Objetivo: avaliar os efeitos imediatos da manipulação de AVBA (alta velocidade e baixa amplitude) na sensibilidade dolorosa e nos parâmetros de avaliação do controle postural em participantes com dor lombar de origem inespecífica. Desenho do estudo: ensaio clínico randomizado, duplo cego (paciente e avaliador dos desfechos), com a presença de dois grupos, controle e intervenção. Contexto: a dor lombar é um problema crescente em vários países do mundo com a geração de altos custos em seu manuseio para os serviços de saúde. A implementação de técnicas de avaliação e tratamento são imperativos no entendimento e manejo dos sujeitos com dor lombar. A manipulação de AVBA lombar torna-se uma das formas de tratamento seguras e com baixo custo para a melhora da dor e da capacidade funcional de sujeitos com dor lombar de origem inespecífica. Método: 24 participantes, distribuídos em dois grupos, controle (recebeu manipulação simulada, apenas posicionamento) e intervenção (manipulação de AVBA lombar), 12 em cada grupo, de maneira aleatória, os quais preencheram os critérios da regra de predição clínica (dor inferior a 16 dias, dor que não passe do joelho, escore inferior a 19 no questionário de medos e crenças, rigidez vertebral e rotação interna de quadril maior que 35 graus, uni ou bilateralmente) para utilização da manipulação de AVBA. Foi utilizado a escala numérica de dor e a avaliação com algômetro (instrumento que avalia o limiar de pressão dolorosa) nos eretores da coluna lombar e no processo espinhoso (L1-L5 avaliado através do teste palpatório de pressão póstero-anterior), antes e depois da manipulação de AVBA lombar. Para avaliação das variáveis do controle postural, se fez uso da plataforma de força a qual mensurou a força de reação do solo, e partir desta utilizamos como variáveis a área da elipse, comprimento da trajetória e velocidade RMS para avaliação das alterações da posição do centro de pressão. Foram realizadas três repetições de cada estratégia do tornozelo (postura ereta semi estática) e do quadril (postura ereta semi estática em uma base de suporte menor nas direções ântero posterior) antes e após a manipulação simulada e manipulação de AVBA lombar. Resultados: obtivemos significância estatística na sensibilidade dolorosa, na escala numérica de dor, com diminuição da dor em ambos os grupos controle (p=0,01) e intervenção (p=0,02). Na avaliação com algômetro obtivemos significância estatística nos participantes alocados apenas para o grupo intervenção e na região do eretor esquerdo (p=0,04). Nas variáveis do controle postural, as quais foram avaliadas com ANOVA(s) de 4, 3 e 2 fatores, obtivemos diferenças significativas nos fatores principais estratégias e direção, com a estratégia do quadril tendo uma área e um comprimento de trajetória maior em comparação à estratégia do tornozelo, e a direção ântero-posterior apresentando um comprimento de trajetória maior, quando comparada à direção médio-lateral. Conclusão: Podemos estabelecer que os resultados e efeitos observados na escala numérica de dor e na algometria, foram atribuídos à resposta placebo da terapia manual e a modificação neurofisiológica provocada pela manipulação de AVBA na coluna lombar, respectivamente. Tornando desta forma, a técnica de manipulação uma ferramenta terapêutica para diminuição da dor nos pacientes com queixa lombar, respeitando as características de apresentação clínica e funcional de cada paciente para a aplicação da técnica de manipulação. Não foi possível demonstrar influência da manipulação lombar nos parâmetros posturais. / Aim: To assessment, the immediate effects of HVLA thrust manipulation (high velocity and low amplitude) in pain sensitivity and parameters of postural control in participants with nonspecific low back pain. Study design: Randomized clinical trial, double blind (patient and measurer of outcomes), with the presence of two groups, control and intervention. Background: low back pain is a growing problem in many countries of the world with the generation of high costs in handling for health services. The implementation of evaluation techniques and treatment are important to understanding management of subjects with nonspecific low back pain. Lumbar HVLA thrust manipulation becomes one of the safest forms of treatment and low costs to the improvement in pain and functionality of subjects with nonspecific low back pain. Methods: 24 participants are allocated randomly in two groups, control (which received sham manipulation) and intervention (lumbar HVLA thrust manipulation), 12 in each group, which met the criteria of clinical prediction rule (pain below than 16 days, pain that does not pass the knee, score less than 19 in the questionnaire fears and beliefs, spinal stiffness and internal rotation of the hip greater than 35 degrees, unilateral and bilateral). Was used the numerical pain scale and the algometer (instrument that assesses the pressure pain threshold) to assessment pain before and after delivery lumbar HVLA thrust manipulation. To evaluate the variables of postural control, if made use of the force platform, which measured the ground reaction force, and the variables of the postural control was area of the ellipse, the total length and RMS speed of the center of pressure displacement. Were performed three repetition for each ankle strategy (semi static upright posture) and hip (semi static upright posture in a lower supporting base) before and after delivery sham and lumbar HVLA thrust manipulation. Results: we obtained statistically significant in pain sensitivity on the rate scale of pain, with decreased in both groups control (p = 0.01) and intervention (p = 0.02). In the evaluation with algometer, we obtained statistically significant in participants allocated only for the intervention group and left erector region (p = 0.04). The variables of postural control, which were evaluated with ANOVA (s) 4, 3 and 2 factors showed significant differences in the major factors strategies and direction, the hip strategy having an area and a trajectory length larger than ankle strategy, and antero-posterior direction having a length trajectory larger than medial-lateral direction. Conclusion: We can establish that the results observed in the numerical pain scale and pressure pain threshold, were attributed to the placebo response of manual therapy and neurophysiological modifications caused by delivery HVLA manipulation in the lumbar spine, respectively. Moreover, the HVLA manipulation for lumbar spine is a therapeutic tool for decreasing pain in patients with back complaints respecting the functional characteristics and clinical presentation of the patient for the application of manipulation technique.

Prior studies have reported differences in lower back biomechanics during activities of daily living between individuals with and without chronic low back pain (LBP). Nevertheless, the literature on lower back biomechanics of patients with non-chronic LBP is scant. Therefore, the objective of this study, as the first step towards future prospective studies, was to investigate the lower back biomechanics in patients with non-chronic LBP. Case-control studies were conducted wherein measures of lumbo-pelvic coordination during bending and return tasks as well as measures of mechanical demand on the lower back during lifting tasks in the sagittal plane were investigated between patients with non-chronic LBP and matched asymptomatic individuals. Patients were enrolled into the study at the non-chronic stage of their LBP. We found distinct difference in measures of lumbo-pelvic coordination as well as mechanical demands on the lower back between patients with non-chronic LBP and controls. Reduced lumbar range of flexion and slower task pace as well as the more in-phase and less variable lumbo-pelvic coordination observed in patients with non-chronic low back pain, may be the result of a neuromuscular adaptation to reduce the forces and deformation in the lower back tissues and avoid pain aggravation. Such a neuromuscular adaptation, however, resulted in a larger shearing demand on the lower back. Persistent abnormal lumbo-pelvic coordination might play a role in transition to chronic stage or recurrence of LBP. However, such inferences need to be further investigated using prospective studies as well as clinical trials involving a combination of physical and psychological treatments aimed at correction of lumbo-pelvic coordination.

Introdução: O acesso lombar transpsoas extremo lateral (LLIF) é uma abordagem retroperitoneal para artrodese intersomática que constitui num implante (cage) o qual se sustenta nas duas margens laterais do anel epifisário, maximizando o apoio na placa terminal. Há também a descompressão indireta das estruturas nervosas através da discectomia e restauro da altura discal pelo cage. Objetivo: Avaliar a eficácia clínica e radiológica da descompressão indireta após o LLIF para estenose do canal lombar. Métodos: Estudo prospectivo clínico e radiológico em único centro, com 20 pacientes portadores de estenose do canal lombar, sem resposta ao tratamento clínico, submetidos à cirurgia de artrodese por via lateral transpsoas minimamente invasiva. Foram coletados dados clínicos e radiológicos no período pré-operatório, em 6 semanas, em três meses, seis e doze meses após a cirurgia. Dados radiológicos medidos em RNM incluíram área e altura dos forâmens, área do canal, diâmetro do canal e altura anterior e posterior do disco intervertebral. Questionários clínicos incluíram EVA e ODI. A incidência de complicações e re-operações foram descritas. Resultados: A idade média do grupo foi de 57,8 anos. Foram tratados ao todo 25 níveis. As cirurgias decorreram sem complicações intra-operatórias. Um caso (5%) recebeu re-operação. A área do canal aumentou de 109 mm para 149mm (p < 0,001) e de 9,3mm para 12,2mm (p < 0,001) em diâmetro anteroposterior. Os valores de área dos forâmens também demonstraram o efeito da descompressão indireta em ambos lados (p < 0,001). A altura do forâmen mostrou ganhos significativos, de 2,8mm de média (p < 0,001). A altura discal foi aumentada em média 25% (p < 0,001). Os resultados de questionários EVA e ODI respondidos pelos pacientes confirmaram o efeito clínico da descompressão indireta demonstrada radiologicamente. Conclusão: Observamos que a descompressão indireta pelo método de LLIF apresenta resultados que comprovam a melhora tanto radiológica quanto clínica com baixa taxa de complicações e re-operações / Background: Lateral transpsoas lateral access (LLIF) is a retroperitoneal approach for intersomatic arthrodesis that constitutes an implant, which is supported on the two lateral margins of the epiphyseal ring, maximizing the support in the terminal plate. There is also indirect decompression of nerve structures through discectomy and restoration of disc height by cage. Aim: Evaluate the clinical and radiological improvement of the indirect decompression after LLIF for lumbar canal stenosis. Methods: Prospective clinical and radiological study in a single center, with 20 patients with lumbar canal stenosis, without response to clinical treatment, submitted to minimally invasive transpsoas lateral lumbar interbody fusion (LLIF) surgery. Clinical and radiological data were collected in the preoperative period, at 6 weeks, at three, six and twelve months after surgery. Radiological data measured on MRI included area and height of foramen, canal area, canal diameter and anterior and posterior height of the intervertebral disc. Clinical questionnaires included VAS and ODI. Complications and re-operations were described. Results: The mean age of the group was 57.8 years. A total of 25 levels were treated. Surgeries were performed without intraoperative complications. One case (5%) received reoperation. The canal area increased from 109 mm to 149 mm (p < 0.001) and from 9.3 mm to 12.2 mm (p < 0.001) in the anteroposterior diameter. The values of the foramen area also demonstrated the effect of indirect decompression on both sides (p < 0.001). The height of the foramen showed significant gains, of 2.8 mm of mean (p < 0.001). Disc height was increased by an average of 25% (p < 0.001). The results of VAS and ODI questionnaires answered by the patients confirmed the clinical effect radiologically demonstrated of indirect decompression. Conclusion: We observed that indirect decompression by the LLIF method is feasible radiologically and clinically with a low rate of complications and reoperations

<p>Musculoskeltal pain is the most common diagnosis for being on sick leave two months or longer in Sweden. The societal costs have been estimated at almost 30 billion Swedish kronor per year. Research aimed at improving occupational rehabilitation is therefore crucial.</p><p>In Study I a multidisciplinary cognitive-behavioral in-patient program conducted at a rehabilitation clinic was empirically evaluated. A randomized controlled trial with 36 chronic pain patients showed a difference in favor of the treated patients compared to their controls on measures of occupational training and activity level at a 1-month follow-up. A consecutive trial with 85 chronic patients showed a decrease in sick leave, pain intensity, depression, and use of analgesics, and an increase in life control and physical fitness from pre-treatment to a 2-month and a 1-year follow-up. Study II was a randomized controlled evaluation of a return-to-work focused cognitive-behavioral out-patient program with a 6-month follow-up conducted by a psychologist. Effects were compared over 36 pain patients on short-term sick leave (2-6 months) and 36 patients on long-term sick leave (>12 months). The treated patients on short-tem sick leave reduced their sick leave and returned to work more than their controls. They also improved their abilities to control and decrease the pain more. However, the patients on long-term sick leave did not improve on any outcome variables compared to their controls. In Study III a questionnaire aimed at identifying obstacles to return to work was developed and evaluated. The questionnaire was administrated to 154 chronic pain patients and was found to predict sick leave nine months after assessment. Important obstacles were perceived prognosis of a work return, social support at work, physical workload and harmfulness of work, pain intensity, and depression.</p><p>In conclusion, this thesis shows that cognitive-behavioral treatment focused on return to work is effective in helping chronic musculoskeletal pain patients back to work. A questionnaire developed to identify obstacles to return to work was shown to predict sick leave. </p>

Die wachsenden Kosten für die Behandlung chronischer lumbaler Rückenschmerzen stehen zunehmend in Diskrepanz mit den begrenzten Mitteln für das Gesundheitswesen.<br /> Untersuchungen zeigen, dass aktive Trainingsprogramme, je früher sie eingesetzt werden, einen positiven Einfluss auf die Senkung von Kosten für die Gesellschaft haben. Ein rechtzeitiger Einsatz der medizinischen Kräftigungstherapie bei Rückenschmerzpatienten ist somit unter rehabilitativen Gesichtspunkten notwendig. Insbesondere das Training im Wasser gestattet gelenkschonende Übungen in frühen Phasen der Rehabilitation und lassen eine raschere Wiederherstellung erwarten.<br /> Über die körperlichen Auswirkungen therapeutischer Trainingsmaßnahmen im Wasser sind bis dato wenige Studien verfügbar, welche die Wirkung des Mediums Wasser auf konditionelle Parameter objektiv quantifizieren und bewerten. Jedoch sind bislang die Möglichkeiten für ein gezieltes Krafttraining im Wasser begrenzt.<br /> <br /> Eine gerätetechnische Entwicklung, die ein rumpfstabilisierendes Krafttraining im Warmwasser ermöglicht, lässt im Vergleich zu herkömmlichen Trainingsmöglichkeiten eine noch effizientere rehabilitative Behandlung erwarten.<br /> Es wird die Fragestellung verfolgt, inwieweit aktive Trainingsformen im Wasser die Maximalkraft und die neuromuskuläre Funktion der Rumpfmuskulatur, sowie den Schmerz von Rückenpatienten beeinflussen. Ferner soll im Rahmen der Untersuchungen die Effektivität eines neu entwickelten Wassertrainingsgerätes geprüft werden.<br /> Die Untersuchungen der Ergebnisse von 80 weiblichen Probanden (in fünf Gruppen aufgeteilt: Kontrollgruppe, Aquajogging, Aquarücken, Aquagerät und Rückengymnastik an Land) zeigen, dass durch aktive Interventionsmaßnahmen eine Verbesserung der Kraftfähigkeit und eine Reduzierung von Schmerzen erzielt werden kann. Hingegen kommt es in der Kontrollgruppe, ohne Trainingsanwendungen, zur Stagnation des chronischen Schmerzzustandes, sogar zur Verschlechterung der Kraftentwicklung der Rückenstreckmuskulatur.<br /> <br /> In allen Trainingsgruppen konnten kurzfristig und mittelfristig weniger Muskelfunktionsstörungen nachgewiesen werden. Bei Betrachtung der Kraftentwicklung der unteren Rumpfmuskulatur fällt auf, dass die höchsten Zuwächse der Bauchmuskelkraft in den Gruppen Aquarücken und Aquagerät festzustellen sind. Die Kraft der Rückenstreckermuskulatur entwickelte sich in der Gruppe Aquagerät mit einer Steigerung von 55% nach der Intervention am stärksten. Es kann die Hypothese aufgestellt werden, dass das Training im warmen Wasser unter stabilisierten Voraussetzungen eine effizientere Methode zur Stärkung der unteren Rumpfmuskulatur zu sein scheint.<br /> Bei der Entwicklung der Kraft der oberen Rücken- und Schultergürtelmuskulatur kommt es in den Gruppen Aquajogging und Aquarücken zu den größten Steigerungen. Dies könnte mit der höheren Aktivität der Arme im Übungsprogramm zusammenhängen.<br /> Positiv ist die hohe Reduzierung der Schmerzen in allen Trainingsgruppen zu bewerten. Jedoch ist bei Betrachtung der Ergebnisse festzustellen, dass für eine weitere Manifestierung der Trainingserfolge ein weiterführendes Training bedeutsam ist.<br /> Die Ergebnisse dieser Studie belegen, dass durch ein gezieltes Training im Wasser und an Land über 6 Wochen, je zweimal pro Woche, deutliche Verbesserungen in der Entwicklung von Kraft, Schmerzintensität, Funktionseinschränkung und Muskelfunktion möglich sind. Ferner werden in dieser Arbeit positive Zusammenhänge zwischen den Entwicklungen Schmerzintensität und Rückenstreckerkraft, sowie Schmerzintensität und Bauchmuskelkraft beobachtet. Zwischen den Versuchsgruppen im Wasser und der Versuchsgruppe an Land konnten nur geringe Unterschiede in den Ergebnissen nachgewiesen werden. Jedoch geben die Resultate Hinweis darauf, dass bei höheren Schmerzintensitäten die Intervention im Wasser die Therapie der Wahl zu sein scheint.<br /> Die Resultate dieser Untersuchungen machen deutlich, dass der Einsatz eines Wassertrainingsgerätes in der Therapie chronischer Rückenschmerzpatienten eine effiziente Methode zur Senkung von Schmerzen und zur Steigerung der Kraft der Rücken- und Bauchmuskulatur ist.<br /> Vorteile des Wassertraingsgerätes sind die gute Stabilisation des Beckens, trotz auftriebswirksamer Mechanismen im Wasser, die bedienerfreundliche Handhabung, der separat einstellbare Widerstand, die schnellen Therapieerfolge und die hohe Motivation der Kursteilnehmer. Diese Beobachtungen lassen eine effizientere Therapie und damit Kostenersparnisse vermuten.<br /> Nachteile sind das hohe Gewicht des Wassertraingsgerätes und die relativ hohen Anschaffungskosten. Die hohe Reduzierung der Schmerzintensität bei den Probanden, die am Wassertrainingsgerät Interventionen durchführten, lassen vermuten, dass diese Geräteanwendungen für Patienten mit sehr schmerzhaften oder subakuten Verlaufsformen besonders geeignet ist.<br /> Der schonende Charakter der Aquatherapie und der Einsatz eines neuen Wassertrainingsgerätes unterstützt in effektiver Weise die modernen Konzepte der Rehabilitation chronischer Rückenschmerzpatienten. / Question: Aim of the study was to evaluate the influence of different aquatic exercise programmes on trunk strength, pain level, neuromuscular function and functional ability for patients with low back pain. Another aim was to construct and implement of a new aquatic exercise machine.<br /> <br /> Methods: 80 female subjects aged from 25 to 45 years with low back pain were randomized into a control group or one of the following training groups: aqua jogging, aqua gymnastics, aqua machine and gymnastics on land. The four training groups took part in a muscle strengthening program two times a week over 6 weeks. The control group did not receive any alternative physiotherapeutic treatment. All groups were tested at the beginning, after 6 weeks and 4 months later.<br /> <br /> Results: The data obtained for the control group remained unchanged over all periods of investigation. The isometric maximum of trunk strength improved significantly in all exercise groups. Furthermore it was to be seen that there were less malfunction in all training groups after 6 weeks. The most significant improvements are in the exercise machine group concerning reduction of pain level and increase strength of lumbar extension.<br /> <br /> Conclusions: The results of this study should be viewed as encouraging. The aquatic exercise machine is to be seen as an effective complement of treatment for low back pain.

Introduction Gender as a social and cultural construction has an impact on physiotherapist and patient beliefs, understanding, and behaviour and could affect physiotherapy encounters. Gender studies in early rehabilitation are scarce. The aim of this thesis was to study gender during different parts of the rehabilitation process for primary health care patients with neck and back pain. Method The analyses are based on data from three different samples. One sample is composed of physiotherapists and two samples consist of patients consulting primary health care providers because of neck and back pain. All data were gathered from primary health care provided in Västerbotten County. Baseline data on 73 physiotherapists and 586 of their patients with neck and back pain were collected by questionnaire during three consecutive days in 2006. Patient data included affected pain site and treatment procedures used by the physiotherapist (Study I). Differences in treatment procedures used by female and male physiotherapists and differences in use for female or male patients were analysed using Chi square-test, Fisher’s exact tests, Mann-Whitney U tests and logistic regressions with cluster analysis. Thematised interviews with 12 patients were made before the patient’s first appointment with a physiotherapist or doctor and repeated after three months. Data were analysed according to grounded theory (Study II) and qualitative content analysis (Study III). A comprehensive questionnaire was answered at the first appointment when patients sought a physiotherapist in primary health care. The questionnaires included questions about pain intensity, self-rated health, function, psychological stress reactions, domestic work, work environment, self-efficacy and kinesiophobia. Response patterns were linked to the International Classification of Functioning Disability and Health (ICF) and analysed using principal component analysis (PCA) and partial least squares projections to latent structures (PLS). Result Patients were given the same treatment procedures irrespective of gender. The treatment procedures most often used were training of joint motion (48%), training of muscle functions and strength training (31%), massage (31%), physical treatment (28%), information about health/ill health (24%), and acupuncture (18%). Female and male physiotherapists used the same treatment procedures with a few exceptions. Female physiotherapists used treatment for mental functions and acupuncture more often than male physiotherapists. The women gave their patients a unique mixture of treatment procedures more frequently (43%) compared to their male colleagues (25%). Male physiotherapists used more training of joint motion. "To be confirmed" emerged as the core category when analysing interviews that considered expectations or experiences. Five categories were extracted: "To be taken seriously", "To get an explanation", "To be individually assessed and treated", "To be invited to participate", and "To be taken care of in a trustworthy environment". These were factors leading to confirmation. Two ideal types were identified: "confident" and "ambiguous". The "confident" did not doubt their right to health care and blamed their work for causing the pain. They related to a positive identity of strong or hard working. The "ambiguous" were afraid of being regarded as old, whining women and not being taken seriously. They were ashamed of having neck or back pain and blamed themselves; they thought they were not fit enough. The ideal types were not completely defined by gender, but more men were among the "confident" ideal type and more women were among the "ambiguous" type. Patients reacted differently to feelings of being confirmed or not, and this depended on whether they were the "confident" or "ambiguous" ideal type. The "confident" were satisfied and reacted with reorientation when they felt confirmed, even if they were not totally cured. When not confirmed, the "confident" reacted with anger, frustration, and feelings of shame or remained proud and blamed the health care personnel for being incompetent. The "ambiguous" also were satisfied and felt reoriented when they were confirmed. They then moved from being an "ambiguous" type to a more "confident" type. When the "ambiguous" were not confirmed in healthcare, they became dissatisfied and unhappy. They doubted the assessment, felt forlorn, and felt increased shame. Not being confirmed was experienced more negatively by women than by men irrespective of ideal type. Interesting information was found about how patients view their body in relation to pain during analysis of expectations and experiences in study II interviews. This led to Study III. In study III, "Fear of hurting the fragile body" emerged as an interview theme. Five categories supported or undermined beliefs about pain and physical activity: "The mechanical body", "Messages about activity", "Earlier experiences of pain and activity", "To be a good citizen", and "Support to be active". Patients thought their pain was due to tissue damage and viewed their bodies in a mechanical way. Clear messages from health care personnel about activity led to less fear of physical activity. Vague and contradictory messages led to more fear. Gender-stereotyped messages were given to patients. "The take it carefully" was such a message, and was more often to women when women were thought to be weak and in need of training. Another message was "Pain goes with heavy work". This message was more often given to men when men were thought to be strong and not in need of training. Earlier experiences of pain and activity could have been positive or negative. If positive, the experiences led to less fear of engaging in physical activity. A wish to be a good citizen, such as being a good parent, led to patients being more engaged in child care and playing more than they thought was good for their pain. Women, more than men, expressed avoidance of sick leave because they did not want to be a burden to society or to their work colleagues. Patients were anxious about how to do the "correct" exercises to avoid further injury. Practical support and a follow up to adjust the training program were important to reduce the fear of engaging in physical activity and to maintain motivation. One hundred and eighteen patients (84 women and 34 men) completed the questionnaire. PCA of all questions identified five significant components. The model explained 37% of the variance. The predictive power was 17%. PC1 explained 17% of the variance and the predictive power was 0.13%. PC1 was mainly explained by questions classified in ICF as Activity and Participation. These included questions about physical function and self-efficacy (classified as Content of Thought). Questions about support (classified as Environmental Factors) and stress reactions (classified as Body Function (Emotional Functions)) mainly explained PC2. PC3 was mainly explained by reported pain and symptoms from muscles (classified as Body Functions) and domestic work and leisure time activities (classified as Activity and Participation). There were differences in t-scores between women and men in PC2 (p=0.045) and PC3 (p=0.003). Variables that discriminated between women and men were questions about stress reactions and support at work in PC2, and questions about pain intensity and domestic work in PC3. Conclusion As a physiotherapist working with neck and back pain rehabilitation patients, it is important to be aware of both one’s own and the patient’s preconceptions about women and men. It is also important to be aware of the impact of gender on the professional role when choosing treatment procedures in order to ensure that choices will be based on evidence of effectiveness and not from stereotypes. Awareness of the patient’s individual needs and subsequent adaptation of treatments is also important. Some patients display a negative self-assessment and shame. They need more support to be able to reorient. Unless these patients are confirmed, they are at risk of prolonged disability. Gender stereotypes can hinder rehabilitation of neck and back pain if women are seen as weak and in need of protection and men are seen as strong and not in need of preventive muscle training. When assessing neck and back pain patients with questionnaires, gender has less significance than when asking questions about physical function and self-efficacy. Questions about emotions of stress reactions, support at work, and pain intensity contribute to gender differences for women. Questions on the level of domestic work contribute to gender differences for men.

Introduction: Musculoskeletal disorders constitute the greatest cause of sickness absence from work. Despite research and efforts at rehabilitation, sickness absence due to these disorders has not decreased, but has instead increased, particularly in women. Clients’ perceptions of care and rehabilitation, i.e. knowledge generated from a lay perspective, is a neglected area of research. This thesis deals with lay experiences of rehabilitation following sickness absence due to back, neck or shoulder problems, termed musculoskeletal disorders (MSD). Aim: The overall aim was to examine hindering and promoting processes in rehabilitation after sickness absence due to MSD from a lay perspective. Specific aims were to study how lay persons experience rehabilitation agents and rehabilitation activities (paper I), how they describe themselves and their experience in relation to work (paper II), the significance of the private arena regarding return to work (paper III), and how clients who have experienced sickness absence due to MSD perceive contact with rehabilitation agents (paper IV). Method: The study population in the four papers is part of a cohort of persons living in the same municipality and who in 1985 were aged 25-34 years and were sick-listed due to back, neck or shoulder diagnoses for 28 days or  more, n=213. During 1995, 148 persons in the cohort responded to a questionnaire, and in 1997-1998, 20 of these persons were interviewed concerning their experiences with rehabilitation. In papers I, II and III the qualitative method of Grounded Theory was used with a focus on creating an empirically-based theory concerning the area under study. Data collection was strategic and analysis of the tape-recorded interviews was done on a continual basis. How previously sick-listed persons experienced contact with professional rehabilitation agents in t he health care sector and social insurance office was investigated in paper IV. Factor analysis and multiple regression analysis were used to analyse the data in this study. Results: The interview study shed light on lay persons’ experiences with medical, social and work-related measures in rehabilitation, their perceptions of rehabilitation actors and family members in relation to rehabilitation, and their self-presentations. The descriptions of lay persons concerned three arenas, the health care arena, the occupational arena, and the private arena. Dilemmas and difficulties in these arenas were described, such as handling the duty to work, experiencing domestic strain, and the experience of lacking socioemotional support from significant persons during the rehabilitation process. In paper I some ideal types of rehabilitation agents emerged from the interviewees’ descriptions concerning the health care arena, and we called these the routine bureaucrat, the empathic administrator, the distant technician, and the professional mentor. The latter agent was requested and was described as a person who could provide socioemotional support, who had professional competence, and who could function as a unifying link during the rehabilitation process. The results from paper II showed that in their self-presentations, the interviewees expressed having a duty to work and that there were differences in how they handled this sense of duty. The selfpresentations contained descriptions of work as a part of personal identity and could be summarised in the following ideal types: the work manic, the workhorse, the workaholic and the relaxed worker. The latter used a strategy that can be considered to promote rehabilitation in that the individual himself/herself had control over his/her work and worked in accordance with his/her own needs rather than those of others. Paper III focused on the private arena. Different patterns were found in the experiences of men and women. Women related that their responsibility for the home and domestic work seldom left any time for themselves, including any time for rehabilitation. Men more often reported having time for themselves that could be used for leisure activities and rehabilitation. Some of the women said that they lacked socioemotional support from their partner and that they had a great deal of responsibility for housework, which seemed to be a hindrance in returning to work after sickness absence. Furthermore, these women, like most of the men, had little education, which could make finding other work alternatives more difficult. Based on the interviews, a hypothesis was developed regarding domestic strain that is related to the distribution of domestic work, the distribution of responsibility for the home, and the quality of the marital relationship. Paper IV dealt with clients’ perceptions of contact with rehabilitation agents in health care and the social insurance office. Three latent dimensions were found in the respondents’ ratings of these contacts: supportive treatment, distant treatment, and empowering treatment. Sex, disability pension status, mental health and diagnostic group were significantly related to how these dimensionswere rated. Women perceived the treatment from both types of rehabilitation agents as more supportive than men. Contact with the social insurance offices were rated higher by persons with disability pensions than by those who had returned to work. Men rated their contact with rehabilitation agents at social insurance offices high on the dimension of distant treatment. Respondents with mental health problems rated the contact as distant for both types of rehabilitation agents, but contact with health care was also scored low on the supportive dimension. Finally, respondents with neck/shoulder diagnoses rated contact with rehabilitation agents in health care as more empowering than was done by persons with back diagnoses. Conclusions: From a lay perspective rehabilitation following sickness absence due to MSD occured in three arenas, the health care arena, the occupational arena and the private arena, where the quality of relationships both with rehabilitation agents, persons at work and in one’s private life was described as important regarding the rehabilitation process. This thesis also showed that both sex and health were important factors regarding how lay persons’ perceived contacts with rehabilitation agents during the rehabilitation process following sickness absence due to MSD.

<p>Low back pain (LBP) is a significant problem among the nursing population worldwide. Manual lifting and shifting of heavy objects and patients are primary contributing factors. Nurses are supposed to be knowledgeable about the risk factors and preventive measures and effectively apply it into practice to prevent them from sustaining back injuries. Strategies to reducing the incidences of LBP in nurses have been previously implemented but with little outcomes. The purpose of this study was to explore the relationship between occupational risk factors and the prevalence of LBP in nurses at MOI, Tanzania. Therefore, the study examined / the prevalence of LBP amongst nurses, work-related risk factors contributing to LBP, knowledge and effectiveness of back care techniques, and barriers to effective back care techniques in clinical nurses.</p>

Musculoskeltal pain is the most common diagnosis for being on sick leave two months or longer in Sweden. The societal costs have been estimated at almost 30 billion Swedish kronor per year. Research aimed at improving occupational rehabilitation is therefore crucial. In Study I a multidisciplinary cognitive-behavioral in-patient program conducted at a rehabilitation clinic was empirically evaluated. A randomized controlled trial with 36 chronic pain patients showed a difference in favor of the treated patients compared to their controls on measures of occupational training and activity level at a 1-month follow-up. A consecutive trial with 85 chronic patients showed a decrease in sick leave, pain intensity, depression, and use of analgesics, and an increase in life control and physical fitness from pre-treatment to a 2-month and a 1-year follow-up. Study II was a randomized controlled evaluation of a return-to-work focused cognitive-behavioral out-patient program with a 6-month follow-up conducted by a psychologist. Effects were compared over 36 pain patients on short-term sick leave (2-6 months) and 36 patients on long-term sick leave (&gt;12 months). The treated patients on short-tem sick leave reduced their sick leave and returned to work more than their controls. They also improved their abilities to control and decrease the pain more. However, the patients on long-term sick leave did not improve on any outcome variables compared to their controls. In Study III a questionnaire aimed at identifying obstacles to return to work was developed and evaluated. The questionnaire was administrated to 154 chronic pain patients and was found to predict sick leave nine months after assessment. Important obstacles were perceived prognosis of a work return, social support at work, physical workload and harmfulness of work, pain intensity, and depression. In conclusion, this thesis shows that cognitive-behavioral treatment focused on return to work is effective in helping chronic musculoskeletal pain patients back to work. A questionnaire developed to identify obstacles to return to work was shown to predict sick leave.

Both spinal pain and temporomandibular disorders (TMD) commonly occur in the general population. Previous studies demonstrate neurophysiologic and biomechanical couplings between the trigeminal and cervical regions. This investigation tested the null hypothesis of no relationship between spinal pain (neck, shoulder and/or low back) and TMD, by using questionnaires and clinical examinations of the jaw function. In an age- and sex-matched case-control study, the specific aim was to compare the prevalence of signs and symptoms of TMD among cases with long-term spinal pain and controls without spinal pain. The results showed that subjects with spinal pain had signs and symptoms of TMD significantly more often than did controls. The associations remained after excluding all participants with jaw pain. Furthermore, the comorbidity pattern was similar, regardless of location of spinal pain. In a cross-sectional study, the specific aim was to test whether there is a reciprocal cross-sectional dose-response-like relationship between spinal pain and TMD. Two different designs were used, one with frequency/severity of spinal pain as independent variable, and the other, with frequency/severity of TMD symptoms as independent variable. The analysis showed increasing odds for presence of TMD symptoms with increasing frequency/severity of spinal pain, and increasing odds for presence of spinal pain with increasing frequency/severity of TMD symptoms. In a case-control study within a 2-year prospective cohort, the specific aim was to test whether there is a reciprocal temporal relationship between signs and symptoms in trigeminally, and symptoms in spinally, innervated areas. Incidence of symptoms in these areas was analyzed in relation to presence of spinal pain, headaches, and signs and symptoms of TMD at baseline. The main findings were that presence of signs of TMD at baseline increased the onset of spinal pain and symptoms in the trigeminal area, and that spinal pain increased the onset of symptoms in the trigeminal area. An augmentation effect between the significant baseline variables was observed for the incidence of headaches and jaw pain. In conclusion, the investigation demonstrated a cross-sectional and temporal relationship between spinal pain and TMD; thus, the null hypothesis was rejected. The results indicate common pathophysiological mechanisms in the development of spinal pain and TMD. The comorbidity and reciprocal influence that were found call for an integrated and multidimensional approach in the management of individuals with long-term spinal pain and TMD.