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Objective: To investigate whether high-intensity lower extremity constraint-induced movement therapy can improve balance, leg strength, and dual-task ability. Design: A longitudinal cohort study in a real-world outpatient clinic. Patients: 147 community-dwelling participants in the subacute and chronic poststroke phases. Methods: Participants received lower extremity constraint-induced movement therapy for 6 hours/day during 2 consecutive weeks, including balance, strength, and functional training. The Berg Balance Scale (BBS), Single-Leg-Stance (SLS) bilaterally, one Repetition Maximum (1RM) in a leg press, symmetry of leg strength (Diff-1RM), Timed Up and Go (TUG), and the TUG Manual test were assessed before, after, and 3 months after lower extremity constraint-induced movement therapy. Results: Compared with preintervention data, statistically significant improvements after lower extremity constraint-induced movement therapy (p

Objective: To follow up patients with post-COVID-19 condition (PCC) 6 months after a multidisciplinary team assessment in specialist care regarding symptoms of pain, anxiety, depression, fatigue and cognition, level of activity, physical activity and sick leave. Methods: A prospective pilot study conducted in a clinical setting of patients (n = 22) with PCC referred from primary healthcare to a specialist clinic for a 2 day-multidisciplinary team assessment followed by a subsequent rehabilitation plan. Data were collected through questionnaires filled in prior to the team assessment and 6 months later. Results: Fifteen of the initial 22 patients participated in the follow-up. No statistically significant improvements were seen in any of the questionnaires after 6 months. However, 76.9% of the participants perceived the intervention as being helpful. This differed between the genders, where all the women 100% (n = 8) perceived it as being helpful, compared with 40% (n = 2) of the men (p = 0.012). Conclusions: Based on these findings, the benefit of a multidisciplinary team assessment of PCC is not fully convincing. However, since the participants themselves perceived the intervention as being helpful, the team assessment seems to be of some value. Further studies with larger populations would be of interest.

Abstract Background A proportion of patients with mild traumatic brain injury (mTBI) suffer long-term consequences, and the reasons behind this are still poorly understood. One factor that may affect outcomes is cognitive reserve, which is the brain's ability to maintain cognitive function despite injury. It is often assessed through educational level or premorbid IQ tests. This study aimed to explore whether there were differences in post-concussion symptoms and symptom resolution between patients with mTBI and minor orthopedic injuries one week and three months after injury. Additional aims were to explore the relationship between cognitive reserve and outcome, as well as functional connectivity according to resting state functional magnetic resonance imaging (rs-fMRI). Method Fifteen patients with mTBI and 15 controls with minor orthopedic injuries were recruited from the emergency department. Assessments, including Rivermead Post-Concussion Questionnaire (RPQ), neuropsychological testing, and rs-fMRI scans, were conducted on average 7 days (SD = 2) and 122 days (SD = 51) after injury. Results At the first time point, significantly higher rates of post-concussion symptoms (U = 40.0, p = 0.003), state fatigue (U = 56.5, p = 0.014), and fatigability (U = 58.5, p = 0.025) were observed among the mTBI group than among the controls. However, after three months, only the difference in post-concussion symptoms remained significant (U = 27.0, p = 0.003). Improvement in post-concussion symptoms was found to be significantly correlated with cognitive reserve, but only in the mTBI group (Spearman’s rho = -0.579, p = .038). Differences in the trajectory of recovery were also observed for fatigability between the two groups (U = 36.5, p = 0.015). Moreover, functional connectivity differences in the frontoparietal network were observed between the groups, and for mTBI patients, functional connectivity differences in an executive control network were observed over time. Conclusion The findings of this pilot study suggest that mTBI, compared to minor orthopedic trauma, is associated to both functional connectivity changes in the brain and concussion-related symptoms. While there is improvement in these symptoms over time, a small subgroup with lower cognitive reserve appears to experience more persistent and possibly worsening symptoms over time. This, however, needs to be validated in larger studies. Trial registration NCT05593172. Retrospectively registered.

Objective: To investigate outcomes in patients with chronic pain after participation in an interdisciplinary pain rehabilitation programme with language interpreters, and to investigate the outcomes in women and men separately. Design: Prospective multi-centre cohort study. Patients: Ninety-five patients in Sweden with chronic pain who have insufficient knowledge of the Swedish language. Methods: Duration and intensity of pain, anxiety and depression, health-related quality of life and fear of movement were evaluated before and after the programme. Patients were compared with a reference group comprising Swedish-speaking patients participating in an ordinary interdisciplinary pain rehabilitation programme. Results: Before the interdisciplinary pain rehabilitation programme with language interpreters, all variables except pain duration differed significantly to the detriment of the studied group. The studied group showed significant improvements after the interdisciplinary pain rehabilitation programme with language interpreters, with regards to pain intensity, depression and fear of movement. The reference group improved significantly for all variables. The women in the studied group showed significant improvements for the same variables as the whole group, while the men in the studied group did not improve in any of the variables. Conclusion: This study indicates that patients with chronic pain, and especially women, who have insufficient knowledge of Swedish seem to benefit from participating in an interdisciplinary pain rehabilitation programme with language interpreters. The result may be of value for the further development of rehabilitation programmes with language interpreters.

Objective: Chronic pain is a common manifestation of Ehlers-Danlos syndrome and hypermobility spectrum disorders; thus it is often suggested that patients undergo generic interdisciplinary pain rehabilitation, despite there being little evidence to support this decision. The aim of this study is to examine the effectiveness of standard rehabilitation programmes for chronic pain on patients with Ehlers-Danlos syndrome and hypermobility spectrum disorders, compared with patients with other chronic pain disorders. Subjects: Data, collected between 2008 and 2016, were extracted from a Swedish national registry. The patient data comprised of 406 cases with Ehlers-Danlos syndrome or hypermobility spectrum disorders, 784 cases with a whiplash-related diagnosis, 3713 cases with diagnoses relating to spinal pain, and 2880 cases of fibromyalgia. Methods: The differences between groups on key outcome measures from pre- to 1-year follow-up after interdisciplinary pain rehabilitation were analysed using linear mixed effects models. Sensitivity analysis in the form of pattern-mixture modelling was conducted to discern the impact of missing data. Results: No significant differences were found in improvements from pre- to 1-year follow-up for patients with Ehlers-Danlos syndrome or hypermobility spectrum disorder compared with other diagnostic groups regarding measures of health-related quality of life, mental health, or fatigue. At follow-up, differences in pain interference (d = –0.34 (95% confidence interval [95% CI] –0.5 to –0.18)), average pain (d = 0.22 (95% CI 0.11–0.62)) and physical functioning (d = 2.19 (95% CI 1.61–2.77)) were detected for the group with spinal-related diagnoses in relation to those with EDS/HSD, largely due to pre-treatment group differences. Sensitivity analysis found little evidence for missing data influencing the results. Conclusion: This study suggests that patients with Ehlers-Danlos syndrome/hypermobility spectrum disorders may benefit from inclusion in an interdisciplinary pain rehabilitation programme.

Dysfunction in executive functions is common among patients with chronic pain. However, the relationships between executive functioning and pain management have not been extensively studied. In this study, 189 outpatients (160 women, 29 men; mean age 33.15) with chronic pain underwent an extensive neuropsychological assessment, including several tests of executive functions. In addition, all participants completed self-assessment questionnaires regarding pain and interference of pain in everyday life. After adjusting for effects of age, education, and depression, several aspects of executive functioning were significantly associated with self-assessed everyday interference of pain (rs = 0.13-0.22, all ps < 0.05). This indicates that lower performance on tests of executive functioning was significantly associated with a higher degree of pain interference and a lower degree of life control. Pain characteristics such as pain intensity, pain duration, and pain spreading were not associated with executive functioning. These results suggest that preserved executive functions are related to better coping with pain, but not directly to the pain itself, in patients with chronic pain. Depression was also associated with self-management of pain, indicating that patients with lower executive functioning in combination with depression may need special attention during rehabilitation.

Background: Every year, many people suffer from traumatic brain injuries (TBI) with dramatic consequences for both the victim and their close relatives in the form of remaining lifelong symptoms and functional disabilities as a result. Methods: This study evaluates the outcomes of 49 patients after mild TBI (mTBI) at follow-up after 5 years by using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) to assess post-TBI symptoms and the Glasgow Outcome Scale Extended (GOSE) to assess disability. The specific aim was to evaluate post-TBI characteristics concerning age, gender, pre-injury systemic disease, computed tomography (CT) result and additional TBIs. Results: Almost eighty percent reported RPQ symptoms, the most common for both genders being fatigue (51%) and poor concentration (51%). Seventy-six percent had a good recovery, 18% moderate disability, while 6% reported severe disability. The number of symptoms was significantly correlated to the level of disability. All participants with severe disability had repeated mTBI. Only twenty-one percent reported that they received some form of rehabilitation intervention after their mTBI. Conclusions: Five years after suffering mTBI, patients reported high rates of symptoms and disabilities. Our findings suggest that tailored rehabilitation interventions should be designed to identify mTBI patients in need of early rehabilitation. This would result in minimized suffering for the individual and improved cost-effectiveness for society.

Introduction Chronic pain (CP) is one of the most frequently presenting conditions in health care and many patients with CP report mental fatigue and a decline in cognitive functioning. However, the underlying mechanisms are still unknown.Methods and analysis This study protocol describes a cross-sectional study aimed at investigating the presence of self-rated mental fatigue, objectively measured cognitive fatigability and executive functions and their relation to other cognitive functions, inflammatory biomarkers and brain connectivity in patients with CP. We will control for pain-related factors such as pain intensity and secondary factors such as sleep disturbances and psychological well-being. Two hundred patients 18–50 years with CP will be recruited for a neuropsychological investigation at two outpatient study centres in Sweden. The patients are compared with 36 healthy controls. Of these, 36 patients and 36 controls will undergo blood sampling for inflammatory markers, and of these, 24 female patients and 22 female controls, between 18 and 45 years, will undergo an functional MRI investigation. Primary outcomes are cognitive fatigability, executive inhibition, imaging and inflammatory markers. Secondary outcomes include self-rated fatigue, verbal fluency and working memory. The study provides an approach to study fatigue and cognitive functions in CP with objective measurements and may demonstrate new models of fatigue and cognition in CP.Ethics and dissemination The study has been approved by the Swedish Ethics Review Board (Dnr 2018/424-31; 2018/1235–32; 2018/2395–32; 2019–66148; 2022-02838-02). All patients gave written informed consent to participate in the study. The study findings will be disseminated through publications in journals within the fields of pain, neuropsychology and rehabilitation. Results will be spread at relevant national and international conferences, meetings and expert forums. The results will be shared with user organisations and their members as well as relevant policymakers.Trial registration number NCT05452915.

Objective: To evaluate patient-reported outcome measures in patients with chronic musculoskeletal pain 1 year after participation in a case manager-led multimodal rehabilitation intervention in a Finnish primary care centre. Changes in healthcare utilization (HCU) were also explored. Methods: A prospective pilot study with 36 participants. The intervention consisted of screening, multidisciplinary team assessment, a rehabilitation plan and case manager follow-up. Data were collected through questionnaires filled in after the team assessment and 1 year later. HCU data 1 year before and 1 year after team assessment were compared. Results: At follow-up, satisfaction with vocational situation, self-reported work ability and health-related quality of life (HRQoL) had improved and pain intensity had diminished significantly for all participants. The participants who reduced their HCU improved their activity level and HRQoL. Early intervention by a psychologist and mental health nurse was distinctive for the participants who reduced HCU at follow-up. Conclusion: The findings demonstrate the importance of early biopsychosocial management of patients with chronic pain in primary care. Identification of psychological risk factors at an early stage may lead to better psychosocial wellbeing, improve coping strategy and reduce HCU. A case manager may free up other resources and thereby contribute to cost savings. LAY ABSTRACT The majority of patients with chronic pain seek and receive care in primary care, yet their identification and management are often fragmented and inadequate. Many patients end up in a vicious circle of healthcare utilization (HCU), undergoing unnecessary diagnostic and medical procedures. Identifying those at risk of developing chronic pain and avoiding exclusion from work, family and social life may generate cost savings and reduce individual suffering. Multimodal rehabilitation (MMR) is an evidence-based treatment for patients with chronic pain, recurrently provided in specialized care but underutilized in primary care. This pilot study evaluated a case manager-led MMR intervention for patients with musculoskeletal chronic pain in a Finnish primary care centre. HCU was also studied. The results showed that addressing physiological, psychological and social factors in the patient’s life simultaneously and at an early stage may lead to reduced pain perception, increased psychosocial wellbeing and cost savings for society.

Introduction About 20% of the adult population have chronic pain, often associated with psychological distress, sick leave and poor health. There are large variations in the clinical picture. A biopsychosocial approach is used in investigation and treatment. The concept of personalised medicine, that is, optimising medication types and dosages for individual patients based on biomarkers and other patient-related factors, has received increasing attention in different diseases but used less in chronic pain. This cooperative project from all Swedish University Hospitals will investigate whether there are changes in inflammation and metabolism patterns in saliva and blood in chronic pain patients and whether the changes correlate with clinical characteristics and rehabilitation outcomes.Methods and analysis Patients at multidisciplinary pain centres at University Hospitals in Sweden who have chosen to participate in the Swedish Quality Registry for Pain Rehabilitation and healthy sex-matched and age-matched individuals will be included in the study. Saliva and blood samples will be collected in addition to questionnaire data obtained from the register. From the samples, proteins, lipids, metabolites and micro-RNA will be analysed in relation to, for example, diagnosis, pain characteristics, psychological distress, body weight, pharmacological treatment and clinical rehabilitation results using advanced multivariate data analysis and bioinformatics.Ethics and dissemination The study is approved by the Swedish Ethical Review Authority (Dnr 2021–04929) and will be conducted in accordance with the declaration of Helsinki.The results will be published in open access scientific journals and in popular scientific relevant journals such as those from patient organisations. Data will be also presented in scientific meetings, meeting with healthcare organisations and disseminated in different lecturers at the clinics and universities.

Objectives: To investigate the outcomes of a multimodal rehabilitation programme (MMRP) regarding pain intensity, emotional functioning, activity and physical functioning, social response, and health, with regard to sex and age. Methods: This retrospective longitudinal study was based on data from patients at 2 specialist pain clinics in northern Sweden immediately after MMRP (short-term) and at 1-year follow-up (long-term). Data from 439 patients were analysed according to sex and to age groups 18–30, 31–45 and 46–65 years. Results: The men improved with larger effect sizes (ESs) than women immediately after MMRP. The youngest age group showed improvements with greater ESs compared with the older age groups, both in the short and long term. Social support decreased for both women and men and in all 3 age groups in the long term. Improvements in both the short and long term were found in pain intensity, emotional functioning, and activity and physical functioning, in both women and men, as well as the different age groups. Conclusion: Both women and men with chronic pain, and from all of the different age groups, benefitted from MRRP. Since improvements for men were not sustained over time, they may need further support after the programme. LAY ABSTRACT This study aimed to determine the outcomes of a multimodal rehabilitation programme in sex and age groups regarding pain intensity, emotional functioning, activity and physical functioning, social response, and health. Data from 439 patients from 2 specialist pain clinics in northern Sweden were analysed according to sex and age groups 18–30, 31–45 and 46–65 years. Improvements were found in both women and men and in all age groups, in both the short and long term, regarding pain intensity, emotional functioning, and activity and physical functioning. Improvements among the men did not sustain over time to the same extent as for women. This study shows that men, women and the 3 age groups improve, both in short and long term, after a multimodal pain rehabilitation programme.

Background Patients with chronic pain who live in rural areas often need to travel long distances to participate in multimodal rehabilitation programs. To reduce traveling during the programs, patients sometimes live at a residency close to the clinic and thus far from home. Aims The aim of this study was to explore how patients with chronic pain experience participation in an multimodal rehabilitation program while living at a residency. Method Twelve patients from two specialist clinics in northern Sweden were interviewed about their experiences of participating in a multimodal rehabilitation program. The data were analyzed qualitatively using a grounded theory method with an emergent design. Results The analyses resulted in a model with the core category “finding my self-worth” consisting of four categories: “space for myself,” “mirroring myself,” “I am of value,” and “dealing with returning to everyday life.” The model illustrates the process whereby participants are given space for themselves and an opportunity to mirror themselves in interaction with other participants. That provided insight about their self-worth that was valuable for return to everyday life at home and work. Conclusion Living at a residency during multimodal rehabilitation provided added value when patients were relived from the obligations of everyday life at home and given time for reflection and interaction with others in similar situations. This contributed to awareness of their own value and the necessity of taking care of themselves. This new insight led to increased motivation to act differently at home.

Objective Interdisciplinary pain rehabilitation (IPR) usually employs a cognitive–behavioural therapeutic (CBT) approach. However, there is growing support for chronic pain treatments based on acceptance and commitment therapy (ACT). Most studies of ACT and CBT for chronic pain have evaluated their effects after psychological interventions, not after IPR. We compared the results of an ACT-based IPR programme with two CBT-based IPR programmes. Methods We used a retrospective multicentre pretest–posttest design with matched patient groups at three centres. Data were collected from the Swedish Quality Registry for Pain Rehabilitation before and after IPR participation. Participants completed the EQ-5D health-related quality of life questionnaire, the Chronic Pain Acceptance Questionnaire, (CPAQ) and the Hospital Anxiety and Depression Scale (HADS). Analyses were performed to compare the effects of the different interventions. Results Neither EQ-5D nor HADS depression scores were affected by the psychological approach used. The score changes on both CPAQ subscales (activity engagement and pain willingness) indicated significant improvements between admission and discharge at all centres. Conclusions These findings indicate the effectiveness of using psychological approaches to manage chronic pain. Both CBT and ACT had a beneficial effect on most of the assessed health-related parameters.

Objectives: To investigate: (i) changes in sick-leave benefits from 1 year prior to multimodal rehabilitation to 1 and 2 years after rehabilitation; (ii) sex differences in sick leave; and (iii) the impact of policy changes on sick leave. Methods: All patients undergoing multimodal rehabilitation registered in a national pain database for 2007-11 (n = 7,297) were linked to the Swedish Social Insurance Agency database. Sick leave was analysed in 3-month periods: T0: 1 year before rehabilitation; T1: before start; T2: 1 year after; and T3: 2 years after rehabilitation. Four sick-leave benefit categories were constructed: no sick leave, part-time sick leave, full-time sick leave, and full-time permanent sick leave. The individual change in sick-leave category at each time-period was analysed. Results: Sick-leave benefits increased from T0 to T1 (p < 0.001) and decreased from T1 to T3 (p < 0.001). Reductions were significant for both men and women from T1 to T3, but men had less sick-leave benefits at T2 and T3. Positive changes in sick-leave benefits at T2 and T3 were found both prior to and after policy changes, with less sick-leave benefits after policy changes at all time-points. Conclusion: Multimodal rehabilitation may positively influence sick-leave benefits for patients with chronic pain, regardless of their sick-leave situation, sex or policy changes.

Abstract Background Many studies have been performed to identify important prognostic factors for outcomes after rehabilitation of patients with chronic pain, and there is a need to synthesize them through systematic review. In this process, it is important to assess the study quality and risk of bias. The “Quality In Prognosis Studies” (QUIPS) tool has been developed for this purpose and consists of several prompting items categorized into six domains, and each domain is judged on a three-grade scale (low, moderate or high risk of bias). The aim of the present study was to determine the interrater agreement of the risk of bias assessment in prognostic studies of patients with chronic pain using QUIPS and to elaborate on the use of this instrument. Methods We performed a systematic review and a meta-analysis of prognostic factors for long-term outcomes after multidisciplinary rehabilitation in patients with chronic pain. Two researchers rated the risk of bias in 43 published papers in two rounds (15 and 28 papers, respectively). The interrater agreement and Cohen’s quadratic weighted kappa coefficient (κ) and 95% confidence interval (95%CI) were calculated in all domains and separately for the first and second rounds. Results The raters agreed in 61% of the domains (157 out of 258), with similar interrater agreement in the first (59%, 53/90) and second rounds (62%, 104/168). The overall weighted kappa coefficient (kappa for all domains and all papers) was weak: κ = 0.475 (95%CI = 0.358–0.601). A “minimal agreement” between the raters was found in the first round, κ = 0.323 (95%CI = 0.129–0.517), but increased to “weak agreement” in the second round, κ = 0.536 (95%CI = 0.390–0.682). Conclusion Despite a relatively low interrater agreement, QUIPS proved to be a useful tool in assessing the risk of bias when performing a meta-analysis of prognostic studies in pain rehabilitation, since it demands of raters to discuss and investigate important aspects of study quality. Some items were particularly hard to differentiate in-between, and a learning phase was required to increase the interrater agreement. This paper highlights several aspects of the tool that should be kept in mind when rating the risk of bias in prognostic studies, and provides some suggestions on common pitfalls to avoid during this process. Trial registration PROSPERO CRD42016025339; registered 05 February 2016.

Background: The long-term impact of transient ischaemic attack is largely unknown. Objectives: To assess the long-term perceived impact of transient ischaemic attack and explore the influence of sex and age on these perceptions; and to evaluate the relationships between activities of daily living, participation and overall recovery, and the other domains of the Stroke Impact Scale 3.0 (SIS). Methods: A retrospective study among adult community-dwelling individuals from 6 months up to 10 years after onset of transient ischaemic attack. A total of 299 survivors of transient ischaemic attack responded to the SIS. Results: Most self-reported disabilities involved emotion, strength, and participation domains of SIS and remained stable until 10 years post-transient ischaemic attack. Women reported significantly more disabilities for emotion and hand function. Elderly subjects (age > 65 years) reported more disabilities for strength, mobility, hand function, activities of daily living/instrumental activities of daily living, and participation. The activities of daily living/instrumental activities of daily living, participation, and overall recovery demonstrated significant, although low-to-moderate, associations with other SIS domains after transient ischaemic attack. Conclusion: The broadly perceived disabilities were demonstrated consistently and played a significant meaningful role in everyday life and recovery among community-dwelling individuals up to 10 years after a transient ischaemic attack. These findings indicate the need for long-term multi-professional follow-up with holistic rehabilitation to improve overall recovery among survivors of transient ischaemic attack.

Objective: To describe the organization, content and dosage of interdisciplinary pain rehabilitation, and the differences in degree of severity of problems of patients admitted to clinical units reporting to a Swedish national quality pain registry, grouped according to unit size and possible affiliation with a university hospital. Methods: Reports from 31 out of 39 clinical units in Sweden, on inclusion processes, organization, content and dosage of interdisciplinary pain rehabilitation, and patient-reported data from a Swedish national quality pain registry at assessment for interdisciplinary pain rehabilitation were analysed. Results: the number of patients treated annually at each unit ranged from 3 to 340. In 17 units, teams comprised 5 professionals. Dosage of interdisciplinary pain rehabilitation ranged from 20–180 h per patient in total. Patients at the university-hospital units scored the highest levels of symptoms and lowest levels of health-related quality of life. Units used similar sets of inclusion criteria, and several treatments, such as education, self-training and psychological interventions, were used by most units. Conclusion: When interpreting outcome data from registries, aspects other than rehabilitation outcomes must be considered. The interpretation of outcomes from quality registries would be facilitated if data, in addition to assessments and patient-reported outcomes, also includes standardized descriptions of the reporting clinical units.

Objectives: To investigate the outcomes one year after multimodal rehabilitation programmes in primary care for patients with chronic pain, both as a whole and for men and women separately. A second aim was to identify predictive factors for not being on sickness absence at follow-up after one year. Methods: A prospective longitudinal cohort study of 234 patients, 34 men and 200 women, age range 18–65 years, who participated in multimodal rehabilitation programmes in primary care in 2 Swedish county councils. Pain, physical and emotional functioning, coping, health-related quality of life, work-related factors, sickness absence (sick leave, sickness compensation/disability pension) were evaluated prior to and one year after multimodal rehabilitation programmes. Results: Patients showed significant improvements at 1-year follow-up for all measures (all p ≤ 0.004) except satisfaction with vocation (p = 0.060). The proportion of patients on sick leave decreased significantly at follow-up (p = 0.027), while there was no significant difference regarding the proportion of patients on sickness compensation/disability pension (p = 0.087). Higher self-rated work ability was associated with not being on sickness absence at 1-year follow-up (odds ratio (OR) 1.19, 95% confidence interval (CI) 1.21–1.06, p = 0.005). Conclusion: This study indicates that multimodal rehabilitation programmes in primary care could be beneficial for patients with chronic pain, since the outcomes at 1-year follow-up for pain, physical and emotional functioning, coping, and health-related quality of life were positive. However, the effect sizes were small and thus further development of multimodal rehabilitation programmes is warranted in order to improve the outcomes.

Objective: To evaluate patient-reported outcome measures in 2 different multimodal pain rehabilitation programmes and to determine whether outcomes are related to sex or age at 1-year follow-up. Design: Longitudinal retrospective study. Subjects: Patients who had participated in 1 of 2 multimodal pain rehabilitation programmes at 2 rehabilitation centres. A total of 356 women and 83 men, divided into 3 age groups. Methods: Data from the Swedish Quality Registry for Pain Rehabilitation regarding activity and physical functions, pain intensity, health status and emotional functions analysed with descriptive statistics. Results: Significant improvements in activity and physical functions, pain intensity and emotional func-tions were found in both multimodal pain rehabilitation programmes. Women improved more than men. The older group improved in all emotional functions (depression, anxiety, mental component summary), while the younger group improved only in depression. The intermediate group improved in all variables except anxiety. Conclusion: Patients improved regardless of the design of the multimodal pain rehabilitation programme. Although only small differences were found between men and women and among the 3 age groups in terms of the measured variables, these findings may have clinical relevance and indicate a need to vary the design of the interventions in multimodal rehabilitation programmes for these subgroups.

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

Abstract Background Chronic musculoskeletal pain is a major public health problem. Early prediction for optimal treatment results has received growing attention, but there is presently a lack of evidence regarding what information such proactive management should be based on. This study protocol, therefore, presents our planned systematic review and meta-analysis on important predictive factors for health and work-related outcomes following multidisciplinary rehabilitation (MDR) in patients with chronic musculoskeletal pain. Methods We aim to perform a synthesis of the available evidence together with a meta-analysis of published peer-reviewed original research that includes predictive factors preceding MDR. Included are prospective studies of adults with benign, chronic (> 3 months) musculoskeletal pain diagnoses who have taken part in MDR. In the studies, associations between personal and rehabilitation-based factors and the outcomes of interest are reported. Outcome domains are pain, physical functioning including health-related quality of life, and work ability with follow-ups of 6 months or more. We will use a broad, explorative approach to any presented predictive factors (demographic, symptoms-related, physical, psychosocial, work-related, and MDR-related) and these will be analyzed through (a) narrative synthesis for each outcome domain and (b) if sufficient studies are available, a quantitative synthesis in which variance-weighted pooled proportions will be computed using a random effects model for each outcome domain. The strength of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation. Discussion The strength of this systematic review is that it aims for a meta-analysis of prospective cohort or randomized controlled studies by performing an extensive search of multiple databases, using an explorative study approach to predictive factors, rather than building on single predictor impact on the outcome or on predefined hypotheses. In this way, an overview of factors central to MDR outcome can be made and will help strengthen the evidence base and inform a wide readership including health care practitioners and policymakers. Systematic review registration PROSPERO CRD42016025339

Will life satisfaction among international students change after having an experience of studying abroad? Some previous studies indicate inequalities and issues of social mobility embedded in international student mobility. International student mobility implies physical movement and new experiences gained while studying abroad. The ubiquity of international students and their generally successful adaptation makes it necessary to understand how they manage to turn a seemingly difficult situation into satisfying adaptation. One area of such concern that this study sought to explore was the students’ level of satisfaction with life. This study investigated the self-reported life satisfaction of inbound university students upon arrival to a university in northern Sweden and at follow-up six months later. After the study period abroad, the students’ levels of perceived satisfaction with their somatic health and activities of daily living had significantly increased. Higher levels, while non-significant, were found for the domains life as a whole, study situation and economy. These findings may indicate that studying abroad could have an impact on students’ reported life satisfaction, which highlights the value of a period of studying abroad. However, when exploring life satisfaction outcomes among internationally mobile students, it seems pertinent to study student mobility within a context. This study mostly targets international student mobility in a Western/European context.

Aim. To assess the clinical course of disability, cognitive, and emotional impairments in patients with severe TBI (s-TBI) from 3 months to up to 7 years post trauma. Methods. A prospective cohort study of s-TBI in northern Sweden was conducted. Patients aged 18-65 years with acute Glasgow Coma Scale 3-8 were assessed with the Glasgow Outcome Scale Extended (GOSE), the Hospital Anxiety and Depression Scale (HADS), and the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) at 3 months, 1 year, and 7 years after the injury. Results. The scores on both GOSE and BNIS improved significantly from 3 months (GOSE mean: 4.4±2.3, BNIS mean: 31.5±7.0) to 1 year (GOSE mean: 5.5±2.7, p=0.003, BNIS mean: 33.2±6.3, p=0.04), but no significant improvement was found from 1 year to 7 years (GOSE mean: 4.7±2.8, p=0.13, BNIS mean: 33.5±3.9, p=0.424) after the injury. The BNIS subscale “speech/language” at 1 year was significantly associated with favourable outcomes on the GOSE at 7 years (OR=2.115, CI: 1.004-4.456, p=0.049). Conclusions. These findings indicate that disability and cognition seem to improve over time after s-TBI and appear to be relatively stable from 1 year to 7 years. Since cognitive function on some of the BNIS subscales was associated with outcome on the GOSE, these results indicate that both screening and follow-up of cognitive function could be of importance for the rehabilitation of persons with s-TBI.

Background: Long-term musculoskeletal pain is common, particularly among women. Pain conditions are a concern in primary health care, and people with severe and complex pain are referred to specialty health care. There is gender bias in access, counselling, assessment, and treatment of long-term pain. Objective: This study explores patient accounts and perceptions about important (social) factors for accessing specialised pain rehabilitation from gender and intersectional equality perspectives. We aimed to identify potential biases and inequalities in accessing rehabilitation resources at a specialised rehabilitation clinic. Design: Individual semi-structured interviews were conducted with 10 adults after an assessment or completion of a specialised rehabilitation programme in northern Sweden. Qualitative content analysis was used to explore patients’ perceptions of important factors for accessing rehabilitation. Results: One main theme was formulated as Access to rehab – not a given. Three categories of perceived inequality were demonstrated: power of gender, power of social status, and power of diagnosis. Participants perceived rehabilitation as a resource that is not equally available, but dependent on factors such as gender, socio-economic status, ability to work, ethnicity, or age, and more subtle aspects of social status and habitus (e.g. appearance, fitness, and weight). The character of diagnosis received (medical versus psychiatric or social) was also noted. Conclusions: It is crucial that professionals are aware of how potential inequalities related to gender, social status, and diagnosis, and their intersections, can be created, perceived, and have influence on the processes of assessment and treatment. Reduction of social determinants of health and biases remain important within global, national, and local contexts.

OBJECTIVE:There is a need for tools addressing gender inequality in the everyday clinical work in health care. The aim of our paper was to develop a tool for increasing the awareness of gendered and intersectional processes in clinical assessment of patients, based on a study of pain rehabilitation. METHODS:In the overarching project named "Equal care in rehabilitation" we used multiple methods (both quantitative and qualitative) in five sub studies. With a novel approach we used Grounded Theory in order to synthesize the results from our sub studies, in order to develop the gender equality tool. The gender equality tool described and developed in this article is thus based on results from sub studies about the processes of assessment and selection of patients in pain rehabilitation. Inspired by some questions in earlier tools, we posed open ended questions and inductively searched for findings and concepts relating to gendered and social selection processes in pain rehabilitation, in each of our sub studies. Through this process, the actual gender equality tool was developed as 15 questions about the process of assessing and selecting patients to pain rehabilitation. As a more comprehensive way of understanding the tool, we performed a final step of the GT analyses. Here we synthesized the results of the tool into a comprehensive model with two dimensions in relation to several possible discrimination axes. RESULTS:The process of assessing and selecting patients was visualized as a funnel, a top down process governed by gendered attitudes, rules and structures. We found that the clinicians judged inner and outer characteristics and status of patients in a gendered and intersectional way in the process of clinical decision-making which thus can be regarded as (potentially) biased with regard to gender, socio-economic status, ethnicity and age. IMPLICATIONS:The clinical implications of our tool are that the tool can be included in the systematic routine of clinical assessment of patients for both awareness raising and as a base for avoiding gender bias in clinical decision-making. The tool could also be used in team education for health professionals as an instrument for critical reflection on gender bias. CONCLUSIONS:Thus, tools for clinical assessment can be developed from empirical studies in various clinical settings. However, such a micro-level approach must be understood from a broader societal perspective including gender relations on both the macro- and the meso-level.

Britt-Marie Stålnacke, Anna ÖstmanDepartment of Community Medicine and Rehabilitation, Umeå University, SwedenAim: To investigate post-traumatic stress, pain intensity, depression, and anxiety in patients with injury-related chronic pain before and after participating in multimodal pain rehabilitation.Methods: Twenty-eight patients, 21 women and seven men, who participated in the multimodal rehabilitation programs (special whiplash program for whiplash injuries within 1.5 years after the trauma or ordinary program) answered a set of questionnaires to assess post-traumatic stress (Impact of Event Scale [IES], pain intensity [Visual Analogue Scale (VAS)], depression, and anxiety (Hospital Anxiety and Depression Scale [HAD] before and after the programs.Results: Both pain intensity and post-traumatic stress decreased significantly after the rehabilitation programs in comparison with before (VAS: 57.8 ± 21.6 vs. 67.5 ± 21.9; P = 0.009, IES total score 21.8 ± 13.2 vs. 29.5 ± 12.9; P < 0.001). Patients younger than 40 years reported a statistically higher level of post-traumatic stress compared with patients older than 40 years both before (P = 0.037) and after rehabilitation (P = 0.023). No statistically significant differences were found on the HAD scores.Conclusion: The multimodal rehabilitation programs were effective in reducing both pain intensity and post-traumatic stress. The experience of higher levels of post-traumatic stress in younger persons has to be taken into account when managing patients with injury-related chronic pain.Keywords: post-traumatic, stress disorder, chronic pain, whiplash injuries

Anna Wenngren, Britt-Marie StålnackeDepartment of Community Medicine and Rehabilitation, Umeå University, SwedenAim: To investigate if pain area in patients with chronic pain could be measured by a computerized assessment on previously marked pain drawings on paper figures and to analyze the further application of the method.Methods: Seventy-two patients (54 women and 18 men) who were admitted to Umeå University Hospital during 2003 for assessment of chronic pain answered a set of questionnaires (pain intensity on the visual analog scale [VAS], disability on the Disability Rating Index [DRI], life satisfaction on the LiSat-11) and filled in pain drawings on paper figures of the human body. The pain drawings were later analyzed by using computerized assessment.Results: Women marked a greater pain area than men, but the difference was not significant (p = 0.433). No significant difference was shown for the previous seven days between men and women on the VAS (p = 0.914), DRI (p = 0.493), or LiSat-11 (p = 0.124). A statistically significant correlation was found between pain area and VAS for the previous seven days (r = 0.250; p = 0.046). Pain area was statistically significantly correlated to the DRI (r = 0.336; p = 0.014) and close to negatively correlated to the LiSat-11 (r = -0.687; p = 0.057).Conclusion: This pilot study shows that pain drawing area could be measured by a computerized assessment of pain drawings. The method points to the possibility of relating pain area with other instruments. In the present study, an association between the patients’ pain drawing area and pain intensity and between pain area and level of activity was shown.Keywords: musculoskeletal pain, screening, pain drawing, computerized assessment

Sofia Åhman, Britt-Marie StålnackeDepartment of Community Medicine and Rehabilitation, Umeå University, SwedenAim: To investigate, in patients with injury-related chronic pain, pain intensity, levels of post-traumatic stress, anxiety and depressions.Methods: One hundred and sixty patients aged 17–62 years, admitted for assessment to the Pain Rehabilitation Clinic at the Umeå University Hospital, Umeå Sweden, for chronic pain caused by an injury, answered a set of questionnaires to assess post-traumatic stress (Impact of Event Scale [IES]), pain intensity (VAS), depression, and anxiety (Hospital Anxiety and Depression Scale [HAD]).Results: Moderate to severe post-traumatic stress was reported by 48.1% of the patients. Possible–probable anxiety on the HAD was scored by 44.5% and possible–probable depression by 45.2%. Pain intensity (VAS) was significantly correlated to post-traumatic stress (r = 0.183, p = 0.022), the HAD-scores anxiety (r = 0.186, p = 0.0021), and depression (r = 0.252, p = 0.002). No statistically significant differences were found between genders for post-traumatic stress, pain intensity, anxiety, or depression. Participants with moderate to severe stress reaction reported statistically significant higher anxiety scores on the HAD (p = 0.030) in comparison with patients with mild stress.Conclusion: The findings of relationships between pain intensity, post-traumatic stress, depression, and anxiety may have implications for clinicians and underline the importance of considering all these factors when managing patients with injury-related chronic pain.Keywords: post-traumatic stress disorder, anxiety, chronic pain

Objectives: The aim of the study was to analyse whether the controlled heading of soccer balls elicits increased serum concentrations of a biochemical marker of brain tissue damage S-100B.Methods: Nineteen male soccer players were randomly divided into two groups, A and B. Group A headed a soccer ball falling from 18 m five times, while group B served as controls (no heading). Blood samples were taken before and 0.5 h, 2 h and 4 h after the heading for analysis of S-100B.Results: No statistically significant (p > 0.05) increases in serum concentrations of S-100B were encountered in group A at 0.5 h (0.109 ± 0.024 μg/L), 2 h (0.098 ± 0.026 μg/L), and 4 h (0.113 ± 0.035 μg/L) when the blood samples obtained before and after the heading were compared (0.157 ± 0.134 μg/L). No statistically significant difference was found when the serum concentrations of S-100B were compared between groups A and B either before or after heading.Conclusions: Heading a soccer ball dropped from a height of 18 m five times was not found to cause an increase in serum concentrations of S-100B, indicating that the impact was not sufficient to cause biochemically discernible damage of brain tissue.

Objective. To assess the clinical course of cognitive and emotional impairments in patients with severe TBI (sTBI) from 3 weeks to 1 year after trauma and to study associations with outcomes at 1 year. Methods. Prospective, multicenter, observational study of sTBI in Sweden and Iceland. Patients aged 18–65 years with acute Glasgow Coma Scale 3–8 were assessed with the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) and the Hospital Anxiety and Depression Scale (HADS). Outcome measures were Glasgow Outcome Scale Extended (GOSE) and Rancho Los Amigos Cognitive Scale-Revised (RLAS-R). Results. Cognition was assessed with the BNIS assessed for 42 patients out of 100 at 3 weeks, 75 patients at 3 months, and 78 patients at 1 year. Cognition improved over time, especially from 3 weeks to 3 months. The BNIS subscales “orientation” and “visuospatial and visual problem solving” were associated with the GOSE and RLAS-R at 1 year. Conclusion. Cognition seemed to improve over time after sTBI and appeared to be rather stable from 3 months to 1 year. Since cognitive function was associated with outcomes, these results indicate that early screening of cognitive function could be of importance for rehabilitation planning in a clinical setting.

BACKGROUND: There is a lack of research about a potential education-related bias in assessment of patients with chronic pain. The aim of this study was to analyze whether low-educated men and women with chronic pain were less often selected to multidisciplinary rehabilitation than those with high education. METHODS: The population consisted of consecutive patients (n = 595 women, 266 men) referred during a three-year period from mainly primary health care centers for a multidisciplinary team assessment at a pain rehabilitation clinic at a university hospital in Northern Sweden. Patient data were collected from the Swedish Quality Registry for Pain Rehabilitation National Pain Register. The outcome variable was being selected by the multidisciplinary team assessment to a multidisciplinary rehabilitation program. The independent variables were: sex, age, born outside Sweden, education, pain severity as well as the hospital, anxiety and depression scale (HADS). RESULTS: Low-educated women were less often selected to multidisciplinary rehabilitation programs than high-educated women (OR 0.55, CI 0.30-0.98), even after control for age, being born outside Sweden, pain intensity and HADS. No significant findings were found when comparing the results between high- and low-educated men. CONCLUSION: Our findings can be interpreted as possible discrimination against low-educated women with chronic pain in hospital referrals to pain rehabilitation. There is a need for more gender-theoretical research emphasizing the importance of taking several power dimensions into account when analyzing possible bias in health care.

Psychological factors such as post-traumatic stress and depression may play an important role in the recovery after whiplash injuries. Difficulties in psychosocial functioning with limitations in everyday life may dominate for some time after the injury. Our study therefore investigates the relationships between pain, post-traumatic stress, depression, and community integration. A set of questionnaires was answered by 191 persons (88 men, 103 women) five years after a whiplash injury to assess pain intensity (visual analogue scale, VAS), whiplash-related symptoms, post-traumatic stress (impact of event scale, IES), depression (Beck depression inventory, BDI-II), community integration (community integration questionnaire, CIQ), life satisfaction (LiSat-11). One or more depressive symptoms were reported by 74% of persons; 22% reported scores that were classified as mild to severe depression. The presence of at least one post-traumatic symptom was reported by 70% of persons, and 38% reported mild to severe stress. Total scores of community integration for women were statistically significantly higher than for men. The total VAS score was correl-ated positively to the IES (r=0.456, P less than 0.456), the BDI (r=0.646, P less than 0.001), and negatively to the CIQ (r=-0.300, P less than 0.001). These results highlight the view that a significant proportion of people experience both pain and psycho- logical difficulties for a long time after a whiplash injury. These findings should be taken into consideration in the management of subjects with chronic whiplash symptoms and may support a multi-professional rehabilitation model that integrates physical, psychological, and psychosocial factors.

Objectives The aim of the study was to analyse whether the controlled heading of soccer balls elicits increased serum concentrations of a biochemical marker of brain tissue damage S-100B. Methods Nineteen male soccer players were randomly divided into two groups, A and B. Group A headed a soccer ball falling from 18 m five times, while group B served as controls (no heading). Blood samples were taken before and 0.5 h, 2 h and 4 h after the heading for analysis of S-100B. Results No statistically significant (p > 0.05) increases in serum concentrations of S-100B were encountered in group A at 0.5 h (0.109 ± 0.024 μg/L), 2 h (0.098 ± 0.026 μg/L), and 4 h (0.113 ± 0.035 μg/L) when the blood samples obtained before and after the heading were compared (0.157 ± 0.134 μg/L). No statistically significant difference was found when the serum concentrations of S-100B were compared between groups A and B either before or after heading. Conclusions Heading a soccer ball dropped from a height of 18 m five times was not found to cause an increase in serum concentrations of S-100B, indicating that the impact was not sufficient to cause biochemically discernible damage of brain tissue.