Physiotherapy in primary care for working-age patients with early back and neck pain. Screening tools, interventions and outcomes.

Patients with back and neck pain are frequently seen in primary care, where they are directed to physiotherapy as first-line treatment. The condition affects both the individual, by causing pain and disability, and society, because of high costs caused by work disability and health care consumption. Clinicians need tools to identify, at an early stage, patients at risk of poor outcome, in order to tailor interventions. We also need more knowledge about what interventions can promote work ability and prevent long-term disability. The overall aim of this thesis was to obtain deeper knowledge on health care interventions in primary care for working-age patients with acute or subacute back and neck pain, by studying screening tools, physiotherapy interventions and self-reported outcomes regarding function, health-related quality of life and work ability.Methods: Study I was a cross-sectional validation study where we compared the concurrent validity of the STarT Back Tool (SBT) and the ÖMPSQ-short form questionnaires, including psychometric properties and clinical utility, for patients with acute or subacute back and/or neck pain (n=315). Study II was a prospective psychometric validation study where we studied the predictive validity of the SBT for the outcomes work ability and health-related quality of life at long-term follow-up (n=238). Study III was a secondary analysis of self-reported function, health-related quality of life and work ability, in a prospective cluster-randomised controlled trial (WorkUp) with one-year follow-up (n=352). The intervention was a workplace dialogue (CDM) as an add-on to structured physiotherapy treatment. Study IV was a descriptive cohort study nested within the WorkUp trial where we described type and number of physiotherapy interventions provided for patients with neck and back pain at risk of work disability. We also examined whether patients in the intervention group received more occupational medicine interventions (n=343). Results and Conclusions: The correlations between the SBT and the ÖMPSQ-short scores were moderately strong for individuals with acute or subacute back and/or neck pain, and the SBT was feasible to use in clinical practice. We therefore suggest that SBT can be used in primary care to identify individuals with both back and neck pain at risk of long-term pain and disability. We found that the SBT also can be used to identify patients at risk for a poor long-term health-related quality of life and/or work ability outcome in a population with acute or subacute back and/or neck pain. We found no effect of the CDM, as an add-on to structured physiotherapy, on self-reported function, health-related quality of life and work ability (point prevalence) at the 12-months follow-up. All self-reported outcomes improved over time in both the intervention and the reference group. We found that patients with neck and back pain at risk of work disability were offered many different types of interventions in primary care, with physical exercise being the most frequently used treatment category. Patients in the intervention group received more occupational medicine-oriented interventions than patients in the reference group. This thesis has deepened the knowledge on health care interventions in primary care for working-age patients with acute or subacute back and neck pain. The Swedish STarT Back Tool, a brief screening tool designed for tailored interventions based on risk stratification/triage, has been validated for individuals with acute or subacute back and neck pain in primary care. Long-term effects of a workplace dialogue as an add-on to structured physiotherapy on self-reported measures have been evaluated. The broad spectrum of interventions used by primary care physiotherapists for patients with back and neck pain in working-age are described

Long-term effects on function, health-related quality of life and work ability after structured physiotherapy including a workplace intervention. : A secondary analysis of a randomised controlled trial (WorkUp) in primary care for patients with neck and/or back pain

Objective: To study the long-term effects of a workplace intervention in addition to structured physiotherapy regarding self-reported measures in patients with acute/subacute neck and/or back pain. Design: WorkUp – a cluster-randomised controlled trial in 32 primary care centers in Sweden, from January 2013 through December 2014 (ClinicalTrials.gov ID: NCT02609750). Intervention: Structured physiotherapy with the workplace dialogue ‘Convergence Dialogue Meeting’ (CDM), conducted by the treating physiotherapist as an add-on. Reference group received structured physiotherapy. Subjects: Adults, 18–67 years (mean 43.7, standard deviation (SD) 12.2), 65.3% women with acute/subacute neck and/or back pain who had worked ≥4 weeks past year, considered at risk of sick leave or were on short-term sick leave (≤60 days) were included (n = 352).Outcome measures: Self-reported function, functional rating index (FRI), health-related quality of life (EQ-5D-3L) and work ability (Work Ability Score, WAS) at 12 months follow-up. Results: The mean differences in outcomes between intervention and reference group were; −0.76 (95% confidence interval (CI): −2.39, 0.88; FRI), 0.02 (95% CI: −0.04, 0.08; EQ-5D-3L) and −0.05 (95% CI: −0.63, 0.53; WAS). From baseline to 12 months, the intervention group improved function from 46.5 (SD 19.7) to 10.5 (SD 7.3) on FRI; health-related quality of life from 0.53 (SD 0.29) to 0.74 (SD 0.20) on EQ-5D and work ability from 5.7 (SD 2.6) to 7.6 (SD 2.1) on WAS. Conclusion: Despite a clinically relevant improvement over time, there were no significant differences in improvement between groups, thus we conclude that CDM had no effect on self-reported measures in this study

Problem-based learning with digitals tools in the nursing programme during the Covid-19 pandemic

During the spring 2019, the prerequisites for conducting education were changed due to the pandemic. For higher education in Sweden almost all education switches on to digital education. Nursing education has focus on both theoretical and practical courses, which is a challenge for digital or distance education. Furthermore, the nursing programme at the studied university used problem-based learning (PBL), with base-groups at campus. Instead of physical meetings at campus, the base-groups took part with digital tools. The impact of base-groupsmeeting with digital tools are important to reflect on, especially since the education and learning of future probably will be more hybrid. © 2022 Christel Borg, Johanna Tell, Terese Lindberg, Lina Nilsson, Anki Olsson, Malin Forsbrand & Lisa Skär

"Blue flags", development of a short clinical questionnaire on work-related psychosocial risk factors : A validation study in primary care

Background: Working conditions substantially influence health, work ability and sick leave. Useful instruments to help clinicians pay attention to working conditions are lacking in primary care (PC). The aim of this study was to test the validity of a short "Blue flags" questionnaire, which focuses on work-related psychosocial risk factors and any potential need for contacts and/or actions at the workplace. Methods: From the original"The General Nordic Questionnaire" (QPSNordic) the research group identified five content areas with a total of 51 items which were considered to be most relevant focusing on work-related psychosocial risk factors. Fourteen items were selected from the identified QPSNordic content areas and organised in a short questionnaire "Blue flags". These 14 items were validated towards the 51 QPSNordic items. Content validity was reviewed by a professional panel and a patient panel. Structural and concurrent validity were also tested within a randomised clinical trial. Results: The two panels (n = 111) considered the 14 psychosocial items to be relevant. A four-factor model was extracted with an explained variance of 25.2%, 14.9%, 10.9% and 8.3% respectively. All 14 items showed satisfactory loadings on all factors. Concerning concurrent validity the overall correlation was very strong rs = 0.87 (p &lt; 0.001).). Correlations were moderately strong for factor one, rs = 0.62 (p &lt; 0.001) and factor two, rs = 0.74 (p &lt; 0.001). Factor three and factor four were weaker, bur still fair and significant at rs = 0.53 (p &lt; 0.001) and rs = 0.41 (p &lt; 0.001) respectively. The internal consistency of the whole "Blue flags" was good with Cronbach's alpha of 0.76. Conclusions: The content, structural and concurrent validity were satisfactory in this first step of development of the "Blue flags" questionnaire. In summary, the overall validity is considered acceptable. Testing in clinical contexts and in other patient populations is recommended to ensure predictive validity and usefulness.Validerad; 2017; Nivå 2; 2017-08-15 (andbra)</p

Early workplace dialogue in physiotherapy practice improved work ability at 1-year follow-up-WorkUp, a randomised controlled trial in primary care

Workplace involvement in rehabilitation for patients with musculoskeletal pain may improve work ability. Convergence Dialogue Meeting (CDM) is a model aimed at helping the patient, the care giver, and the employer to support work ability and return-to-work. Our aim was to study the effect on work ability when adding a workplace dialogue according to CDM in physiotherapy practice for patients with pain in ordinary primary care. We conducted a prospective pairwise cluster randomised controlled trial (ClinicalTrials.gov ID: NCT02609750) in primary care involving 20 primary care rehabilitation units with 1-year follow-up. Adult patients with acute/subacute neck and back pain, worked ≥4 weeks past year and not currently on sick leave or no more than 60 days of sick leave and considered at-risk of sick leave were included (n = 352). All patients received structured physiotherapy and the intervention was the addition of CDM, delivered by the treating physiotherapist. The main confirmatory outcome, work ability (defined as working at least 4 consecutive weeks at follow-up), was assessed by a weekly short text message question on number of sick leave days past week. Work ability was reached by significantly more patients in the intervention group (108/127, 85%) compared with the reference group (127/171, 74%) (P = 0.02). The intervention increased the odds of having work ability at 1-year follow-up, also after adjustment for baseline health-related quality of life (odds ratio 1.85, confidence interval 1.01-3.38). We conclude that an early workplace dialogue in addition to structured physiotherapy improved work ability significantly

Referring to multimodal rehabilitation for patients with musculoskeletal disorders - a register study in primary health care

BACKGROUND: In 2008, the Swedish government introduced a National Rehabilitation Program, in which the government financially reimburses the county councils for evidence-based multimodal rehabilitation (MMR) interventions. The target group is patients of working age with musculoskeletal disorders (MSD), expected to return to work or remain at work after rehabilitation. Much attention in the evaluations has been on patient outcomes and on processes. We lack knowledge about how factors related to health care providers and community can have an impact on how patients have access to MMR. The aim of this study was therefore to study the impact of health care provider and community related factors on referrals to MMR in patients with MSD applying for health care in primary health care.METHODS: This was a primary health care-based cohort study based on prospectively ascertained register data. All primary health care centres (PHCC) contracted in Region Skåne in 2010-2012, referring to MMR were included (n = 153). The health care provider factors studied were: community size, PHCC size, public or private PHCC, whether or not the PHCCs provided their own MMR, burden of illness and the community socioeconomic status among the registered population at the PHCCs. The results are presented with descriptive statistics and for the analysis, non-parametric and multiple linear regression analyses were applied.RESULTS: PHCCs located in larger communities sent more referrals/1000 registered population (p = 0.020). Private PHCCs sent more referrals/1000 registered population compared to public units (p = 0.035). Factors related to more MMR referrals/1000 registered population in the multiple regression analyses were PHCCs located in medium and large communities and with above average socioeconomic status among the registered population at the PHCCs, private PHCC and PHCCs providing their own MMR. The explanation degree for the final model was 24.5%.CONCLUSIONS: We found that referral rates to MMR were positively associated with PHCCs located in medium and large sized communities with higher socioeconomic status among the registered population, private PHCCs and PHCCs providing their own MMR. Patients with MSD are thus facing significant inequities and were thus not offered the same opportunities for referrals to rehabilitation regardless of which PHCC they visited