| 131. |
- Ringsberg, Karin
(author)
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Patients with asthma-like symptoms but negative asthma tests and patients with bronchial asthma
- 1997
-
Doctoral thesis (other academic/artistic)abstract
- Patients with asthma-like symptoms but with negative results in asthma tests have recently been identified. The symptoms are mainly triggered by strong odours, physical exercise and mental stress. These patients are often misdiagnosed and mistreated. They mostly have to find coping strategies by themselves. Patients with diagnosed bronchial asthma sometimes are 'educated in their own disease' by health care professionals in order to increase their compliance and to help them to find coping strategies.The overall aim of this thesis was to identify and describe patients with asthma-like symptoms but negative asthma tests and to find diagnostic instruments to differentiate these patients from patients with bronchial asthma and healthy subjects and to investigate some possible mechanisms behind the disorder. A further aim was to describe the effects of a cognitive and affective treatment of patients with diagnosed bronchial asthma and to discuss if this model might also be applicable to patients with asthma-like symptoms but negative asthma tests.Altogether 24 patients with asthma-like symptoms but negative asthma: tests, 28 patients with bronchial asthma and 10 healthy controls participated in four studies. Only women aged 18-60 years were included. They were investigated with psychological tests, questionnaires and provocation with physical exercise, voluntary hyperventilation and mental stress. In-depth interviews were also performed. In a fifth study, the effects of a cognitive and affective model for treating patients with bronchial asthma, an "asthma school'', were studied by means of different questionnaires and lung function testo;, Althogether 38 patients with bronchial asthma, women and men aged· 18-70 yrs, participated.The results showed that the patients with asthma-like symptoms suffered more frequently from a greater variety of symptoms compared to the patients with asthma and healthy contJ:ols. They were more depressed, less hedonic, more hypochondriac and had lower trust in others than the patients of the astluna group. They had a higher health care consumption compared to the patients with asthma The physical exercise test did not provoke any bronchoconstriction in the patients with asthma-like symptoms. Neither could the symptoms be explained by physical unfitness. The provocations with voluntary hyperventilation and mental stress revealed that hyperventilation might be present in these patients and that mental stress might be one trigger factor. In a qualitative study, the patients stated that they felt dejected, confused and non confirmed by health care professionals, family and friends. Their subjective hyperreactivity limited them socially. They lacked adequate coping strategies. The findings were characterised by numerous self-reinforcing vicious circles where the circles comprised subjective hyperreactivity, social limitations and non confinnation. Patients with bronchial asthma benefit from being treated in an "asthma-school''. After having attended an "asthma-school", the patients increased their knowledge of the disease slightly more than a control group. They also increased their quality of life and decreased their health care conswnption.In summary, no evidence was found for the diagnosis of asthma in the patients with asthmalike symptoms but negative asthma tests. It is possible to separate them from patients with bronchial asthma by using different lung function tests, and different provocation tests. Patients with bronchial asthma benefit from taking part in an "asthma school". A similar treatment, with both a cognitive and an affective approach, might also be applicable in patients with asthma-like symptoms but negative asthma tests. A multidisciplinary approach and confirmation of these patients is important.
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| 132. |
- Risto, Olof
(author)
-
Heterotopic bone formation following total hip arthroplasty : clinical and experimental studies using NSAID and patelet-derived growth factor
- 1995
-
Doctoral thesis (other academic/artistic)abstract
- A consecutive series of 104 Lubinus IP arthroplasties was retrospectively studied with regard to heterotopic bone formation (HBF). Fifty-three cases were treated for 10 ± 2 days postoperatively with the NSAID oxyphenbutazone. Radiological follow up three months postoperatively showed significant HBF (;;,20mm) in 21 patients in the untreated and in none in the treated group (pIn another retrospective series, all except 4 of 220 total hip arthroplasties were treated for about two weeks with oxyphenbutazone. Charnley (C), McKee-Farrar (M) and Bmnswik (B) arthroplasty were studied. The incidence ofHBF in the entire series was low (15%). Some degree ofHBF was seen in 37% (C), 8.3% (M) and 8.5% (B). Significant HBF (;;, 20mm) was seen in 30% (C), 4,8%(M) and 1,2% (B). Five years postoperatively,no significant functional differences were seen between the patients with HBF and those without HBF. Trochanter osteotomy (C) seemed to be the reason for the significantly higher incidence of HBF for C than for M and B, respectively (pIn a randomized, double-blind, placebo-controlled clinical study of 100 Lubinus SP Il arthroplasties diclofenac treatment (50mgx3) almost completely abolished substantial HBF (;;,20mm). In the placebo group, significant HBF was found in 3 3 of a total of 4 7 hips, compared to 1 of a total of 46 hips in the treated group (pPDGF (20 ng/ml) and induction of heterotopic new woven bone was studied in rats. The agent was administered locally and continuously for two weeks by means of mini-osmotic pumps inserted subcutaneously. The PDGF reached 6-mm long pieces of demineralized rat femur implanted into gluteal muscle pouches. Each rat had a contralateral control piece implanted. PDGF increased the ash-weights of the samples significantly (p<0.05).Using the same type of administration system, the effects ofa very small total dose (40 ng) of diclofenac on induction of new woven bone, were studied. The diclofenac treated samples showed significantly reduced ashweights (p<0.05).The effects of 0-200 11g diclofenac/ml after 48 h on the proliferation of cultured, serum starved human fibroblasts stimulated or not stimulated with PDGF, were studied using [3H]-thymidine. A dose-dependent inhibition was obvious at 211g/ml and significant at 5 11g/ml (p<0.05) both in the presence and in the absence of PDGF. The inhibiting effect occurred during the first 24 h of the PDGF-induced mitogenic signal. TRlTC-labelled phalloidin was used to study early and late effects of diclofenac on the organization of actin. Typical PDGF-induced changes of the actin cytoskeleton were inhibited by diclofenac. Diclofenac also caused the cells to assume a more epitheloidlike shape.The effects of diclofenac (50 l!g/ml) on whole cell appearance of human, serum starved fibroblasts, stimulated or not stimulated with PDGF, were studied using scanning electron microscopy. Cellular effects equivalentto the actin organization changes were detected at 15 min, 1 hand 48 h after administration of diclofenac. The morphological changes caused by diclofenac probably represent decreased cell motility.The extent of surgical trauma, and especially detachment of periosteum, seems to be the factor eliciting HBF after THA by activation of endogenous factors. NSA!Ds probably act prophylactically against HBF by inhibiting the recruitment of fibroblasts and their subsequent proliferation stimulated by PDGF and other growth factors.NSAID treatment for two weeks after THA and avoidance, if possible, of trochanter osteotomy is recommended for prophylaxis against HBF.
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| 133. |
- Ryding, Elsa Lena
(author)
-
Psychological Aspects of Emergency Cesarean Section
- 1998
-
Doctoral thesis (other academic/artistic)abstract
- According to earlier research, emergency cesarean section (Em CS) can have a deleterious effect on maternal psychological well-being. Whether the women thus delivered already had more psychological problems during pregnancy than other women, is not known.ln our pilot study of 25 women who underwent EmCS, we found that the concept of post-traumatic stress was relevant to the subject.In the main study, 1,981 Swedish-speaking women completed questionnaires concerning fear of childbirth, general anxiety, and coping with stress at about 32 weeks' gestation. Those 97 women who were subsequently delivered by Em CS were compared with 194 controls, matched for age and parity.All told, 124 women, who underwent Em CS, participated in the study postpartum. Fiftythree of these were randomized for early postpartum counselling, which began with an interview about the delivery experience. The remainder (n = 71) participated in comparisons with women who underwent other types of delivery. Those delivered by elective cesarean section (n = 70) or who had an instrumental vaginal delivery (n = 89) participated, as did 96 of those who had a completely normal vaginal delivery. Questionnaires inquiring into the birth experience, post-traumatic stress reactions, and general mental distress were filled in a few days and again at one month postpartum. The Em CS groups also completed questionnaires 6 months postpartum. Altogether 79 women who underwent EmCS completed questionnaires, both during pregnancy and up to one month postpartum.Healthy pregnant women with a serious fear of childbirth appeared to be at greater risk of subsequent EmCS. The degree of fear of childbirth during pregnancy was the best predictor of the degree of maternal well-being after an Em CS. Many of the women had experienced during the delivery an intense fear for their own life and health and/or for that of their baby. Thus, the trauma of EmCS may well meet the stressor criterion of the Diagnostic and Statistical Manual of Mental Disorders. Appraisal of the delivery was more negative after an EmCS than after other modes of deliveries. The women reported more post-traumatic stress reactions following Em CS as well as after instrumental vaginal delivery, than after elective cesarean section or normal vaginal birth. Generally speaking, early postpartum counselling had a beneficial effect on maternal well-being and especially on appraisal of delivery. The women with most frequent symptoms of post-traumatic stress reactions and mental distress did not get adequate help by our mode of counselling.In conclusion, an emergency cesarean section is often a traumatic experience. Antenatal fear of childbirth may increase the risk of an Em CS. More intense fear of childbirth late during pregnancy is associated with a more negative appraisal of an experienced EmCS, and also with more frequent symptoms of post-traumatic stress reactions and general mental distress following a surgical delivery. The psychological well-being of mothers is generally not so good after EmCS or an instrumental vaginal delivery, as after elective cesarean section or normal vaginal birth.
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| 134. |
- Seldén, Anders
(author)
-
Occupational hexachloroethane exposure and toxicity : With special reference to the formation of Hexachlorobenzeneiin aluminium degrassing
- 1997
-
Doctoral thesis (other academic/artistic)abstract
- For about half a century, hexachloroethane (HCE) has been used as an essential component of military white smoke munition and as a degassing agent in almninium foundries and secondary aluminium smelters. However, the acute or chronic health risks associated with occupational exposure to HCE have not been investigated in humans.In exposed white smoke munition workers (n=12), the mean plasma level of HCE increased from 0.08 µ/l during a production break to 7.30 µ/1 after five weeks of continuous production, but there was a considerable interindividual variation. HCE was not detected in local controls. Slight irritation of the skin and mucous membranes was also reported, but clinical examination, spirometry and routine biochemical analyses revealed no specific deviations from normal.A wide spectrum of organochlorine compounds was identified -in the emissions from experimental degassing of aluminium with HCE. Chlorobenzenes, notably hexachlorobenzene (4.3 mg/g HCE), octachlorostyrene (0.78 mg/g HCE) and umeacted HCE were the major findings. At considerably lower levels, several congeners of chlorinated dioxins (in total 3 .4· 10·' mg/g HCE) and dibensofurans (3.6·104 mg/g HCE) were also identified.As compared to local controls, increased levels of hexachlorobenzene (313.1 vs 66.9 ng/g lipid) as well as octachlorostyrene (54.6 vs 0.7 ng/g lipid) were found still some years after last exposure in a group of aluminium foundry workers (n~9) with experience of HCE as a degassing agent. These workers also showed some evidence of secondary coproporphyrinuria, the first recognised step in the gradual development of chronic hepatic porphyria.In a cohort (n~6,454) of aluminium foundry and secondary aluminium smelter workers, no clearly increased cancer risk could be attributed to the potential exposure to HCE and its byproducts in aluminium degassing, although a slight excess of non-Hodgkin' s lymphoma was observed among males. This finding was restricted to workers with less than 10 years of employment, red~cing the probability of a causal association. Evidence of a lung cancer hazard related to sand founding of aluminium for I 0 years or more was obtained, however.
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| 135. |
- Serrander, Lena
(author)
-
Neutrophil phagocytosis and secretion : The role of calcium and the cytoskeleton
- 1999
-
Doctoral thesis (other academic/artistic)abstract
- Neutrophils assure rapid removal of bacteria by a variety of processes. They crawl out of the vessels, phagocytose the bacteria and kill them by secretion of bactericidal substances and production of oxidative metabolites. The aims of this study were to investigate the signalling pathways during these processes, in particular i) how complement receptors mediate phagocytosis and NADPH~oxidase activity ii) the role of Ca2+ in secretion and the role of a Ca2+-dependent, actin-binding protein, _gelsolin, in neutrophil phagocytosis and secretion. Conventional biochemical methods, capacitance measurements of secretion with the patchclamp technique and visualisation with fluorescence microscopy techniques were used. We found that phospholipase D (PLD) is an early Ca2+-independent signal in complementmediated phagocytosis, preceding cytoskeletal rearrangements. We also demonstrated'that the NADPH-oxidase could be activated in situ to generate oxidative metabolites intracellularly after particle stimulation of complement receptors in the absence of phagocytosis. This permits cells to use oxidative metabolites for signalling and not only to kill bacteria. This activation involved the cytoskeleton and PLD. Whereas signalling during pha~ocytosis can occur independently of Ca2+, other neutrophil functions are highly Ca +-dependent. Investigating the relative importance of Ca2+-release from intracellular stores versus Ca2+ influx over the plasma membrane, we found that secretion of primary granules induced by fMLP is dependent on Ca2+ -influx. ci+-influx alone is not sufficient to induce secretion in neutrophils. A second synergistic signal is required. This missing signal was not PLD, PLC or tyrosine kinases, but involved a pertussis-sensitive 0-protein and PI3-kinase. When further investigating the role of Ca2+ in secretion, we found that secretion of different granules is regulated by different [Ca2+:J. Primary granules are secreted at 100 ~ Ca2+ whereas the other granules are secreted at 1.5-5 ~ ci+, suggesting two mechanisms involving different Ca2+ activated systems/sensor proteins. One sensor protein could be the Ca2+-dependent, actinbinding protein, gelsolin, which has earlier been shown to stimulate secretion in different celltypes. Secretion from gelsolin-deficient mouse neutrophils was nevertheless nonnal. Gelsolin was however found to be essential for !gO-mediated-, but not complement-induced phagocytosis. Activation of the oxidase and phagolysosorne-fusion was unaffected in gelsolin-deficient neutrophils. This suggests gelsolin to be a Ca2+ -sensor specifically for !gOmediated phagocytosis. !gO-mediated phagocytosis often leads to more efficient killing than complement-mediated phagocytosis. Gelsolin seems to be part of the machinery that distinguishes the two pathways of phagocytosis. The present data show that receptor mediated activation of neutrophil functions involves several signalling pathways. This allows selective modulation of the inflammatory response.
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| 136. |
- Sidenvall, Birgitta
(author)
-
The meal in geriatric care : Habits, values and culture
- 1995
-
Doctoral thesis (other academic/artistic)abstract
- The aim of the present thesis was to study the meal situation in geriatric care, focusing on cultural, social, psychological and nutritional qualities of the meals for the patients as well as caring strategies and actions performed at meals by the nursing staff. The studies were carried out in a rehabilitation and long-term care clinic providing geriatric care. The data were gathered during two periods. In the first period 18 consecutive elderly patients and their personal enrolled nurses participated (paper I and II). In the second study the informants were 45 patients as well as registered nurses, enrolled nurses and nurse's assistauts working in the clinic (paper III, IV and V). The main approach was ethnographic, using interviews, observations and documents. Furthermore, the nutritional status was assessed by weight index and biochemistry as well as by records of dietary intake. The meal situation was found to be a meeting place between individual patients and the collective hospital culture. In the ward the patients strove to reach their own standards of acceptable table manners and retain their independence and dignity. Their conflicts at table were related to three themes. The first, "Mind your manners", demonstrated problems in managing food and objects, keeping clean, and conduct at table. Thesecond, "Appetite for food", was connected to tradition and taste, healthy food and the need not to waste food. The third, "Be content and do not complain", illustrated the elderly patients' socialized manners in talking about meals and food. The evaluation of the elderly patients' meal patterns showed a strong reduction in daily eating frequency during the time before hospitalization, which might lead to nutritional deficiency. The nursing assessment strategies were defective as patients at risk of malnutrition were missed and patients' experiences of their own and others' limited eating competence were rarely taken into consideration enough. One reason for this was shown to be the organization of the meal and the fixed form of the working phases. Ritualized practices gave the main form to the hospital meal and the serving procedures. Based on checks of patients' ability and caregivers' working conditions, the praxis was to make eating possible and facilitate the procedures. Three norms guided the caregivers; "To provide a homelike situation with fellowship for training purposes", "To ensure each patient gets what they need/want by means of a fair method of serving"and "To keep things in order and to be responsible". The thesis points out the problem that arises when institutionalized habits and values gave the meals such a fixed form that alterations in serving procedures were difficult to make. As the elderly patients strove to keep their dignity and adapt to the demands communicated, these were factors which minimized the possibilities of adjusting the eating procedures to the individual needs of the patient.
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| 137. |
- Sigurs, Nele
(author)
-
Studies on sensitization and atopic disease in infants and children
- 1995
-
Doctoral thesis (other academic/artistic)abstract
- Sensitization to food allergens dominated in infancy and IgE antibodies to inhalant allergens appeared later in a cross-sectional multicentre study of 224 children with atopic disease (113 children aged 0-3 years and 111 children aged 4-15 years). IgE antibodies to peanut, hazelnut, and almond were important in both age groups and even before known ingestion in infancy, suggesting sensitization through breast-milk.A similar pattern of food sensitization in infancy and later appearance ofantibodies to inhalant allergens was seen in 324 children constituting an enlarged group from three different cohorts of children and followed prospectively from birth to age 4 to 15. Antibodies to inhalant allergens developed in 76% of children with IgE antibodies to egg white (EW) in infancy. Of children with inhalant antibodies up to age 12-15, 32 % had previously had antibodies to EW.The possible effects of maternal antigen avoidance during lactation on the development of atopic disease were studied in children with a positive family history of atopy. The mothers of 65 infants avoided eggs, cow's milk and fish during the first three months of lactation, whereas the mothers of 50 infants had no dietary restrictions. (Previous reports from this study had shown significantly less atopic dermatitis (AD) during the first 6 months of life in the diet group, and after that a non-significant trend towards less AJ;:> up to age 18 months.) The present follow-up at age 4 years showed significantly less AD in the diet group, both as cumulative (29 %versus 56 %, p=0.007) and as current prevalence (12 % versus 38 %, p=0.03). The frequencies of asthma and allergic rhinoconjunctivitis were similar, as were the number of sensitized children.Possible effects of an early severe respiratory viral infection on the development of asthma, other atopic symptoms and sensitization were studied in 47 infants hospitalized with respiratory syncytial virus (RSV) bronchiolitis, and their 93 matched controls obtained from the local child health centres. Asthma, up to age 3, was significantly more common in the RSV children (23% versus 1 %, p< 0.001). This was also the case with serisitization at age 3, as measured by skin-prick tests and two screening tests in serum for food and inhalant antibodies (32 % versus 9 %, p=0.002), whereas the frequency of AD was similar in the two groups. The combination of RSV bronchiolitis and a family history of asthma was the most important risk factor for the development of asthma. For sensitization, the combination of RSV bronchiolitis and a family history of atopic disease was the most important risk factor.In a study of 34 infants hospitalized with RSV bronchiolitis, the eosinophil cationic protein (ECP)/albumin ratios in nasal secretions increased during the 6 months following RSV bronchiolitis, suggesting a long-standing inflammatory reaction, which might be important for the high frequency of post-bronchiolitic wheezing. ECP and myeloperoxidase in serum and ECP/albumin ratios in nasal secretions could not be used to predict later asthma or sensitizat:ion.In conclusion, food sensitization dominated in infancy, and antibodies toaeroallergens appeared later. In infants with a family history of atopic disease, the risk of developing atopic dermatitis up to age 4 years was reduced in the group in which the mothers avoided cow's milk, egg and fish during lactation. An early RSV bronchiolitis increased the likelihood of future asthma and sensitization up to age 3 especially if combined with heredity for asthma and atopic disease.
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| 138. |
- Singh, Ashok Kumar
(author)
-
Global EDS information support for local MCHC activity with emphasis on immunisation and evaluation
- 1996
-
Doctoral thesis (other academic/artistic)abstract
- This research, in the field of Medical Informatics within a defined sector of Primary Health Care services, namely, Maternal and Child Health Care (MCHC) is a realisation, implementation and evaluation of the WHO motto "Think globally, act locally". It has been conducted in three distinct phases. The first phase involved the design and development of an application software in the MCHC domain, The applicable Essential Data Set (EDS) was established after an analysis of the literature and Indian and the Swedish Maternal Health records (I), which also showed deficiencies in the existing documentation, pointing at a general need in both external audit and internal quality improvement for the MCHC application software (II). The MCHC software was developed and tested for microcomputer implementation, suitable for peripheral use in developing countries (Ill). The second phase comprised of the pilot implementation of the system at a number of sites in India and in particular at Bhorugram, a village in the Thar desert of Rajas than State of India (IV), where the application software was permanently installed and tested for clinical use (V). Cost-effectiveness of the information system is demonstrated through an economic evaluation of the project using a local quality indicator comprised by the immunisation subprogram, in particular the Fully Immunised Child (FIC) (VI). The third phase of the study was the performance evaluation of the information system after four years of constant use (VII). This had been successful in all operational terms, and the F1C index could be used as a local cardinal index to monitor and evaluate the quality of care, cost-effectiveness and community participation of the Information system, MCHS. Health Systems and Health Economy Research alike have long searched for apt quality and performance markers that in themselves could embrace and express a number of aspects and factors. The FIC index isshown to well meet the criteria of such a cardinal measure in the MCHC services, and the inferences to the value of the information system are comparatively straightforward. Participation and compliance improved asreflected in a markedly decreased drop-out frequency. These results could be extrapolated to the larger, even the global, scale.
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| 139. |
- Skamris Matthiesen, Leif, 1954-
(author)
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Immune Changes in Pregnancy : A Survey of some Immunological Variables in Normal and Complicated Pregnancies
- 1998
-
Doctoral thesis (other academic/artistic)abstract
- The maternal systemic immune response during pregnancy is only fragmentarily understood. An adequate immune response to the gestational product is of vital importance for a successful pregnancy. Research in the field of reproductive immunology could clarify whether there is a difference between the immune responses in women with normal pregnancies and women with complicated pregnancies.The present thesis is a survey of selected immunological variables in non-pregnant women and in women with uncomplicated and complicated pregnancies. This was done by studying Jymphocyte populations, the proliferative capacity of lymphocytes as stimulated with mitogcns and immunomodulating drugs, the presence of iL-4 and JFN-g secreting cells, and the presence of certain autoantibodies in a low-risk pregnant population.Normal pregnancies were characterised by decreased levels of B cells (CD19+),_ NK cells (CD56+), expression of the IL-2 Receptor on lymphocytcs (CD25+) as well as HLA-DR+ on T cells (CD3+) and increased level of inactivated CD4+CD45RA+ T cells. Increased levels of NK cells, expression ofHLA-DR on T cells and antigen activated CD4+CD45R0+ T cells was found in preeclamptic patients compared with normal pregnancies. Thus, the immunosuppression that was found in normal pregnancies was not seen in pregnancies complicated by prccclampsia.Addition ofmitogens to cell cultures in either autologous or AB serum culture media demonstrated the existence of serum and cell mediated suppressor activity. The lymphoprolifcrative response to mitogens was reduced during nmmal pregnancies, possibly mediated by PGE2 and the presence ofT lymphocytes with suppressor function. The lymphoproliferative response in pregnancies complicated with severe precclampsia was further reduced as compared with normal pregnancies.Circulating IFN-g and IL-4 secreting cells increased during nonnal pregnancies. By the use of a mixed lymphocyte culture test it was found that paternal lymphocytes as stimulator-cells generated an elevated IL-4 secretion from maternal responder cells. These results indicate that the maternal immune response is shifted towards humoral immunity (TH2) by the recognition of the paternal allo-antigens, possibly to avoid maternal allo-reactivity against the fetus. The present findings also indicate that cell-mediated immunity (THl) to antigens were allowed to occur.The prevalence of anticardiolipin antibodies (aCL, IgG, ELISA), antinuclear antibodies (ANA, Indirect immunofluorescence) and rheumatoid factor (RF, agglutination test) in a low-risk pregnant population was low. However, there was an association, albeit weak, between ANA and women with preeclampsia.In summary, the maternal systemic immune response is characterised by suppression and non-aggression in nmmal human pregnancies. In women with pregnancy complications, such as preeclampsia, this suppression and inactivation is only partially achieved.
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| 140. |
- Skargren, Elisabeth, 1948-
(author)
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Evaluation of Physical exercise, Physiotherapy and Chiropractic in the Management of Back Pain
- 1998
-
Doctoral thesis (other academic/artistic)abstract
- The lack of evidence concerning the effectiveness of most existing interventions for back pain, has created room for the expansion of a variety of interventions and the need to evaluate these.The general aim of this thesis was to assess three interventions used for health promotion (exercise programme) and treatment (chiropractic and physiotherapy) of musculoskeletal pain, primarily back pain, and to identify potential predictors of long-term outcome in the treatment of back pain.The thesis consists of material from two studies. Firstly, a health promotion study assessing the effects of a moderate weekly exercise programme among nursing personnel (n=86), during work time, using a cross-over design. Self-reported questionnaires were used to follow the effects on perceived musculoskeletal and psychosomatic symptoms and work conditions. As a complement, physical capacity was tested. Secondly, a randomised, pragmatic treatment study comparing the short-term and long-tenn (one-year) effects and costs of chiropractic and physiotherapy as first-line treatment for 323 patients with back pain seeking care at ten primary health care centres. Self-reported questionnaires were used to follow the effects on perceived health (pain, function and general health) and costs.The exercise programme decreased the number of musculoskeletal symptoms and increased the physical capacity among the 50 subjects who participated regularly. The effects were primarily explained by the subgroups: those who were non-regular exercisers in their spare time and those ~40 years of age, i.e. those who initially had low physical capacity. The results suggested a relationship between the number of musculoskeletal symptoms and physical capacity as well as a relationship between changes in these factors that need further evaluation. Besides the positive effect, a negative effect was seen in perceived work planning, suggesting that exercise during work time must be well organised so as not to add extra stress.Chiropractic and physiotherapy resulted in significant effects. The effects and costs were equal at short-term and long-term follow-ups. In other words neither strategy was more cost-effective than the other according to the total groups. However, subgroup analyses showed that patients with acute back pain (duration of current episode ≤ week) benefit more from chiropractic and patients with chronic back pain (duration of current episode ≥ 1 month) benefit more from physiotherapy, and at similar costs. Chiropractic consisted mainly of spinal manipulation, and physiotherapy of a great variety of treatment forms. Recurrence was common among patients visiting primary health care for back pain, and a high proportion, higher in the chiropractic group than in the physiotheraPy group, consumed additional health care during the follow-up year. Five prognostic factors ("duration of current episode", "Oswestry score at entry", "number of localisations", "expectations of treatment" and "well-being") for disability at the one-year follow-up were identified. The factors were of similar importance in the two treatment strategies, chiropractic and physiotherapy.Both studies showed that the outcome differed among subgroups of subjects. This suggests that potential predictive factors for outcome need to be considered in the development of intervention policies and in clinical decision models conceming back pain patients.
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