| 1. |
- Bernhardsson, Susanne, 1958-
(författare)
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Advancing evidence-based practice in primary care physiotherapy : Guideline implementation, clinical practice, and patient preferences
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Research on physiotherapy treatment interventions has increased dramatically in the past 25 years and it is a challenge to transfer research findings into clinical practice, so that patients benefit from effective treatment. Development of clinical practice guidelines is a potentially useful strategy to implement research evidence into practice. However, the impact of guideline implementation in Swedish primary care physiotherapy is unknown. To achieve evidence-based practice (EBP), research evidence should be integrated with clinical expertise and patient preferences, but knowledge is limited about these factors in Swedish primary care physiotherapy.The overall aim of this thesis was to increase understanding of factors of importance for the implementation of EBP in Swedish primary care physiotherapy. Specific aims were: to translate and adapt a questionnaire for the measurement of EBP and guidelines; to investigate physiotherapists’ attitudes, knowledge and behaviour related to EBP and guidelines; to examine clinical practice patterns; to evaluate the effects of a tailored guideline implementation strategy; and to explore patients’ preferences for physiotherapy.The thesis comprises four studies (A-D), reported in five papers. In Study A, a questionnaire for the measurement of EBP and guidelines was translated, cross-culturally adapted, and tested for validity (n=10) and reliability (n=42). Study B was a cross-sectional study in which this questionnaire was used to survey primary care physiotherapists in the county council Region Västra Götaland (n=271). In Study C, a strategy for the implementation of guidelines was developed and evaluated, using the same questionnaire (n=271 at baseline, n=256 at follow-up), in a prospective controlled trial. The strategy was based on an implementation model, was tailored to address the determinants of guideline use identified in Study B, and comprised several components including an educational seminar. Study D was an exploratory qualitative study of patients with musculoskeletal disorders (n=20), using qualitative content analysis.The validity and reliability of the questionnaire was found to be satisfactory. Most physiotherapists have a positive regard for EBP and guidelines, although these attitudes are not fully reflected in the reported use of guidelines. The most important determinants of guideline use were considering guidelines important to facilitate practice and knowing how to integrate patient preferences with guidelines. The tailored, multi-component guideline implementation significantly affected awareness of, knowledge of, and access to guidelines. Use of guidelines was significantly affected among those who attended an implementation seminar. Clinical practice for common musculoskeletal conditions included interventions supported by evidence of various strengths as well as interventions with insufficient research evidence. The most frequently reported interventions were advice and exercise therapy. The interviewed patients expressed trust and confidence in the professionalism of physiotherapists and in the therapists’ ability to choose appropriate treatment, rendering treatment preferences subordinate. This trust seemed to foster active engagement in their physiotherapy.In conclusion: The adapted questionnaire can be used to reliably measure EBP in physiotherapy. The positive attitudes found do not necessarily translate to guideline use, due to several perceived barriers. The tailored guideline implementation strategy used can be effective to reduce barriers and contribute to increased use of guidelines. The clinical practice patterns identified suggest that physiotherapists rely both on research evidence and their clinical expertise when choosing treatment methods. Patients’ trust in their physiotherapist’s competence and preference for active engagement in their therapy need to be embraced by the clinician and, together with the therapist’s clinical expertise, integrated with guideline use in the clinical decision making. Further research is needed on how the EBP components and different knowledge sources can be integrated in physiotherapy practice, as well as on implementation effects on patient outcomes.
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| 2. |
- Gutke, Annelie, 1967-
(författare)
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Pelvic Girdle Pain and Lumbar Pain in relation to pregnancy
- 2007
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The prevalence of low back pain (LBP) is higher in pregnant women compared to women of the same age in a general population. Pregnancy-related LBP persists 6 years after pregnancy in 16% of women. Consequently, pregnancy represents a specific risk for LBP and persistent LBP. Pregnancy-related LBP is usually studied as a single entity, however, only one subgroup of LBP, i.e. pelvic girdle pain (PGP), seems to be associated with pregnancy. Accordingly, possible differences in subgroups of patients with LBP are unknown.The aims of this thesis were the following: 1) to describe the prevalence of clinically classified subgroups of women with LBP in a cohort (no LBP, lumbar pain, PGP, and combined pain (PGP and lumbar pain)) during pregnancy and postpartum, and 2) to determine if there was a disparity in the course, health-related quality of life (HRQL), pain intensity, disability, depressive symptoms, or muscle function in subgroups of the cohort, and 3) to identify predictors for having persistent pregnancy-related PGP postpartum.Consecutively-enrolled pregnant women were classified into LBP subgroups by mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history, and pain drawings. All women answered questionnaires (background data, EQ-5D). Women with LBP completed the Oswestry Disability Index and pain measures. The Edinburgh Postnatal Depression Scale was used to evaluate depressive symptoms at 3 months postpartum (cut-off ≥10). Trunk muscle endurance, hip muscle strength, and gait speed were investigated. Multiple logistic regression was used to identify predictors from self-reports and clinical examination.At the 12-18 gestational week evaluation, 118/308 (38%) women had no LBP, 33 (11%) had lumbar pain, 101 (33%) had PGP, and 56 (18%) had combined pain. Three months postpartum, 183/272 (67%) women had no LBP, 29 (11%) had lumbar pain, 46 (17%) had PGP, and 14 (5%) had combined pain. Pregnant women with combined pain were most affected in terms of HRQL, pain intensity, and disability. Depressive symptoms were three times more prevalent in women with LBP (27/87, 31%) than in women without LBP (17/180, 9%). Women with PGP and/or combined pain had lower values for trunk muscle endurance, hip extensor strength and gait speed compared to women without LBP. Postpartum, 16-20% of the women had persistent combined pain or PGP, whereas 1/29 had lumbar pain. Predictors for persistent PGP or combined pain were work dissatisfaction, older age, combined pain in early pregnancy, and low endurance of the back flexors.In conclusion, women with combined pain were identified to be a target group since they had the lowest recovery rate and since the classification of combined pain was found to be a predictor for persistent PGP or combined pain postpartum. The hypothesis of an association between muscle dysfunction and PGP was strengthened. Based on the finding of high comorbidity of postpartum depressive symptoms and LBP, it seems important to screen for and consider treatment strategies for both symptoms.
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| 3. |
- Holmgren, Theresa, 1974-
(författare)
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Exercise treatment of patients with long-standing subacromial pain
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Subacromial pain is the most common problem among patients with shoulder complaints seeking primary care. The recommended treatment for these patients is primarily non-surgical with a focus on exercise treatment. If this treatment fails arthroscopic subacromial decompression (ASD) followed by exercise treatment is recommended. Surgical treatment with ASD has increased substantially in Sweden in recent years even though studies comparing exercise treatment with surgery report equally positive results. Still, there is a need of evidence based preand postoperative exercise treatments, standardised and described in detail, to guide treatment of these patients in clinical practice.The overall aim of this thesis was to evaluate the efficacy of pre- and postoperative exercise strategies on shoulder function and how the preoperative strategy affects the need for surgery in patients with long-standing subacromial pain.This thesis comprises four papers which are based on two randomised controlled trials. In study A, patients were randomised after ASD surgery to either physical therapist (PT) supervised strength-endurance exercises for the rotator cuff and scapula stabilisers or to home-based movement exercises for a period of three months. Shoulder function and pain, health related quality of life and return to work was evaluated for 6 months (paper I). In study B, patients on the waiting list for surgery were randomised to either specific exercise strategy with strengthendurance exercises for the rotator cuff and the scapula stabilisers or to control exercises with movement exercises for the neck and shoulders for a period of three months. After completing the exercise program and also after 12 months, shoulder function and pain, need for surgery and health related quality of life was evaluated. Baseline shoulder function, rotator cuff status and radiological findings were analysed in relation to the choice of surgery (paper II, III). The minimal important clinical change (MIC) of the Constant-Murley (CM) score, used as primary outcome in this thesis, was determined by using a visual anchor-based MIC distribution method (paper IV).Six months after ASD surgery, patients who performed PT-supervised strength-endurance exercises improved significantly more in shoulder function and pain compared to patients who had performed home-based movement exercises (paper I). Patients on the waiting list for surgery who performed specific strength-endurance exercises had significantly greater improvements in shoulder function and pain compared to patients performing movement exercises (paper II). A significantly lower proportion of those performing specific strength-endurance exercises chose surgery at the three- and 12 months follow-ups (paper II, paper III). Low baseline values in shoulder function and pain measured with the CM score and/or having a full thickness rotator cuff rupture were associated with an increased risk of choosing surgery (paper III). Regarding the CM score, a change between 17-24 points seems to be clinically important for patients with long-standing subacromial pain (paper IV).Supervised strength-endurance exercises seem to be more effective than home-based movement exercises after ASD surgery. For patients on the waiting list for surgery, the specific strategy of strength-endurance exercises was effective in improving shoulder function and pain and the need for surgery was reduced at 12 months. Low baseline values for shoulder function and pain measured with the CM score and/or having a full thickness rotator cuff tear seem to be predictors for choosing surgery. The CM score is able to detect the MIC in individual patients with long-standing subacromial pain when the rotator cuff is intact. In all patients with longstanding subacromial pain, the MIC value was dependent on the subgroup as well as the choice of statistical analysis.
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| 4. |
- Lindbäck, Yvonne, 1967-
(författare)
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Pre-surgery physiotherapy and pain thresholds in patients with degenerative lumbar spine disorders
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Patients scheduled for spinal surgery often experience long duration of pain, which may influence the pain-regulation system, function and health and have an impact on post-surgery outcome. Prehabilitation potentially augments functional capacity before surgery, which may have beneficial effects after surgery.Aim: The overall aim of the thesis is to study pre-surgery physiotherapy and somatosensory function in patients with degenerative lumbar spine disorders and to explore the patients’ experiences of pre-surgery physiotherapy.Methods: Somatosensory function was measured with quantitative sensory testing (QST). Pre-surgery physiotherapy was evaluated with patient-reported outcome measures (n = 197). Patients’ experiences of how symptoms are explained and their experiences of the influences on back-related health after pre-surgery physiotherapy were explored.Results: Half of the patients reported back or leg pain for more than 2 years. On a group level, the somatosensory profiles were within the reference range. On an individual level, an altered somatosensory profile was found in 23/105 patients, these were older, more often women, and reported higher pain, larger pain distribution and worse SF-36 MCS (mental health component summary). Patients with disc herniation, more sensitive to pressure pain in the hand presurgery, was associated with poorer function, self-efficacy, anxiety and depression score pre-surgery, worse function, self-efficacy and leg pain 3 months post-surgery and worse health related quality of life, self-efficacy, depression score 1 year postsurgery. The results for sensitivity for cold pain were similar, except that it even was associated with poorer function and pain 1 year post-surgery. The pre-surgery physiotherapy group had less back pain, better function, health, self-efficacy, fear avoidance score, depression score and physical activity level than the waiting-list group after the pre-surgery intervention. The effects were small. Both groups improved significantly after surgery, with no differences between groups, except that the higher physical activity level in the physiotherapy group remained at the 1-year follow-up. Only 58% of the patients reported a minimum of one visit for rehabilitation during the 1 year preceding the decision to undergo surgery. Patients experienced that pre-surgery physiotherapy had influenced symptoms, physical function, coping, well-being and social functioning to various degrees. Pre-surgery physiotherapy was experienced as a tool for reassurance and an opportunity to reflect about treatment and lifestyle. The patients mainly used biomedical explanatory models based on image reports to explain their backrelated symptoms. Both broader and more narrow, as well as lack of explanations of symptoms emerged. Further, wanting and sometimes struggling to be wellinformed about symptoms and interventions were described.Conclusions: Being more sensitive to pressure- and cold pain in the hand, as a sign of widespread pain pre-surgery, was associated with poorer function, pain and health at post-surgery in patients with disc herniation. Pre-surgery physiotherapy decreased pain, fear avoidance, improved health related quality of life; and it decreased the risk of a worsening in psychological well-being before surgery. The improvements were small, and improvements after surgery were similar for both groups. At the 1-year follow-up, the physiotherapy group still had a higher activity level than the waiting list group. The pre-surgery physiotherapy was well tolerated. Patients’ reported experiences also illustrates the influence on function, pain and health. Patients experienced that pre-surgery physiotherapy provided reassurance and gave time to reflect on treatments and lifestyle. Symptoms were mainly described in line with a biomedical explanatory model. Those using a broader explanation were confident that physiotherapy and self-management could influence their back-related symptoms.
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| 5. |
- Nilsing Strid, Emma, 1973-
(författare)
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The Sick Leave Process : Sick Leave Guidelines, Sickness Certificates, and Experiences of Professionals
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Decisions on entitlement to sickness benefits and return to work interventions have substantial impact on individuals’ lives and on society. In most Western European countries, such decisions are based on sickness certificates, which should provide information on how a disease or injury reduces the individual’s work ability. These are challenging and complex assessments. In 2008, guidelines for the management of sick leave were implemented in Sweden, emphasizing early assessments of work ability and return to work, and increasing the quality demands of sickness certificates by underscoring descriptions of activity limitations related to work. The overall aim of this thesis was to gain a deeper knowledge of the sick leave process with special emphasis on the content of sickness certificates and primary health care (PHC) professionals’ experiences with the process. Specific aims were to compare the quality of sickness certificates regarding descriptions of functioning by the use of WHO’s International Classification of Functioning, disability, and health (ICF), as well as the prescribed interventions before versus after implementation of the Swedish sick leave guidelines.The thesis comprises three studies. A cross-sectional design was used in studies I and II, which included 475 and 501 new sickness certificates consecutively collected in Östergötland County, Sweden, in 2007 and 2009, respectively. Text on functioning was analysed with a deductive content analysis using the ICF. Study III was an exploratory study using data from four semi-structured focus group discussions with a purposeful sample of PHC professionals (n=18) in Östergötland County. An inductive content analysis was used in this study.The thesis comprises three studies. A cross-sectional design was used in studies I and II, which included 475 and 501 new sickness certificates consecutively collected in Östergötland County, Sweden, in 2007 and 2009, respectively. Text on functioning was analysed with a deductive content analysis using the ICF. Study III was an exploratory study using data from four semi-structured focus group discussions with a purposeful sample of PHC professionals (n=18) in Östergötland County. An inductive content analysis was used in this study.An overall conclusion drawn from this thesis is that patient functioning and needs might not be adequately communicated in the sick leave process. Despite the implementation of sick leave guidelines, this information is limited in sickness certificates and the collaboration is poor among the involved stakeholders, i.e., health care, the social insurance office, the employer and the OHS. The basis for decisions on entitlement to sickness benefits could be improved by including a description of the patients’ activity limitations or participation restrictions related to work demands. One way to enhance the decision basis might be to use the available team competencies at the PHC.
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| 6. |
- Nordqvist, Jenny, 1976-
(författare)
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Patients with subacromial pain in primary care : Assessment and efficacy of physiotherapy-guided exercise treatment
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Shoulder pain is a common musculoskeletal disorder and 40-74% of the patients attending primary healthcare with a shoulder disorder are diagnosed with subacromial pain. Subacromial pain is characterized by restricted and painful movement of the arm that leads to difficulties in performing arm-related activities and often affects the quality of life profoundly, with respect to everyday function, work capacity, sleep quality and mental health. It is crucial that the measurements used to evaluate shoulder function and treatment response have acceptable psychometric properties and also that they are patients-specific and time-efficient to administer. For patients with subacromial pain, exercises are recommended as first-line treatment but consensus about which exercises and dosage to recommend has not been reached. The lack of evidence for one specific exercise model may be partly due to heterogeneity among this group of patients. The overall aim of this thesis were to evaluate the efficacy of a previously tested exercise strategy for patients with subacromial pain in a primary care setting, to describe the heterogeneity with possible subcategories among patients with subacromial pain, and finally to validate and adjust the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for more diagnosis-specific clinical assessment. Methods: The four papers in this thesis are based on two clinical studies, one randomized controlled trial (RCT) and one clinical cohort. The participants in both studies were patients with subacromial pain attending physiotherapist (PT) in a primary care setting. Two of the papers are based on psychometric analyses, with evaluation of construct validity and responsiveness for the DASH when used to evaluate shoulder function in patients with subacromial pain, and also calculation of minimal important change (MIC) for a diagnosis-specific short version of DASH (DASH 7). A third paper describe clinical presentation in patients with subacromial pain, based on the components active range of motion (AROM), rotator cuff function and scapular kinematics and the fourth paper evaluated the efficacy of a 3-month specific exercise strategy in comparison to an active control strategy. Results: Seven items from the original DASH were identified as being the most important in evaluating patients with subacromial pain (resulting in the DASH 7 questionnaire). The DASH 7 shows good responsiveness, can discriminate between patients who perceive themselves as improved and those who do not, and maintain a high level of internal consistency for the assessment of shoulder function in patients with subacromial pain, using only a quarter of the items of the original DASH. Based on clinical presentation, patients with subacromial pain in the primary care setting comprise a heterogeneous group. Rotator cuff dysfunction, defined as pain during resisted isometric muscle-testing, is very frequently present while limitation in active range of motion and scapular dyskinesia are less common. After three months of exercise, both groups in the RCT had significantly improved with no between group difference as measured with the primary CM-score. However, as measured with the DASH and the DASH 7, the patients in the specific exercise group was significantly more improved compared to those in the active control group. Conclusions: The DASH 7 questionnaire is a short patient-reported outcome measurement (PROM) with good responsiveness, specific for patients with subacromial pain. Heterogeneity was confirmed with identified variability in AROM, rotator cuff function and scapular kinematics in clinical presentation which confirms that these components are important in the clinical examination of patients with subacromial pain. Shoulder function evaluated with the CM score did not improve to a significantly different degree between the two groups studied. The specific exercises might not be necessary for all patients in the primary care setting to achieve a clinically relevant improvement. However, the specific exercise strategy was significantly better when improvement was assessed by DASH and DASH 7, and this leads us to recommend this strategy, with its progressive loading of the rotator cuff muscles and scapula stabilizers, as first choice, provided that it is tolerated by the patient.
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| 7. |
- Sjödahl, Jenny, 1979-
(författare)
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Pregnancy-related pelvic girdle pain and its relation to muscle function
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Pregnancy-related lumbopelvic pain affects approximately 50% of all pregnant women. For the majority the pain disappears during the first months after delivery; however, for a significant number of women, the pain is persistent, with little improvement for more than three months after delivery. Moreover, women who experience persistent lumbopelvic pain three months postpartum are at substantial risk for new episodes or for chronic lumbopelvic pain later in life. Hence, pregnancy-related lumbopelvic pain should be considered a major public health issue. In order to develop and offer specific treatment strategies, it is important to identify different subgroups of lumbopelvic pain based on different clinical presentations. Pelvic girdle pain (PGP) is one of the major subgroups of pain related to pregnancy. There is no consensus regarding the underlying mechanisms although instability in the pelvis has been proposed as one of the possible mechanism; thus, further studies are necessary to determine how to treat these women. The local lumbopelvic muscle system, including the pelvic floor muscles (PFM) is thought to contribute to the stabilization of the pelvis and they are also the target for many treatment strategies for lumbopelvic pain.The overall aim of this thesis was to improve rehabilitation for women with persistent postpartum PGP by investigating three areas, including: 1) the postural response of the PFM, 2) the effect of home-based specific stabilizing exercises (SSE) that target the local lumbopelvic muscle system and, 3) predictors for disability at 15 months postpartum.The thesis comprises three studies: A) a methodological study, B) an experimental study, and C) a clinical randomized controlled trial (RCT). The data is mainly based on muscle function, including recordings of electromyographic (EMG) activation, muscle endurance, and muscle strength. We also collected subjective ratings of disability, healthrelated quality of life, and pain.The methodological study showed that the designed protocol, which included limb movements performed at a comfortable speed in both standing and supine positions, was useful for detecting a postural response in the PFM. The experimental study demonstrated that women with persistent postpartum PGP and those free of pain exhibited a feed-forward mechanism in the PFM that responded in anticipation to leg lifts performed in a supine position. However, we cannot rule out the possibility that women with difficulties in transferring load between the trunk and legs (i.e., those with functional pelvic instability) might have a different postural response in the PFM. In the present study, one woman with persistent postpartum PGP failed to present a feed-forward mechanism in the PFM, in agreement with previous studies on other parameters of the PFM from other similar groups.The clinical RCT demonstrated that the concept of home-based SSE with visits every second week with the treating physiotherapist was not more effective than the clinical natural course for improving subjective ratings or muscle function in women with persistent postpartum PGP.A linear regression analysis revealed a complex picture that suggests that disability 15 months postpartum in women with persistent PGP could be partially predicted by two interaction effects comprising factors from different dimensions: biological, physical functioning, and self-rated function. The proposed association between muscle function and PGP was strengthen. New approaches are most likely needed to further identify subgroups of patients with persistent postpartum PGP that can be considered homogeneous for treatment.
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| 8. |
- Tagesson (Sonesson), Sofi, 1977-
(författare)
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Dynamic knee stability after anterior cruciate ligament injury : Emphasis on rehabilitation
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Anterior cruciate ligament injury leads to increased sagittal tibial translation, and perceptions of instability and low confidence in the knee joint are common. Many patients have remaining problems despite treatment and are forced to lower their activity level and prematurely end their career in sports. The effect of ACL reconstruction and/or rehabilitation on dynamic knee stability is not completely understood. The overall aim of this thesis was to study the dynamic knee stability during and after rehabilitation in individuals with ACL injury. More specific aims were 1) to elaborate an evaluation method for muscle strength, 2) to evaluate the effect of exercises in closed and open kinetic chain, and 3) to evaluate dynamic knee stability in patients with ACL deficiency or ACL reconstruction.Sagittal tibial translation and knee flexion angle were measured using the CA‐4000 computerised goniometer linkage. Muscle activation was registered with electromyography.The intra‐ and inter‐rater reliability of 1 repetition maximum (RM) of seated knee extension was clinically acceptable. The inter‐rater reliability of 1RM of squat was also acceptable, but the intra‐rater reliability was lower. The systematic procedure for the establishment of 1RM that was developed can be recommended for use in the clinic.One specific exercise session including cycling and a maximum number of knee extensions and heel raises did not influence static or dynamic sagittal tibial translation in uninjured individuals. A comprehensive rehabilitation program with isolated quadriceps training in OKC led to significantly greater isokinetic quadriceps strength compared to CKC rehabilitation in patients with ACL deficiency. Hamstring strength, static and dynamic translation, and functional outcome were similar between groups. Five weeks after ACL reconstruction, seated knee extension produced more anterior tibial translation compared to the straight leg raise and standing on one leg. All exercises produced less or equal amount of anterior tibial translation as the 90N Lachman test.Five weeks after the ACL reconstruction the static and dynamic tibial translation in the ACL reconstructed knee did not differ from the tibial translation on the uninjured leg. Patients in the early phase after ACL injury or ACL reconstruction used a joint stiffening strategy including a reduced peak knee extension angle during gait and increased hamstring activation during activity, which reduces the dynamic tibial translation. Patients with ACL deficiency that completed a four months rehabilitation program used a movement pattern that was more close to normal.
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| 9. |
- Wibault, Johanna, 1978-
(författare)
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Neck disability in patients with cervical radiculopathy and evaluation of structured postoperative physiotherapy
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Non-surgical and surgical approaches to treatment are used in patients with cervical radiculopathy (CR) due to disc disease. Overall, good effects of surgery have been reported on arm pain and neurological symptoms. However, the effects on neck functioning are more uncertain. Studies have shown persistent activity limitations; participation restrictions; and impairments in neck-related body functions after surgery. Structured physiotherapy combining neck-specific exercises with a behavioural approach has been suggested as treatment before as well as after surgery to improve clinical outcomes in patients with CR. Randomized clinical trials of postoperative physiotherapy to inform evidence-based clinical guidelines for the treatment of patients with CR are lacking.The overall aim of the thesis was to investigate the additional benefit of structured postoperative physiotherapy combining neck-specific exercises with a behavioural approach compared to standard postoperative approach in patients with CR. A further aim was to evaluate the contribution of different aspects of neck-related body functions and mental functions on preoperative neck disability in these patients.A total of 202 patients with CR who were scheduled for surgery were recruited, and randomized preoperatively to either structured postoperative physiotherapy, or standard postoperative approach. Standard postoperative approach was in accordance with Swedish postoperative care, and may have included pragmatic physiotherapy after surgery when needed. Patients were evaluated with a set of questionnaires and clinical examinations before surgery and at 3 and 6 months after surgery. Outcomes included patient-reported measures of pain, neck functioning, global outcome, clinical evaluation of neckrelated body functions, self-efficacy and coping strategies, as well as expectation fulfilment and enablement. Differences between treatment groups were investigated in complete case and per-protocol approaches (Paper III & IV). A sub-sample of patients with CR who were scheduled for surgery were also compared with neck-healthy individuals for assessment of head repositioning accuracy with a cervical range of motion device (Paper I). In patients with CR who were scheduled for surgery, associations between preoperative measures of neck-related body functions, mental functions, and other contextual factors with patientreported neck disability were studied (Paper II).With the exception of greater expectation fulfilment in patients who received structured postoperative physiotherapy (p = 0.01), there were no differences between the treatment groups in outcomes at 6 months after surgery. There were no differences reported for changes in outcomes from before surgery to 6 months after surgery between the groups, but all outcomes significantly improved from baseline in both groups (p<0.001) (Paper III & IV). However, global outcome and frequency of neck pain improved during the postoperative period only in patients who received structured postoperative physiotherapy (p< 0.01) (Paper III). Six months after surgery, patients with at least 50% attendance to treatment sessions in the structured postoperative physiotherapy group reported less neck pain frequency (p = 0.05), and greater expectation fulfilment (p = 0.001), and enablement (p = 0.04) than those who received standard postoperative approach. These patients also had larger improvements in neck functioning, arm pain and catastrophizing during the rehabilitation period from 3 to 6 months after surgery (p< 0.03). Sixty-one percent of the patients who received standard postoperative approach reported additional use ofpostoperative physiotherapy. These patients had a worse surgical outcome compared with patients who reported no additional use of postoperative physiotherapy. In patients with CR who were scheduled for surgery, larger errors in head repositioning accuracy were found compared to neck-healthy individuals (Paper I). Preoperative measures of neck-related body functions, mental functions and other contextual factors explained 73% of the variance in Neck Disability Index scores in patients with CR who were scheduled for surgery (Paper II).The results may suggest a benefit from combining surgery with structured postoperative physiotherapy in patients with CR. Moreover, the results confirm that neck-specific exercises are tolerated by patients with CR after surgery. However, CR is a heterogeneous condition and specific subgroups of patients are likely to benefit from different interventions. More studies are needed to inform evidence-based clinical guidelines for the treatment of patients with CR. A broader preoperative assessment in patients with CR improved the description of patient-reported neck disability.
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| 10. |
- Wåhlin, Charlotte, 1961-
(författare)
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The Rehabilitation Process for Individuals with Musculoskeletal and Mental Disorders : Evaluation of Health, Functioning, Work Ability and Return to Work
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Musculoskeletal disorders (MSD) and mental disorders (MD) are common among working-age individuals, and reduced work ability is often a problem that influences functioning in working life. Having MSD and MD is also a common cause of seeking health care and these conditions account for the majority of sick leave in most western countries. The overall aims of the thesis were to increase knowledge about biopsychosocial assessment of health, functioning and work ability for individuals with MSD and MD seeking care. A further aim was to gain better understanding of praxis behaviour in the rehabilitation process for sick-listed patients by evaluating patient-reported work ability, type of interventions given, usefulness of interventions, and return to work.This thesis comprises four studies based on two different cohorts. A cross-sectional design was used for studies I and II, which included 210 individuals diagnosed with MSD and MD seeking occupational health services. Data collection consisted of questionnaires to patients on self-reported health, functioning, work conditions, work ability and reports of professional assessment of diagnosis, main clinical problem, recommended intervention and sick leave. Studies III (n=699) and IV (n=810) were based on a longitudinal cohort study, ReWESS, with a 3-month follow-up comprising individuals who sought primary health care or occupational health services for MSD or MD and were sick-listed. The data collection included repeated questionnaires to the patients on self-reported health, functioning, work conditions, work ability, type and usefulness of intervention and return to work.There was an association between the professional biopsychosocial assessment and patients’ self-reported measures of health, functioning and work ability in clinical reasoning. Self-reported health and work measures can complement the expert-based diagnosis. Patients who had MSD and MD with co-morbid conditions reported more problems with mental functioning, had higher psychological demands at work and reported poorer work ability compared with those with MSD only. Patients with co-morbid conditions also had worse outcome compared to having mental disorders only. Psychosocial problems and activity limitations concerning social interaction skills were a frequent problem. This can be identified in clinical screening by physiotherapists in dialogue with the patient using the Patient-Specific Functional Scale. Three-quarters of sick-listed individuals with MSD or MD returned to work within 90 days. The treatment approach to sick-listed persons is still very medical and clinically oriented. Access to work-related interventions seems to be limited in the early rehabilitation process and may not be equal in practice. Those who were younger, had higher educational level and reported stronger health resources were favoured. There is a need to strive for access to work-related interventions.Return to work was associated with receiving combined clinical- and work-related interventions for patients with MD, and with better health-related quality of life, positive return to work expectations and better work ability for patients with MSD. Factors associated with return to work can be identified using self-reported measures. Patients with MD who received a combination of work-related and clinical interventions perceived best usefulness and best effect of health care contacts on work ability. Patients with MSD did not report as good usefulness. There seems to be a gap between scientific evidence and praxis behaviour in the early rehabilitation process; unimodal rehabilitation was widely applied, use of a multimodal treatment approach was limited and only one-third received work-related interventions. For patients with MSD, behavioural treatment seems to be underutilized in clinical practice considering the effect it may have on developing coping strategies and reducing symptoms. In order to meet recommendations in guidelines, physical activity needs to increase as a treatment strategy for patients with MD. A clinical implication is that the rehabilitation process needs to adopt a broader perspective for patients with MSD and MD to include patients’ individual health-related needs, aspects of employment and work conditions. Still, it remains a challenge to understand who needs what type of intervention.
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