by Chan Kwai Foon May. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2000. / Includes bibliographical references (leaves 103-114). / Abstracts in English and Chinese. / Declaration --- p.2 / Abstract --- p.3 / Abstract in Chinese --- p.6 / Acknowledgements --- p.8 / Chapter Chapter 1. --- Introduction --- p.15 / Chapter Chapter 2. --- Osteoporosis : The relationship between aging and skeletal organization between men and women --- p.17 / Chapter 2.1. --- Skeletal organization --- p.17 / Chapter 2.1.1. --- Bone structure --- p.17 / Chapter 2.1.2. --- Bone metabolism --- p.17 / Chapter 2.1.3. --- Peak bone mass --- p.18 / Chapter 2.2. --- Bone loss between men and women --- p.20 / Chapter 2.2.1. --- Aging and bone loss --- p.20 / Chapter 2.2.2. --- Clinical aspects of bone loss in men and women --- p.21 / Chapter Chapter 3. --- Vertebral deformity : Bone Mineral Density and Body Composition --- p.23 / Chapter 3.1. --- Bone mineral density --- p.23 / Chapter 3.1.1. --- Types of vertebral deformity --- p.23 / Chapter 3.1.2. --- Clinical diagnosis in vertebral deformity --- p.24 / Chapter 3.1.3. --- Bone mineral density measurements --- p.25 / Chapter 3.1.4. --- Vertebral deformity and bone mineral density --- p.28 / Chapter 3.2. --- Bone composition --- p.33 / Chapter Chapter 4. --- Literature Review on Health Consequences of Vertebral Deformity --- p.36 / Chapter 4.1. --- Back pain --- p.36 / Chapter 4.1.1. --- Back pain and vertebral deformity --- p.36 / Chapter 4.1.2. --- Back pain in men and women with vertebral deformity --- p.38 / Chapter 4.2. --- Morale and functional limitation and vertebral deformities --- p.39 / Chapter 4.2.1. --- Function evaluation : The Barthel Index --- p.40 / Chapter 4.2.2. --- Philadelphia Geriatric Morale Scale --- p.41 / Chapter Chapter 5. --- Objectives --- p.43 / Chapter Chapter 6. --- "Subjects and methods for phase I: anthropometric measurement, body composition and bone mineral density measurement in vertebral deformity patients and controls" --- p.44 / Chapter 6.1. --- Study subjects --- p.44 / Chapter 6.2. --- Radiology and digitization protocol for diagnosis vertebral deformity --- p.46 / Chapter 6.3. --- Diagnosis of vertebral deformity --- p.48 / Chapter 6.4. --- Body composition and bone mineral density measurements --- p.54 / Chapter 6.4.1. --- Body composition analysis --- p.54 / Chapter 6.4.2. --- Lumbar spine and hip bone mineral analysis --- p.54 / Chapter 6.5. --- Quality control --- p.56 / Chapter 6.5.1. --- Routine quality control of measurements --- p.56 / Chapter 6.5.2. --- Precision on patient repositioning --- p.56 / Chapter Chapter 7. --- Subjects and methods for phase II: health consequences of vertebral deformity patients and controls --- p.57 / Chapter 7.1. --- Questionnaire on health consequences --- p.57 / Chapter 7.1.1 --- Back pain and disability --- p.57 / Chapter 7.1.2 --- Activities of daily living --- p.59 / Chapter 7.1.3 --- Morale --- p.59 / Chapter 7.2. --- Statistical methods --- p.60 / Chapter 7.2.1. --- Bone mineral density and body composition --- p.60 / Chapter 7.2.2. --- Back pain and disability --- p.60 / Chapter 7.2.3. --- Activities of daily living and morale --- p.61 / Chapter Chapter 8. --- "Results for phase I: anthropometric measurement, body composition and bone mineral density measurement in vertebral deformity patients and controls" --- p.62 / Chapter 8.1. --- Demographic characteristics of study population --- p.62 / Chapter 8.2. --- Anthropometric measurements : Body composition and bone mineral density --- p.64 / Chapter Chapter 9. --- Results for phase II: Health Consequences of vertebral deformity patients and control --- p.76 / Chapter 9.1. --- Back pain --- p.76 / Chapter 9.2. --- Disability --- p.78 / Chapter 9.3. --- Activities of daily living --- p.81 / Chapter 9.4. --- Morale --- p.82 / Chapter Chapter 10. --- Discussion I --- p.83 / Chapter 10.1. --- Study Sample --- p.83 / Chapter 10.2. --- Digitization method and definition of vertebral deformity --- p.84 / Chapter 10.3. --- Methods for bone mineral density measurement --- p.87 / Chapter 10.4. --- Questionnaire validity --- p.88 / Chapter 10.4.1. --- Back pain and disability --- p.88 / Chapter 10.4.2. --- Barthel Index --- p.88 / Chapter 10.4.3. --- Philadelphia Geriatric Morale Scale --- p.89 / Chapter Chapter 11. --- Discussion II --- p.92 / Chapter 11.1 . --- Body composition and bone mineral density --- p.92 / Chapter 11.2. --- Differences of vertebral deformity between Chinese men and Caucasian men --- p.93 / Chapter 11.3. --- Health consequences in Chinese men --- p.96 / Chapter 11.4. --- Comparison of health consequences between Chinese men and Caucasian men --- p.98 / Chapter 11.5. --- Variation of health consequences between Chinese men and Chinese women --- p.101 / Chapter 11.5.1. --- Back pain and disability --- p.101 / Chapter 11.5.2. --- Morale --- p.102 / Chapter Chapter 12. --- Conclusion --- p.103 / Reference --- p.104 / Appendix I --- p.115 / Appendix II Publication

<p>The objectives of this study were to determine the effects of a back education programme on biomechanical knowledge, back beliefs, the occurrence of LBP, disability, and work loss among employees at an industrial setting in Cape Town, South Africa. Furthermore, the study sought to determine the perceptions of back education that are held by industrial<br /> employees.</p>

<p>Construction manual workers are at a high risk of suffering from occupational related low back pain because of high-risk activities involved and the nomadic nature of the workforce. Low back pain and its associated disability continue to plague the construction industry. The prevalence of occupational related low back pain among manual workers in construction companies is believed to be due to high exposure to awkward postures for long hours, heavy manual work and exposure to whole-body vibration in the work environment. As a result of these risky exposures, low back pain has consistently been the leading cause of both occupational disability and absenteeism in the construction industry. The purpose of this study was to determine the effect of occupationalrelated low back pain on the functional activities of the manual workers in a construction company in Cape Town. The prevalence and the predisposing factors of low back pain among construction manual workers were established as well as the effect of occupational-related low back pain on the functional activities of the manual workers was also determined. A crosssectional descriptive study using quantitative method was utilized. A convenient sampling method was employed and all the 212 available participants at two construction settings were recruited for the study. The population was categorised into four main occupational groups / &nbsp / masons, handymen, labourers and foremen. Data was collected using a structured questionnaire as a closed ended interview guide. The questionnaire comprised of four parts. Part one was used to determine the demographic data while parts two, three and four utilised three standardizedclose-ended validated questionnaires. These are / the Nordic Musculoskeletal Disorder Questionnaire, the Profile Fitness Mapping questionnaire and the Pain and Disability Questionnaire. Data was captured and analyzed using the statistical package for social sciences (SPSS) version 17.0 spreadsheet for statistical analysis. The study was conducted under the adherence of the ethical considerations. Descriptive and inferential statistical analyses describe the association between the investigated independent variables with the occurrence of occupational related low back pain in the study. Results are presented using tables, charts and graphs. The results revealed a 25% prevalence of low back pain while the one month and one week prevalence rates were 69% and 54% respectively. Masons recorded the highest low back pain prevalence rate (58%). Initial onset of low back pain was mainly attributed to bending (48%) and load lifting (28%). The chi-square test at p&lt / 0.05 was done. The results revealed a lack of association between low back pain and the socio-demographic characteristics. Participants confirmed suffering physical, emotional, financial and functional problems with 41.5% reporting sickness absence and a mean of 4 days being lost during the past year. Further chi-square test for proportion revealed an association between low back pain and participants ‟ability to / lift (p=0.006), bend back forwards (p=0.001) and ability to bend back backwards (p=0.014). To prevent impairment, activity limitation and participation restriction among construction manual workers, a number of factors must be addressed at epidemiological level as highlighted in the recommendations of this study.</p>

<p>The objectives of this study were to determine the effects of a back education programme on biomechanical knowledge, back beliefs, the occurrence of LBP, disability, and work loss among employees at an industrial setting in Cape Town, South Africa. Furthermore, the study sought to determine the perceptions of back education that are held by industrial<br /> employees.</p>

<p>Construction manual workers are at a high risk of suffering from occupational related low back pain because of high-risk activities involved and the nomadic nature of the workforce. Low back pain and its associated disability continue to plague the construction industry. The prevalence of occupational related low back pain among manual workers in construction companies is believed to be due to high exposure to awkward postures for long hours, heavy manual work and exposure to whole-body vibration in the work environment. As a result of these risky exposures, low back pain has consistently been the leading cause of both occupational disability and absenteeism in the construction industry. The purpose of this study was to determine the effect of occupationalrelated low back pain on the functional activities of the manual workers in a construction company in Cape Town. The prevalence and the predisposing factors of low back pain among construction manual workers were established as well as the effect of occupational-related low back pain on the functional activities of the manual workers was also determined. A crosssectional descriptive study using quantitative method was utilized. A convenient sampling method was employed and all the 212 available participants at two construction settings were recruited for the study. The population was categorised into four main occupational groups / &nbsp / masons, handymen, labourers and foremen. Data was collected using a structured questionnaire as a closed ended interview guide. The questionnaire comprised of four parts. Part one was used to determine the demographic data while parts two, three and four utilised three standardizedclose-ended validated questionnaires. These are / the Nordic Musculoskeletal Disorder Questionnaire, the Profile Fitness Mapping questionnaire and the Pain and Disability Questionnaire. Data was captured and analyzed using the statistical package for social sciences (SPSS) version 17.0 spreadsheet for statistical analysis. The study was conducted under the adherence of the ethical considerations. Descriptive and inferential statistical analyses describe the association between the investigated independent variables with the occurrence of occupational related low back pain in the study. Results are presented using tables, charts and graphs. The results revealed a 25% prevalence of low back pain while the one month and one week prevalence rates were 69% and 54% respectively. Masons recorded the highest low back pain prevalence rate (58%). Initial onset of low back pain was mainly attributed to bending (48%) and load lifting (28%). The chi-square test at p&lt / 0.05 was done. The results revealed a lack of association between low back pain and the socio-demographic characteristics. Participants confirmed suffering physical, emotional, financial and functional problems with 41.5% reporting sickness absence and a mean of 4 days being lost during the past year. Further chi-square test for proportion revealed an association between low back pain and participants ‟ability to / lift (p=0.006), bend back forwards (p=0.001) and ability to bend back backwards (p=0.014). To prevent impairment, activity limitation and participation restriction among construction manual workers, a number of factors must be addressed at epidemiological level as highlighted in the recommendations of this study.</p>

Diss. (sammanfattning) Linköping : Univ., 2002. / Härtill 5 uppsatser.

Magister Scientiae (Physiotherapy) - MSc(Physio) / The objectives of this study were to determine the effects of a back education programme on biomechanical knowledge, back beliefs, the occurrence of LBP, disability, and work loss among employees at an industrial setting in Cape Town, South Africa. Furthermore, the study sought to determine the perceptions of back education that are held by industrial employees. / South Africa

Magister Scientiae (Physiotherapy) - MSc(Physio) / Construction manual workers are at a high risk of suffering from occupational related low back pain because of high-risk activities involved and the nomadic nature of the workforce. Low back pain and its associated disability continue to plague the construction industry. The prevalence of occupational related low back pain among manual workers in construction companies is believed to be due to high exposure to awkward postures for long hours, heavy manual work and exposure to whole-body vibration in the work environment. As a result of these risky exposures, low back pain has consistently been the leading cause of both occupational disability and absenteeism in the construction industry. The purpose of this study was to determine the effect of occupational related low back pain on the functional activities of the manual workers in a construction company in Cape Town. The prevalence and the predisposing factors of low back pain among construction manual workers were established as well as the effect of occupational-related low back pain on the functional activities of the manual workers was also determined. A crosssectional descriptive study using quantitative method was utilized. A convenient sampling method was employed and all the 212 available participants at two construction settings were recruited for the study. The population was categorised into four main occupational groups; masons, handymen, labourers and foremen. Data was collected using a structured questionnaire as a closed ended interview guide. The questionnaire comprised of four parts. Part one was used to determine the demographic data while parts two, three and four utilised three standardizedclose-ended validated questionnaires. These are; the Nordic Musculoskeletal Disorder Questionnaire, the Profile Fitness Mapping questionnaire and the Pain and Disability Questionnaire. Data was captured and analyzed using the statistical package for social sciences (SPSS) version 17.0 spreadsheet for statistical analysis. The study was conducted under the adherence of the ethical considerations. Descriptive and inferential statistical analyses describe the association between the investigated independent variables with the occurrence of occupational related low back pain in the study. Results are presented using tables, charts and graphs. The results revealed a 25% prevalence of low back pain while the one month and one week prevalence rates were 69% and 54% respectively. Masons recorded the highest low back pain prevalence rate (58%). Initial onset of low back pain was mainly attributed to bending (48%) and load lifting (28%). The chi-square test at p&lt; 0.05 was done. The results revealed a lack of association between low back pain and the socio-demographic characteristics. Participants confirmed suffering physical, emotional, financial and functional problems with 41.5% reporting sickness absence and a mean of 4 days being lost during the past year. Further chi-square test for proportion revealed an association between low back pain and participants ‟ability to; lift (p=0.006), bend back forwards (p=0.001) and ability to bend back backwards (p=0.014). To prevent impairment, activity limitation and participation restriction among construction manual workers, a number of factors must be addressed at epidemiological level as highlighted in the recommendations of this study. / South Africa

In der Therapie orthopädischer Erkrankungen/Verletzungen gewann in den letzten Jahren das Training im Wasser als aktive Maßnahme an Bedeutung. Auf der Suche nach Möglichkeiten einer frühfunktionellen, aber schonenden Behandlung wurde das Bewegungstraining im Wasser wieder entdeckt (vgl. Froböse/ Nellessen/ Eckey 2003, 211-29). Innenmoser (2007) betonte, dass therapeutisches Aqua-Jogging geeignet bzw. notwendig ist für Menschen mit Schädigungen, chronischen Krankheiten und mit Beeinträchtigungen bzw. Gefährdungen vor allem der körperlichen Funktionen, aber auch bei Schwächen des Stütz- u. Bewegungsapparats und chronischen Erkrankungen wie Rheuma, Wirbelsäulenschäden und auch bei „Low-Back-Pain“-Patienten. Der Bewegungsraum Wasser bietet im Vergleich zu Bewegungen an Land, aufgrund seiner besonderen physikalischen Eigenschaften (vgl. hierzu alle zitiert in: Innenmoser 2001, 27: Aschoff 1971; Klauck 1977, 1998; Stegemann 1991; Stuart 2000 u.a.), eine weitestgehende Entlastung des Stütz- und Bewegungsapparates, insbesondere bei Teilnehmern mit stark verändertem Bewegungsbild. Für viele Menschen mit körperlichen Schädigungen sind bewegungstherapeutische Maßnahmen im Wasser die einzige Möglichkeit zur Erhaltung bzw. Steigerung ihrer Leistungsfähigkeit. 2 Ziele der vorliegenden Untersuchung Ziel der vorliegenden Untersuchung ist es, die möglichen Wirkungen der Aktiven Wassertherapie in Form des therapeutischen Aqua-Jogging nach dem Konzept Innenmoser (2001) bei „chronischen“ Rückenschmerz- Patienten nachzuweisen. Weil in sportwissenschaftlichen Studien die in klinischen Studien üblichen medizinischen Kontrollverfahren (Röntgendiagnostik, Oberflächen- EMG usw.) nicht zur Anwendung kommen können, wird in dieser Studie versucht, die Wirkungen der „ Bewegungstherapie im Wasser“ über den Weg eines indirekten Schließverfahrens zu ermitteln. Dieses beruht darauf, dass die Wirkungen der Aktiven Wassertherapie sich in einer verbesserten Bewegungsmöglichkeit bzw. einem höheren Bewegungsausmaß der Bewegungen des Rumpfes bzw. der unteren Wirbelsäule dann zeigen, wenn die Personen unmittelbar nach Verlassen des Wassers mit unserem ultraschallgestützten Prüfverfahren kontrolliert werden. Der Vergleich zwischen den Veränderungen der Messwerte bei ausgesuchten Bewegungsaufgaben / Tests im Bereich der Wirbelsäule vor Beginn des Aqua-Joggens und unmittelbar danach wird als Indikator für eine bessernde Wirkung der Bewegungen im Wasser angesehen. Dabei galt es nachzuweisen, dass tatsächlich die Kontrolle am Beckenrand deutlichere Zeichen einer Wirkung der Bewegungen im Wasser erbringen kann, als die zeitlich immer viel später liegenden Laboruntersuchungen. 3 Methodik und Design In einer kontrollierten prospektiven Studie wurden 11 Probanden im Alter zwischen 41 und 71 Lebensjahren mit chronischen Rückenschmerzen in der Lendenwirbelsäule (Dauer > 2 Jahre) in Rahmen einer Einzelfallstudie (ohne begleitende physiotherapeutische Behandlung) erfasst. Sie nahmen über die Dauer von 14 Wochen ein mal pro Woche an einem Aqua-Jogging-Programm von 60 min Dauer teil. Alle Probanden absolvierten das Trainingsprogramm ausschließlich im Wasser. Neben den Messungen von Mobilität und Schmerz wurden durch Prä-, Post-, Follow-up-Tests und die verlaufsdiagnostische Untersuchung mit Hilfe eines „Befindlichkeitsfragebogens“, auch die subjektiven Einschätzungen von Leistungsfähigkeit, Befinden und Schmerzempfinden ermittelt. Im Labor kamen als ergänzende Parameter die Ermittlung der statischen Körperhaltung und der anthropometrischen Date hinzu. Der alltäglich wechselnde Schmerzzustand der Probanden wurde anhand eines „Tagebuchs“ festgehalten. Die Lendenwirbelsäule-Mobilität wurde mit Hilfe der Bestimmung des „Schoberzeichens“ im Labor in die Analyse mit einbezogen. Die Schmerzvarianten der Personen wurde mit Hilfe einer Befragung (Fragebogen FSR), dem ein Schmerzregulationsmodell zugrunde liegt, am Anfang und am Ende des Aqua-Jogging-Programms und nach dessen Ende im Follow-Up Zeitraum gemessen. Wichtigste Aufgabe aber waren die Messungen der Bewegungsmöglichkeiten der Lendenwirbelsäule mit Hilfe des Ultraschallmessverfahrens System Zebris am Beckenrand vor und nach dem Aqua-Jogging und dessen Auswertung unter Berücksichtung jedes einzelnen Probanden. 4 Ergebnisse Die Auswertung der Veränderungen mit dem ultraschalltopografischen Messverfahren nach Zebris in den Verlaufsuntersuchungen ergab bei 8 Probanden eine Verbesserung der LWS Beweglichkeit. Bei 8 Probanden waren auch Verbesserungen im Follow-Up Test im Merkmal Flexion zu sehen. Diese fiel deutlich umfangreicher aus. Bei weiteren 6 Probanden ergaben sich Verbesserungen der Extension im Bereich der LWS. Ebenfalls 6 Probanden konnten die Lateralflexion nach links vergrößern. Nur bei 5 Probanden verbesserte sich die Lateralflexion nach rechts. Bei 5 Probanden war die Rotation nach links besser, während bei 8 Probanden die Rotation nach rechts besser gelang. 6 Probanden verbesserten ihre LWS Beweglichkeit in der Flexion, wenn man das Schoberzeichen als Kriterium heranzog. Nur 3 Probanden verbesserten ihre FSR- Kompetenz, während 5 Probanden eine geringere Schmerzintensität lt. FSR aufwiesen. 7 Probanden zeigten eine geringere Angst gemäß FSR und bei 7 Probanden verringerte sich die Neigung zu Depression, Die Effekte sind unabhängig von Geschlecht und Chronifizierungsausmaß. Verallgemeinernd gesehen waren mit Hilfe der ausgewählten Messkriterien eine Verbesserung der Beweglichkeit der Wirbelsäule, eine Linderung der Schmerzen und Steigerung der Lebensqualität zu beobachten. Trainingsbedingt zeigte sich teilweise eine kräftige Beschwerdereduktion (Linderung der Schmerzintensität) und eine relativ deutliche Steigerung der körperlichen Leistungsfähigkeit. Teilnehmer über 60 Jahre zeigen gegenüber jüngeren Teilnehmern einen höheren Beweglichkeitszuwachs der Flexion bei gleicher Schmerzreduktion. Es wurde eindeutig klar, dass die individuell unterschiedlichen Wirkungen des Aqua-Joggings auf Flexion, Extension, Lateralflexion links und rechts und Rotation links und rechts nur dann sicher erfasst werden können, wenn die Kontrolle tatsächlich am Beckenrand erfolgte. Diese akuten Wirkungen erklärten auch das fast stets gesteigerte Gefühl des Wohlbefindens bei den Probanden und ihre regelmäßig geäußerten Wünsche nach einer Fortsetzung der Trainingsmaßnahmen 5 Schlussfolgerungen Das Aqua-Jogging bestätigte sich als wirksame Maßnahme im Sinne einer Trainingstherapie. In der untersuchten Stichprobe wurden schon nach kurzer Zeit und im Verlauf der Studie bis zum Ende deutliche positive Veränderungen der Bewegungsmöglichkeiten der Lendenwirbelsäule festgestellt. Dass dies nicht bei allen Probanden bei allen Provokation einheitlich gleich war, lässt sich erklären durch die sehr unterschiedlichen Ausprägungen der Symptome, obwohl alle sicher zur Gruppe der „Low-Back-Pain“-Patienten zu zählen sind. Die Ergebnisse der Untersuchungen und die Durchführung des Trainings unter den festgelegten Bedingungen können weitere Erkenntnisse für effektive Therapiemaßnahmen für Rückenpatienten bringen. 6 Schlussthesen 6.1 Mit Hilfe des Ultraschall-Diagnoseverfahrens (System Zebris) am Beckenrand gelingt es, die unmittelbaren Auswirkungen des Aqua Joggings – repräsentiert durch eine verbesserte Beweglichkeit in Flexion, Extension, Lateralflexion und Rotation der LWS – nach jeder Therapieeinheit nachzuweisen. 6.2 Ein erhöhtes Niveau der Lendenwirbelsäulen–Bewegungsmöglichkeiten und eine Verbesserung der „Schmerzfaktoren“ kann durch ein spezifisches Aqua-Jogging Training erreicht werden. Eine längerfristige Wirksamkeit der Intervention in Form von geringeren Rückbildungsprozessen auf den alten Zustand vor Beginn des Programms konnte am Follow-up-Messzeitpunkt nur teilweise gezeigt werden. 6.3 Alle Teilnehmer der Studie reagierten beim Post Test im Vergleich mit dem Prä-Test – im Sinne der Schmerzreduktion – positiv auf die Teilnahme am Aqua-Jogging. Die Patienten fühlten sich nach dem Aqua Jogging wohler als vor dem Aqua-Jogging.

BACKGROUND: The relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants' expectations of treatment changed over the course of a therapy. METHODS: We conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time. RESULTS: Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health. CONCLUSIONS: The shift in treatment expectations to greater acceptance of pain and the need for continued self-care suggests that future research should explore how CAM practitioners can capitalize on these shifts to encourage feelings of empowerment rather than disappointment surrounding realizations of the need for continued engagement with self-care.