Bakgrund: Smärta från rörelseorganen ligger bakom många sjukskrivningar. För att stärka den medicinska rehabiliteringen gjorde Socialdepartementet en överenskommelse med Sveriges kommuner och landsting 2008; Rehabgarantin. Den insats som skulle få prestationsersättning var multimodal rehabilitering. I Landstinget Dalarna har man startat multimodala team med resurser från Rehabgarantin i primärvården. Denna uppsats beskriver ett sådant teams uppbyggnad och faktorer som personal uppfattar som viktiga för teamets uppbyggnad och arbete. Syfte: Syftet med förändringsarbetet är att patienter med långvarig värk ska få ett snabbt och adekvat omhändertagande av ett team som har kunskaper och erfarenhet av att jobba tillsammans. Studiefrågor: Vilka effekter för patienterna kan kopplas till ansatsen att skapa multimodal rehabilitering på en primärvårdspraktik? Vilka faktorer, upplever personal på vårdcentralen, har påverkat skapandet av ett smärtteam på vårdcentralen? Metod: En blandad studie med flera metoder för datainsamling. Öppen intervju med personal, strukturerad telefonintervju med patienter och journalgranskning. Resultat: Smärtteamet har lyckats påverka arbetsåtergången och patienterna har en positiv upplevelse av genomförandet av rehabiliteringen där de varit med och skapat en rehabiliteringsplan. De faktorer som personal upplever har påverkat smärtteamets uppbyggnad är: syfte, mätningar, patientcentrering, samarbete, miljö, engagemang, information, stöd från ledning och tid. Diskussion: Oavsett om man fokuserar på ett teams uppbyggnad eller generellt på ett förbättringsarbete återkommer vissa faktorer som viktiga. Här ingår en tydlig plan för arbetet där delta-garna ställer sig bakom syftet med det arbete som man i teamet ska utföra och kontinuerliga mät-ningar för att öka engagemanget för deltagarna i arbetet och de som direkt eller indirekt berörs av arbetet. Vidare finns det en vinst att skapa sig en gemensam bild av vad vi tillsammans ska uppnå. Vidare forskning behövs av effekterna av teamarbete med smärtpatienter. Patientnytta och eko-nomiska konsekvenser behöver kartläggas. Är multimodal rehabilitering det bästa alternativet eller kan intermediär rehabilitering vara ett alternativ för små enheter? / Background: Pain from the musculoskeletal system is the cause of sick leave. To reinforce the medical rehabilitation the Social Ministries did an agreement with Sweden's municipalities and county councils 2008; the rehab warranty. The effort that would receive performance bonuses was multimodal rehabilitation. In the county council of Dalarna they have been starting multi-modal teams of the resources of the rehab warranty. This thesis describes the start of one of these teams and factors that staff perceived important for teambuilding and work. Purpose: Aim for the improvement: Patients with chronic pain should receive prompt and adequate care from a team that has experience and knowledge to work together. Study questions: What effects for the patients can be connected to the attempts to create multi-modal rehabilitation in a primary care practice? What factors, experienced by staff at the centre, has influenced the creation of the pain team at the centre? Method: A mixed methods study with several methods for collecting results. Open interviews with personnel, structured telephone interviews with patients and journal review. Results: The pain team has managed to influence patients’ possibilities to return to work. Patients perceived the rehabilitation process positively when they could participate in the care in the making of a rehab plan. The factors that staff experience has affected team building were: purpose, measurements, patient centeredness, cooperation, environment, commitment, information, support from management, and time. Discussion: Whether you focus on team-building or on improvement work some factors remain important. Among these factors are a clear plan for the work that the participants align to and continuous measurements to increase the engagement for the participants in the team and others that is affected of the teams work. Further research is needed about teamwork in rehabilitation of pain patients and the economic consequences it brings. Is it multimodal rehabilitation that gives good effects or could intermediate rehabilitation be an alternative for small organisations?

Background Musculoskeletal disorders (MSDs) are one of the most important causes of temporary and permanent disability, causing acute or persistent pain, resulting in reduced and/or lost ability to work. Return to work (RTW) is multidimensional problem including many different factors and aspects. Few recent studies have analyzed factors predicting RTW after multimodal rehabilitation (MMR). Identification of predictors for RTW may help to improve the planning and optimization of the RTW strategy. The REHSAM II project is a randomized controlled trial with the aim to evaluate if MMR together with a web Behavior Change Program for Activity could increase work ability among persons with persistent MSDs as compared to MMR. Therefore the aim of this study was to identify factors explaining RTW 12 month after baseline in the REHSAM II project. Methods The present study is a secondary assessment of the data from the randomized controlled trial REHSAM II. A total of 97 participants with persistent musculoskeletal pain were randomly allocated to MMR + web-based education or only MMR group. The subjects were followed from baseline to 12 months. Information on potential predictors was obtained from self-administered questionnaires. Data were analyzed with univariate and multiple logistic regression models. Results In the final multiple regression model RTW was predicted by the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ score) (p=0.003, OR=0.961) and EuroQol (EQ-5D index) (p=0.017, OR=7.283). The univariate regression analyses showed that pain and disability level, the capacity to perform a task in relation to pain and other symptoms, hospital and psychiatric care, medication for insomnia, catastrophizing, self-assessed work ability compared with the lifetime best, satisfaction with life, ability for coping and controlling work situation, ability for coping with life outside work and sense of responsibility for managing health condition were significantly associated with RTW. Conclusion In conclusion, psychosocial pain-related variable and health-related quality of life predicted RTW in the final model. The result confirms the fact that RTW is a multidimensional problem involving a complex interaction of many factors.

Bakgrund: Långvarig smärta är ett stort folkhälsoproblem som innebär stora kostnader för samhället och självklart också stort lidande för individen. Multimodal smärtrehabilitering (MMR) innebär att olika yrkeskategorier arbetar gemensamt kring dessa patienter. Forskningen visar måttligt till starkt vetenskapligt stöd för MMR vid komplex smärtproblematik. Det finns kunskapsluckor kring vilken typ av fysioterapeutiska interventioner som används vid multimodal smärtrehabilitering. Syfte: Syftet med studien var att kartlägga fysioterapeuternas arbete inom ramen för multimodal smärtrehabilitering i primärvården. Metod: Enkätstudie av tvärsnittstyp med kvantitativ ansats baserad på en egenkonstruerad webbenkät. Populationen utgjordes av fysioterapeuter anslutna till Nationella Registret över Smärtrehabilitering (NRS) primärvård och resultatet bygger på de 23 fysioterapeuter som valde att svara på webbenkäten. Resultat: Resultaten baseras på svar från 71 % av de NRS-anslutna klinikerna. Sammanfattning av resultaten visade framför allt att råd/undervisning samt olika former av fysisk träning utgjorde grunden i fysioterapeutens arbete inom MMR-team i primärvården. Det framkommer att så gott som alla patienter träffade fysioterapeut under behandlingsperioden. Det var en klar övervikt mot gruppbehandling eller en kombination av grupp och individuell behandling gällande de fysioterapeutiska interventionerna. Behandlingsperioderna var för det mesta fyra till elva veckor där patienten träffade fysioterapeut oftast varje vecka eller flera gånger/vecka. I primärvårdens MMR-team var fysioterapeut, arbetsterapeut, KBT terapeut, läkare och rehabkoordinator de vanligast förekommande yrkeskategorierna i teamen. Slutsats: Fysioterapeuten har en central roll i primärvårdens MMR-team och använder sig primärt av evidensbaserade, aktiva interventioner. / Background: Chronic pain is a major public health problem which involves high costs for society and, of course, also great suffering for the individual. Multimodal rehabilitation (MMR) means that different occupational categories work together around these patients. Research shows moderately to strong scientific evidence for MMR in complex pain problems. There are a lack of evidence about which type of physiotherapeutic interventions that are used in multimodal pain rehabilitation. Aim: The aim was to study which physiotherapy interventions that are used in multimodal primary healthcare rehabilitation in Sweden. Method: Cross-sectional survey with quantitative approach based on a self-designed web questionnaire. The population consisted of physiotherapists working in clinics reporting to the Swedish Quality Registry for Pain Rehabilitation (SQRP) in primary care and the result is based on the 23 physiotherapists who responded to the web questionnaire. Results: The results are based on 71% of the NRS-affiliated clinics. Counseling/teaching and various forms of physical training formed the basis of the physiotherapist's work in MMR teams in primary care. Almost all patients meet physiotherapists during the treatment period. Group treatment or a combination of group and individual treatment were most common. The treatment periods were mostly between four to eleven weeks where the patient met a physiotherapist most often weekly or several times a week. In the primary care MMR-team, the physiotherapist, occupational therapist, KBT therapist, physician and rehab coordinator were the most common occupational categories. Conclusion: Physiotherapists have a central role in the MMR-teams in primary care, they primarily use evidence-based, active interventions.

Bakgrund: Långvarig smärta har konsekvenser på såväl individ- som samhällsnivå och är ett stort folkhälsoproblem. Forskning har visat måttligt till starkt vetenskapligt stöd för multimodal rehabilitering (MMR) vid komplex smärtproblematik. Vad fysioterapeuten använder för åtgärder inom MMR och hur samarbetet med andra yrkeskategorier ser ut finns dåligt beskrivet. Syfte: Att kartlägga fysioterapeutens arbete inom ramen för multimodal smärtrehabilitering inom specialistvården (MMR2). Metod: Webbenkätstudie där data samlades in från 71 fysioterapeuter som arbetade på enheter anslutna till Nationella registret över smärtrehabilitering (NRS). Resultat: Fysioterapeuternas arbete bestod framförallt av undervisning/råd och olika former av träning. Strategier för beteendeförändring, övningar i medveten närvaro/kroppsmedvetenhet och hemövningar var andra vanliga åtgärder. Acceptance and Commitment Therapy (ACT) och Kognitiv beteendeterapi (KBT) användes i flera moment av rehabiliteringen på många enheter. Rehabilitering i grupp var vanligast med aktiva åtgärder som till exempel träning. Rehabiliteringsperioden var vanligen 8-11 veckor, under vilken patienten träffade en fysioterapeut flera gånger i veckan. Teamen hade ett tätt samarbete med regelbundna teamträffar, uppföljningar och gemensamma åtgärder. Slutsats: Fysioterapeutens arbete inom MMR2 utgår från ett biopsykosocialt perspektiv där tyngdpunkten ligger i att återställa och/eller förbättra kroppsfunktion. Fysioterapeuterna har bred kompetens och lång erfarenhet vilket möjliggör att deras kunskaper om kroppen och rörelsesystemet kan integreras med åtgärder för beteendeförändring. Tillsammans med övriga yrkeskategorier täcker fysioterapeutens arbete in alla domäner i Klassifikation av funktionstillstånd, funktionshinder och hälsa (ICF). För en ökad förståelse kring vad som styr valet av fysioterapeutiska åtgärder inom MMR2 och hur arbetet med dessa åtgärder ser ut i den kliniska vardagen behövs fortsatt forskning. / Background: Chronic pain is a common cause for patients seeking care. The consequences of chronic pain can be seen at both individual and social level. Research has shown moderate to strong scientific support for multimodal rehabilitation (MMR) in complex pain problems. What the physiotherapist uses for interventions within MMR and how the collaboration with other occupational categories works is poorly described. Aim: To study what interventions physiotherapist’s use in multimodal pain rehabilitation in specialist care settings (MMR2) in Sweden. Methods: Web survey study where data was collected from 71 physiotherapists working at units connected to the Swedish Quality Registry for Pain Rehabilitation (SQRP). Results: The most common interventions were teaching/counseling and various forms of exercise. Strategies for behavioral change, mindfulness/body awareness and homework exercises are other commonly used interventions. Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT) were used in several stages of rehabilitation on many units. Rehabilitation in group were the most common form of work and the interventions are primarily patient active as physical activity. The rehabilitation period were usually 8-11 weeks, where the patient saw a physiotherapist several times a week. The teams worked closely with regular team meetings, follow-ups and sometimes joint actions such as patient education and group training. Conclusion: The physiotherapist's work in MMR2 is based on a biopsychosocial perspective where the focus lies in restoring and/or improving body function. Physiotherapists have broad competence and long experience, enabling their knowledge about the body and the movement system to be integrated with behavioral change technics. Together with other occupational categories, the physiotherapist's work covers all domains in the Functional Classification, Disability and Health Classification (ICF). For increased understanding of the choice of physiotherapeutic interventions within MMR2, and how these interverventions works in the clinical setting, further research is needed.

Chronic pain is usually defined as pain of more than three months duration. The prevalence of chronic pain among the general population in Sweden is 18%. Compared with the general population, these patients report lower life satisfaction, decreased activity in daily life and higher levels of depression with decreased work ability, and increased sick leave. Research indicates that multimodal rehabilitation (MMR) programmes, including cognitive behavioural approaches for patients disabled by chronic pain, are effective for return to work. The primary aim of this thesis was to assess outcomes by a long-term follow-up of patients with chronic musculoskeletal pain. Furthermore, the aim was to evaluate two different rehabilitation strategies regarding impact on pain intensity, activity, depression, life satisfactions, and sick leave. Two groups, comprising 255 (between the years 1999-2002) and 296 (between 2007-2008) patients respectively, from the Pain Rehabilitation Clinic at Umeå University Hospital, Sweden, were all assessed by interdisciplinary teams. They completed questionnaires regarding pain intensity, disability, life satisfaction, anxiety and depression, and sick leave, before intervention, immediately after intervention (only the first group; n=255), and at one-year follow-up, after participating in a MMR programme in a specialist clinic, or after receiving a rehabilitation plan (RP) with follow-up in primary care. Allocation to either of the two groups was based on the initial interdisciplinary team assessment. Furthermore, a five-year follow-up of 158 patients with whiplash injury was conducted. Pain intensity decreased and life satisfaction increased significantly regarding somatic health in both groups, at follow-up. In addition, depression improved and disability decreased to a higher extent after participating in the MMR programme as compared to RP and subsequent follow-up in primary care. Patients’ positive beliefs about recovery, and positive expectations about work correlated with favourable rehabilitation outcomes. Sick leave at one year follow-up decreased in both groups. Regarding whiplash injury, patients who reported moderate or severe disability also reported significantly higher pain intensity, depression and post-traumatic stress scores and lower perception of general health compared with patients who reported mild or no disability. In conclusion, MMR programmes seem to be beneficial by decreasing pain intensity, depression, disability and sick leave among patients with chronic musculoskeletal pain. Furthermore, patients’ positive beliefs correlate with more favourable long-term outcomes. An interdisciplinary team assessment based on a biopsychosocial approach may be of value for selection of rehabilitation strategy.

The purpose of this study is to describe the content and effects of implemented interventions for people with chronic pain in multimodal rehabilitation in primary careA literature study has been carried out, with a systematic review of all available studies of varying study designs that meet the study's inclusion criteria.Implementation of multimodal rehabilitation can have positive effects on the patient’s health. There is still no information about the care group that would be able to work together in a primary care to achieve the best results. / <p>Validerat; 20160830 (global_studentproject_submitter)</p>

Chronic pain is a complex health issue and a major cause of disability worldwide. Although multimodal rehabilitation (MMR) has been recognized as an effective form of treatment for chronic pain, some patients do not benefit from it. If treatment outcomes could be reliably predicted, then patients who would benefit more from MMR could be prioritized over others. Machine learning has been proven capable of accurately predicting outcomes in other healthcare related domains. Therefore, this study aims to investigate the use of it to predict outcomes of MMR, using data from the Swedish Quality Registry for Pain Rehabilitation (SQRP). XGBoost regression was used for this purpose, and its predictive performance was compared to Ridge regression. 12 models were trained on SQRP data for each algorithm, in order to predict pain and quality of life related outcomes. The results show similar performances for both algorithms, with mean cross-validated R² values of 0.323 and 0.321 for the XGBoost and Ridge models respectively. The average root mean squared errors of 6.744 for XGBoost and 6.743 for Ridge were similar as well. Since XGBoost performed similarly to a less computationally expensive method, the use of this method for MMR outcome prediction was not supported by the results of this study. However, machine learning has the potential to be more effective for this purpose, through the use of different hyperparameter values, correlation-based feature selection or other machine learning algorithms.

Personer med långvarig smärta är en stor patientgrupp inom primärvården i Sverige med olika bakgrund och hälsa. Interdisciplinärt multimodalt smärtrehabiliteringsprogram (IPRP) är en behandlingsmetod som används både i specialist- och primärvård för patienter med långvarig smärta. Denna studie är en retrospektiv registerstudie där svar från självrapporterade enkäter analyserats. Syftet var att undersöka om självskattad hälsorelaterad livskvalitet, fysisk funktion, aktivitetsnivå, ångest och depression skiljer sig mellan patienter med låg respektive hög utbildningsnivå hos de som genomgått IPRP för långvarig smärta inom primärvården i Sverige. Studien undersökte skillnader mellan grupperna både vid baslinje och 1-års uppföljning samt skillnader i förändring däremellan. Resultaten visade statistiskt signifikanta skillnader vid baslinje och 1-års uppföljning vad gäller hälsorelaterad livskvalitet och fysisk funktion. För ångest och depression var skillnaderna enbart signifikanta vid 1-års uppföljning. Skillnaden i förändring mellan grupperna var signifikant för ångest och depression. Gruppen med hög utbildningsnivå skattade högre hälsorelaterad livskvalitet och bättre fysisk funktion. Det var även en mindre andel patienter med diagnosen ångest och depression i den gruppen och de förbättrades i större utsträckning vad gäller ångest och depression. Denna studie indikerar att utbildningsnivå är en bakgrundsfaktor som hälso- och sjukvården bör ta hänsyn till för att bidra till en mer jämlik hälsa i befolkningen. Det behövs mer forskning där resultat jämförs mellan patienter med låg och hög utbildningsnivå som genomgått IPRP för långvarig smärta då detta är en forskningslucka.