av samhällets avfallshantering. Nya lagar om vilket avfall som skall återvinnas tillkommer kontinuerligt. Denna kretsloppsanpassning i samhället har vanligen skett utan att några speciella krav har ställts på utformningen av produkterna eller på hur produkterna skall insamlas på bästa sätt för att kunna ta reda på materialet så effektivt och skonsamt som möjligt. Istället har man utgått från att de eventuella problem som kan uppstå när produkterna ska återvinnas får lösas när produkterna blir avfall och att producenterna via producentansvaret får ta kostnader och problem som uppstår i avfallshanteringen.

Samhället av idag står inför flera stora utmaningar när systemen för återvinning av produkter och material ska utvecklas. Studien har visat att frågor som rör arbetsförhållanden, ekonomi och effektivitet samt miljönytta bör behandlas på ett integrerat sätt när branschen utvecklas för framtiden.

Arbetsförhållandena för de som är verksamma inom återvinningsindustrin förväntas vara sådana att de anställda långsiktigt bibehåller god hälsa och välbefinnande. De arbetsplatser där avfallet sorteras och hanteras har utvecklats under kort tid och inom en avfallshanteringstradition där man inte utnyttjat kunskap från industrin och forskningen om arbetsplatsutformning och hantering av gods. Det finns påtagliga arbetsmiljöproblem i återvinningsbranschen som visar sig i statistiken både gällande olycksfall och arbetsrelaterade sjukdomar.

Konsumenterna får bära mycket av kostnaderna för materialåtervinningen dels genom ett högre pris på nya produkter de köper, dels genom att de står för en del av arbetet med sortering och transporterna av avfallet till återvinningscentraler eller återvinningsstationer samt vidare via avfallstaxan. För kommunerna kan ökad sortering av avfall också medföra ökade kostnader. Det är angeläget att hålla nere dessa kostnader genom god utformning av anläggningar för återvinning.

Syftet med denna förstudie var att identifiera förekommande problem- och utvecklingsområden inom återvinningsbranschen med focus på återvinningscentralernas roll.

Studien utformades som en kartläggande och utforskande studie. Datainsamlingen genomfördes på totalt 7 anläggningar som representerar olika delar av återvinningsbranschen varav fyra återvinningscentraler (i kommuner med 32 000 till 135 000 invånare). Två av dem byggdes på mitten av 1990-talet medan de andra två har utvecklats från soptippar. Tre av anläggningarna drevs direkt i kommunal regi eller som kommunägt bolag och ett drevs på entreprenad. Anläggningarna valdes för att ge en variation mellan återvinningscentraler från större kommuner såväl som mindre, och också för att representera olika typer och byggnadsår. Dessutom besöktes en elektronikdemonteringsanläggning, en fragmenteringsanläggning samt en anläggning för rekonditionering av vitvaror. Detta möjliggjorde att ett par avfallsfraktioner kunnat följas från återvinningscentralen till efterbehandling i nästkommande steg.

Besöken genomfördes av de forskare som är författare till denna rapport, och därmed representerade disciplinerna arbetsmiljö, hälsa, produktionssystem, säkerhet och miljö. Besöken inleddes med en presentation / rundvandring i anläggningen. Halvstrukturerade intervjuer genomfördes med de anställda och besökare. Observationer genomfördes av hur olika aktiviteter genomfördes av besökarna såväl som av de anställda. Med hjälp av digitalkamera med videofunktion dokumenterades layouter, materialfraktioner, skyltning etc. samt vissa rörelsemoment. Relevanta dokument som fanns tillgängliga samlades in. Respektive besök genomfördes under en dag, under januari - mars 2003.

Återvinningscentralerna är ofta den första instansen för insamlandet av avfall och har en nyckelposition för hur avfallet kan hanteras på ett så produktivt och kostnadseffektivt sätt som möjligt. Det är därför viktigt att studera återvinningsproblematiken med ett helhetsperspektiv med utgångspunkt från såväl arbetsmiljö, säkerhet, produktionssystemutformning och yttre miljö. Vidare att betrakta återvinningscentraler utifrån en systemsyn, och se dess funktion också i relation till avnämarna, d.v.s. de behov och förutsättningar som efterföljande anläggningar i avfallskedjan har.

Studien kan konkluderas enligt följande:

Identifierade problemområden

• Det föreligger olika typer av arbetsmiljörisker i de olika stegen av avfallshanteringen.
• Vid återvinningscentraler idag finns risker för skada för de anställda såväl som för besökarna.
• Återvinningscentralen har identifierats att inneha en nyckelroll i hanteringen av avfall.
• Det brister i de ekonomiska incitament för förbättring av hanteringen av avfallet vid återvinningscentralerna.
• Det föreligger dålig kommunikation mellan de olika aktörerna i återvinningskedjan om hur avfallet hanteras i respektive led och vilka förväntningar man har på det inkommande avfallet. Incitamentsbristen och den därav försämrade kommunikationen påverkar såväl arbetsmiljön, kvaliteten som ekonomin i efterföljande led.

Utvecklingsområden

• Goda möjligheter finns att utforma och organisera återvinningscentraler så att risken för skada påtagligt minskar för såväl personal som besökare.
• Goda förbättringsmöjligheter finns att inom miljöområdet åstadkomma bättre sorteringskvalitet och därmed förbättra kvaliteten av det återvunna materialet.
• Genom en bättre industrialisering av återvinningscentralerna kan effektiviteten och ekonomin förbättras, samtidigt som det finns möjligheter att också förbättra arbetsförhållanden och miljö i återvinningssystemen som helhet. Vissa enkla åtgärder, t.ex. tydlig skyltning och information till besökarna, kan ge avsevärd förenkling av arbetet i återvinningscentralerna och även senare i återvinningskedjan.
• En bättre helhetsoptimering skulle erhållas genom förbättrad interorganisatorisk samverkan för ökad förståelse mellan de olika aktörerna i återvinningskedjan och därmed en bättre optimering av hur avfallet hanteras.

En återvinningscentral ett viktigt ansikte utåt för kommunen. Om utformningen är anpassad till besökarna kan en positiv attityd till återvinning skapas med positiva miljöeffekter och en bättre arbetsmiljö för de anställda som följd.

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.

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.

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.

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.

This study is an investigation of the relationship between muscle morphology and surface electromyographic (EMG) parameters [mean frequency of the power spectrum (MNF), signal amplitude (root mean square, RMS) and the signal amplitude ratio (SAR, i.e. the ratio between the RMS level during the passive part of the contraction cycle and the RMS level during the active part of the contraction cycle)] during 100 maximal dynamic knee extensions at 90░.s-1. Each contraction cycle comprised of 1 s of active knee extension and 1 s of passive knee flexion. The surface EMG was recorded from the vastus lateralis muscle. Twenty clinically healthy subjects participated in the study, and muscle biopsy samples of the vastus lateralis were obtained from 19 of those subjects. The relationships between muscle morphology and EMG were investigated at three stages of the test: initially, during the fatigue phase (initial 40 contractions), and at the endurance level (the final 50 contractions). Major findings on correlations are that SAR and MNF tended to correlate positively with the proportion of type 1 fibres, and RMS correlated positively with the proportion of type 2 muscle fibres. The muscle fibre areas showed little correlation with the EMG variables under investigation. The results of the present study showed that the three EMG variables of a dynamic endurance test that were investigated (RMS, MNF and SAR were clearly correlated with the proportions of the different fibre types, but only to a small extent with fibre areas. These findings contradict some of the theoretical models of the EMG, especially for parameters in the frequency domain.

The aim of this study was to investigate whether therapeutic riding (TR, Sweden) hippotherapy (HT, United States) may affect balance, gait, spasticity, functional strength, coordination, pain, self-rated level of muscle tension (SRLMT), activities of daily living (ADL), and health-related quality of life. Eleven patients with multiple sclerosis (MS) were studied in a single-subject experimental design (SSED) study, type A-B-A. The intervention comprised ten weekly TR/HT sessions of 30 minutes each. The subjects were measured a maximum of 13 times. Physical tests were: the Berg balance scale, walking a figure of eight, the timed up and go test, 10 m walking, the modified Ashworth scale, the Index of Muscle Function, the Birgitta Lindmark motor assessment, part B, and individual measurements. Self-rated measures were: the Visual Analog Scale for pain, a scale for SRLMT, the Patient-Specific Functional Scale for ADL, and the SF-36. Data were analyzed visually, semi-statistically and considering clinical significance. Results showed improvement for ten subjects in one or more of the variables, particularly balance, and some improvements were also seen in pain, muscle tension, and ADL. Changes in SF-36 were mostly positive, with an improvement in Role-Emotional seen in eight patients. Conclusively, balance and Role-Emotional were the variables most often improved, but TR/HT appeared to benefit the subjects differently.

Dizziness and disequilibrium can be caused by several dysfunctions within the balance system, and are common symptoms especially in higher ages. The general aim of this thesis was to evaluate the effects of vestibular rehabilitation therapy in patients with dizziness and disequilibrium, and to examine the influence of age, vestibular function and psychological aspects on recovery.

Four study samples were included in the thesis: physically active elderly, central vestibular dysfunction (CVD), acute unilateral vestibular loss (AUVL), and in the last study both AUVL and CVD. The measurements static and dynamic clinical balance tests, V AS, EuroQol, Hospital Anxiety and Depression Scale, UCLA Dizziness Questionnaire, Dizziness Handicap Inventory, Dizziness Beliefs Scale, electronystagmography, vestibular-evoked myogenic potentials, and computerized dynamic posturography were used.

The change in balance performance over a 7-year period was evaluated in 17 physically active elderly. Both static clinical balance tests and maximum walking speed showed impaired balance. The amount of sway measured by computerized dynamic posturography had not changed, but increased latencies of force response to sudden backward translations of the platform were seen.

The effects of balance training were evaluated in 23 elderly patients with dizziness and disequilibrium caused by CVD. Patients were randomized to exercise group or control group. The exercise group received group balance training twice a week for eight weeks. Improvements were seen only in the exercise group in clinical balance tests, dynamic posturography, maximum walking speed and subjective ratings.

The effects of home training with and without additional individualized physical therapy were evaluated in a randomized controlled study of 54 patients during six months after AUVL. Similar recovery was seen in the two training groups. Higher age correlated with worse performance on clinical balance tests on follow-ups but not with change over time. Higher age also correlated with higher subjective ratings of vertigo at the six-month follow-up. Greater caloric vestibular asymmetry correlated with worse performance on clinical balance tests and higher subjective ratings.

In a long-term follow-up after 3-6 years, about half of the patients reported residual symptoms after the AUVL. Patients with and without reported symptoms differed with respect to health-related quality of life, anxiety and depression, but not in clinical balance tests, electronystagmography or vestibular-evoked myogenic potentials.

The test-retest and inter-rater reliability of, and the relationships between, clinical balance tests and subjective ratings and questionnaires were assessed in 50 patients with residual symptoms of dizziness and disequilibrium after AUVL or CVD. Sharpened Romberg's test with eyes closed, standing on foam with eyes closed, standing on one leg with eyes open, and walking in a figure-of-eight were the most reliable and appropriate clinical balance tests. Clinical balance tests were seldom correlated with subjective ratings and questionnaires, which shows the importance of measuring both aspects of dizziness and disequilibrium.

In conclusion, balance performance deteriorates with aging, vestibular rehabilitation therapy may improve balance and decrease symptoms of dizziness and disequilibrium, and it is important to use clinical balance tests together with subjective ratings and questionnaires in these patients.

The aim was to assess (i) the test–retest and inter-rater reliability of, and (ii) the relationships between, commonly used clinical balance tests and subjective ratings in subjects with dizziness and disequilibrium. Fifty subjects (26 men and 24 women, mean age 63 years) with dizziness and disequilibrium following acute unilateral vestibular loss or central neurological dysfunction were tested with static and dynamic clinical balance tests, visual analogue scales (VAS), University of California Los Angeles Dizziness Questionnaire (UCLA-DQ), Dizziness Beliefs Scale (DBS), European Quality of Life questionnaire (EQ-5D), Dizziness Handicap Inventory (DHI), and Hospital Anxiety and Depression Scale (HADS). Most tests showed good test–retest and inter-rater reliability. Few correlations were seen between objective and subjective tests, but several correlations were found between the different subjective instruments. Sharpened Romberg's test eyes closed, standing on foam eyes closed, standing on one leg eyes open and walking in a figure-of-eight are recommended as reliable and appropriate clinical balance tests in subjects with dizziness and disequilibrium. Subjects with central lesions may have difficulties when rating their symptoms on VAS. Total scores rather than scores for separate items are recommended for UCLA-DQ and DHI.

Conclusions. About half of the subjects in this study reported remaining symptoms 3–6 years after acute unilateral vestibular loss. Differences could be seen between subjects with and without remaining symptoms regarding health-related quality of life, anxiety and depression.

Objective. To evaluate the presence of self-rated remaining symptoms 3–6 years after acute unilateral vestibular loss, and to compare subjects with and without such symptoms.

Material and methods. Firstly, 51 subjects answered a questionnaire which included the EuroQol EQ-5D, the Hospital Anxiety and Depression Scale, the University of California Los Angeles Dizziness Questionnaire, visual analogue scales and the Dizziness Handicap Inventory. Secondly, nine subjects with and nine without remaining symptoms participated in an extended testing procedure, including electronystagmography (ENG), determination of vestibular-evoked myogenic potentials (VEMPs) and clinical balance tests.

Results. In the first part of the study, 27 subjects reported remaining symptoms, 3 reported 1 additional period of symptoms and 21 had not experienced any symptoms at all in the 3–6 years since acute unilateral vestibular loss. In the second part, the group with remaining symptoms rated a lower health-related quality of life and a higher level of anxiety and depression. There were no differences between the two groups in terms of ENG tests, VEMPs or clinical balance tests.

Objective: To evaluate the effects of additional physical therapy on recovery after acute unilateral vestibular loss given to patients receiving home training.

Design: Randomized controlled trial.

Setting: Ear, nose and throat departments in three hospitals.

Subjects: Fifty-four patients (mean age 52 years) with acute unilateral vestibular loss within the last week confirmed with electronystagmography testing were included. Patients with central neurologic or auditory symptoms or other vertigo disease were excluded.

Interventions: Home training with or without additional physical therapy 12 times during 10 weeks.

Main measures: Electronystagmography testing was performed before and after the training period. Clinical static (Romberg?s test, sharpened Romberg?s test, standing on foam and standing on one leg) and dynamic (walking forward and backward on a line) balance tests and subjective ratings of vertigo and balance problems on a visual analogue scale were done one week, 10 weeks and six months after the start of training.

Results: Similar changes were seen in the two training groups.

Conclusions: No significant differences in outcome regarding balance function or perceived symptoms were found between home training with or without additional physical therapy.

Objective: To evaluate the influence of asymmetry of vestibular caloric response and age on balance and perceived symptoms after acute unilateral vestibular loss.

Design: Prospective study.

Setting: Ear, nose and throat departments in three hospitals.

Subjects: Fifty-four patients (mean age 52 years) with acute unilateral vestibular loss participating in a randomized controlled training study were included.

Main measures: Electronystagmography testing was performed within one week after onset of symptoms and after 10 weeks. The outcome measures clinical static balance tests (sharpened Romberg's test with eyes closed, standing on foam with eyes closed, and standing on one leg with eyes open and closed) and subjective symptom ratings on a visual analogue scale were done after one week, 10 weeks and six months. The correlation between age and asymmetry of vestibular caloric response, respectively, and the outcome measures were analysed.

Results: Greater caloric asymmetry correlated with poorer performance at the sharpened Romberg's test and standing on one leg with eyes closed at all three follow-ups (rho=-0.31 to -0.54), and with higher symptom ratings at the 10-week and six-month follow-ups (rho=0.30-0.60). Higher age was associated with poorer performance on the sharpened Romberg's test and standing on one leg at all three follow-ups (rho=0.31-0.64), but did not change over time. Higher age was also associated with higher ratings of vertigo at the six-month follow-up, and less reduction of vertigo between the 10-week and six-month follow-ups (rho=0.29-0.48).

Conclusions: A higher degree of asymmetry of vestibular caloric response and high age seem to be associated with poor outcome in balance and perceived symptoms after acute unilateral vestibular loss.

Neck pain is a highly prevalent and often long-lasting problem with substantial personal and economic consequences. Individuals with neck pain are often referred for physiotherapy treatment, but there is limited evidence of the effect of treatment in these patients, mainly because conservative interventions have not been studied in sufficient detail.

The aim of the research underlying this thesis was to improve existing knowledge about neck pain, focusing on prognoses and on the effects of physiotherapy treatment in patients with neck pain. The thesis includes four different studies. a 12-year follow-up study comparing individuals initially on sick leave due to neck/shoulder or low back diagnoses; a critical review of the literatme on randomised studies of neck pain: a prognostic study with focus on both an impairment and a disability outcome at 1-year follow-up: and a randomised study comparing active exercise and McKenzie treatment with a placebo therapy in patients with neck pain.

Compatison of individuals with neck/shoulder and low-back diagnoses revealed that the neck/shoulder group rated their present discomfort as worse than those sick listed with low back diagnoses. Only 4% of the neck/shoulder group but 25% of the low back group reported no present discomfort. Notably. both groups reported the same duration of low back discomfort dming the last year, which may indicate a higher risk for symptoms in more than one location in subjects with neck/shoulder problems.

The regression analyses identified different prognostic factors, except duration of cunent episode, depending on the focus of outcomes. Other factors for the dependent variable pain intensity were Oswestry score and similar problem during the previous 5 years: adjusted R~ was 0.24. For the dependent variable Oswestry score. the other factors were pain intensity. well being, and expectations of treatment; adjusted R² was 0.32. Using pain intensity as outcome, 60% of the patients were identified as being at risk of poor outcome: the corresponding value for Oswestry score as outcome was only 20%.

In the critical review. twenty-seven studies were analysed, most of them of poor quality: only one-third scored≥ 50 on a scale of I 00. Positive outcome was noted for 18 of the studies. Inclusion criteria, intervention, and outcome were based mainly on impainnent in the analysed studies, thus there is a lack of evidence of treatment effect in patients with neck pain measured with outcomes focusing on functional limitation and disability.

In the randomised study, significant improvements were recorded at 12-month follow-up for all three groups in regard to the main outcomes pain intensity and Neck Disability Index. with no significant difference between the groups. In all, 79% reported that they were better or completely restored after treatment. although 51% reported constant/daily pain. The slope of recovery differed during the first three weeks, with more rapid improvement in the McKenzie group. Only 30% of the study population consumed additional health care. although the mean nmnber of visits were lowest in the McKenzie group.

Individuals with sickness absence > 28 days due to neck/shoulder or low back diagnoses appear to be a high risk group for developing long-standing symptoms with stronger evidence for the neck/shoulder group. In clinical settings, it is important to take treatment goals into consideration when choosing the outcome, since a pain-free result may be difficult to obtain if the problems have been long-lasting. Despite a lack of definite evidence. there was a tendency toward better outcome at short-term follow-up with the two active treatments than with placebo therapy, in regard to both impainnent and disability outcomes.

The efficacy of physiotherapy or chiropractic treatment for patients with neck pain was analysed by reviewing 27 randomised clinical trials published 1966-1995. Three different methods were employed: systematic analyses of; methodological quality; comparison of effect size; analysis of inclusion criteria, intervention and outcome according to The Disablement Process model. The quality of most of the studies was low; only one-third scored 50 or more of a possible 100 points. Positive outcomes were noted for 18 of the investigations, and the methodological quality was high in studies using electromagnetic therapy, manipulation, or active physiotherapy. High methodological quality was also noted in studies with traction and acupuncture, however, the interventions had either no effect or a negative effect on outcome. Pooling data and calculation of effect size showed that treatments used in the studies were effective for pain, range of motion, and activities of daily living. Inclusion criteria, intervention, and outcome were based on impairment in most of the analysed investigations. Broader outcome assessments probably would have revealed relationships between treatment effect and impairment, functional limitation and disability.

Purpose: To identify prognostic factors for perceived pain and function with focus at one-year follow-up in primary care patients treated for non-specific neck pain.

Methods: A prospective study was performed including 193 neck pain patients. Before and after treatment period, and 12 months after the start date for treatment, patients completed a questionnaire including background data and aspects of pain, function and general health. Linear multiple regression analysis was used to identify prognostic factors with the dependent variables Oswestry score and pain intensity at 12-month follow-up. Response rate 81%.

Results: At 12-month follow-up, Oswestry score identified four prognostic factors: pain intensity; well-being; expectations of treatment; and duration of current episode. Adjusted R² for the model was 0.32, and 20% of the patients had three of the four prognostic factors at entry, indicating risk of poor outcome. The dependent variable pain intensity revealed three prognostic factors: Oswestry score; duration of current episode; and similar problem during the previous five years. Adjusted R² was 0.24, and 60% of the patients had two of the three prognostic factors at entry, indicating risk of poor outcome.

Conclusions: Different prognostic factors (with the exception of duration of current episode) were identified by the two outcome variables. Thus the results suggest that it should be taken into account whether an impairment or disability outcome is used.

Seventy-seven patients with neck pain in the piimary health care were included in a prospective, randomised clinical trial and randomly assigned to active exercise, McKenzie treatment, or placebo therapy. Seventy patients completed the treatment; response rate 93% at 12-month follow-up. All three groups showed significant improvement regarding the main outcomes, pain intensity and Neck Disability Index (NDI), even at 12-month follow-up, but there was no significant difference between the groups. In all, 79% reported that they were better or completely restored after treatment, although 51% reported constant/daily pain. In the McKenzie group compared to placebo group, a tendency toward greater improvement was noted for pain intensity at 3 weeks and at 6-month follow-up, and for post-treatment NDI. Significant improvement in DRAM scores was shown in the McKenzie group only. The three groups had similar recurrence rates, although after 12 months the McKenzie group showed a tendency toward fewer visits for additional health care.

Seventy-seven patients with neck pain in the primary health care were included in a prospective, randomized clinical trial and randomly assigned to general exercise, McKenzie treatment, or a control group. Seventy patients completed the treatment, response rate 93% at 12-month follow-up. All three groups showed significant improvement regarding the main outcomes, pain intensity and Neck Disability Index, even at 12-month follow-up, but there was no significant difference between the groups. In all, 79% reported that they were better or completely restored after treatment, although 51% reported constant/daily pain. In the McKenzie group compared with the control group, a tendency toward greater improvement was noted for pain intensity at 3 weeks and at 6-month follow-up, and for post-treatment Neck Disability Index. Significant improvement in Distress and Risk Assessment Method scores was shown in the McKenzie group only. The three groups had similar recurrence rates, although after 12 months the McKenzie group showed a tendency toward fewer visits for additional health care. The study did not provide a definite evidence of treatment efficacy in patients with neck pain, however, there was a tendency toward a better outcome with the two active alternatives compared with the control group.

Background and Purpose Neck/shoulder and low back pain are common in the Western world and can cause great personal and economic consequences, but so far there are few long term follow-up studies of the consequences of back pain, especially studies that separate the location of back pain. More knowledge is needed about different patterns of risk factors and prognoses for neck/shoulder and low back pain, respectively, and they should not be treated as similar conditions. The aim of the present study was to investigate possible long-term differences in neck/shoulder and low back symptoms, experienced over a 12-year period, with regard to work status, present health, discomfort and influence on daily activities.

Method A retrospective cohort study of individuals sicklisted with neck/shoulder or low back diagnoses 12 years ago was undertaken. Included were all 213 people who, in 1985, lived in the municipality of Linköping, Sweden, were aged 25–34 years and who had taken at least one new period of sickleave lasting >28 days with a neck/shoulder or low back diagnosis. In 1996, a questionnaire was mailed to the 204 people who were still resident in Sweden (response rate 73%).

Results Those initially absent with neck/shoulder diagnoses rated their present state of discomfort as worse than those sicklisted with low back diagnoses. Only 4% of the neck/shoulder group reported no present discomfort compared with 25% of the low back group. Notably, both groups reported the same duration of low back discomfort during the last year, which may indicate a higher risk for symptoms in more than one location for subjects with neck/shoulder problems.

Conclusions Individuals with sickness absence of more than 28 days with neck/shoulder or low back diagnoses appear to be at high risk of developing long-standing symptoms, significantly more so for those initially having neck/shoulder diagnoses.

Although the elderly population consumes a relatively large proportion of health care, international research has focused little attention on older people and their perception of health care and its outcome. Information is also scanty concerning relatives in hospital care and their actions and the circumstances related to relatives' participation in the care process.

The overall aim of this thesis is to contribute to a better knowledge and understanding of the perspectives of older patients and relatives regarding hospital care and how this knowledge can be used in measurements of quality of hospital care from the patient perspective.

This thesis uses both qualitative and quantitative methods. Study I and II are based on semistructured interviews. In study I a midrange theory and a theoretical model of patients' evaluation process regarding the care was derived. In study II relatives' actions and the circumstances related to their participation in the care process were described. In study III the knowledge obtained in study I was used as a base for development of an instrument 'Patients perspectives on care and rehabilitation process' (POCR) containing structured questions for measuring patients' perceptions regarding the care process. The instrument was used in telephone-interviews for the data collection in study III and IV. In study IV analyses were conducted regarding the interrelation between some of the concepts in the model of patients' evaluation process.

The patient and relative perspectives on hospital care, are based on complex processes that involve their past experiences, present situation and expectations of the of future regarding care and illness/health. The encounters patients and relatives have with staff and the organisation lay the foundations for their future expectations and experiences regarding a potential forthcoming care process. Relatives carry out a variety of actions and engagements based on their own knowledge and ability. Patients and relatives have disparate realities and needs. The three-part interaction between patient, relative and staff is an important factor in patients' and relatives' actions and participation in the care process and in how their needs are met.

Patient perceived needs differ during the different phases of the care process. Patients' perception of needs and care are associated with patients' previous experiences with illness and care, their perception of themselves and the situation, and their expectations regarding health and care.

Patient-perceived results of the care process include how needs were met as well as health outcome. Patients' evaluation of the hospital care is shown to be associated with their previous experiences of the care unit, perceived health outcome including their overall lifesituation post-discharge, as well as patients' expectations regarding their future health postdischarge. These aspects ought to be focused in measures regarding quality of care from patients' perspective.

The POCR instrument was found to have adequate validity and reliability. The instrument reflects patients' different needs during the care process and measure patients' perceptions regarding fulfilment of needs and their importance. Using the telephone interview technique makes it possible for data collectors to learn more about the patient perspective and it resulted in high response rate.

Purpose: To gain a deeper understanding of how elderly persons experience and evaluate the care and rehabilitation process. Method: Qualitative interview data from elderly patients were analysed using a grounded theory approach. The patients were interviewed twice, at the beginning of geriatric hospital care and some weeks after discharge. Results: The patient-perceived outcome of the care and rehabilitation process reflected two dimensions, the effect on their health and the quality of the process, i.e. how their needs were met. The analysis revealed that the patients' needs differed during the care and rehabilitation process. It also indicated that patients perceived their needs and the care differently based on their previous experience of the care unit, their perceived trajectory of illness and their 'patient character' which represented the patient's definition of himself/herself and the situation. A hypothetical model of the patients' evaluation process has been derived. Conclusion: The results indicate the importance of using a process perspective in the assessment and the interpretation of patient-perceived outcome of care and rehabilitation, and that patient expectations, trajectories of illness and the patient character must be taken into consideration.