<p>The present thesis is based on four empirical studies concerning risk factors related to musculoskeletal pain (MSP), disability, and sick leave among three non-clinical samples of health care staff. Initially, in Study I, cognitive, behavioural and environmental factors related to MSP of nurses' aides<b> </b>were explored. An experimental design including baseline, intervention and follow-ups among 29 nurses' aides<b> </b>working in a home for the elderly was used to evaluate effects of a workplace intervention based on cognitive behaviour (CB)- and conventional, symptom reduction principles. In Study II, a cross-sectional and correlational design was applied. A self-administered questionnaire was used to describe and investigate the relationship between risk factors and development of persistent pain, sick leave and long sick leave among 914 municipal health care staff. In Study III and IV, a longitudinal design was used among 200 registered nurses (RN) working in a county hospital to describe and predict pain, disability and sick leave. Data collection involved two self-administered questionnaires covering: 1) work and personal factors, pain, disability and sick leave at baseline and 2) valued life dimensions at baseline. The results showed that MSP was common among the staff. Study I showed positive effects among nurses' aides<b> </b>receiving the CB principles related to MSP compared with nurses' aides receiving the conventional principles. In Study II, pain severity and expectations to be working in 6 months were associated with persistent MSP and sick leave, respectively. In Study III, pain, disability and sick leave at baseline were the strongest predictors of pain, disability and sick leave at the three-year follow-up. In Study IV, the findings support the notion that individual values in different life domains are possible predictors of pain and disability. </p>

Background: In Sweden, as well as in most Western countries, sickness absence is a major public health problem that has increased in recent years. This is a complex phenomenon related not only to ill health factors, but also to other factors on the levels of the individual, the family, the workplace, and the society. Most studies of sickness absence are cross sectional, which makes it difficult to investigate aetiological factors. A longitudinal study design is preferable, because sick-leave spells can have a long duration and are often due to chronic or recurrent disorders. Objectives: The aim of the present research was to conduct a pilot study to gain further information about factors associated with sickness absence and disability pension, perceptions of contacts with rehabilitation professionals, and self-rated health over time among younger persons initially on sick leave with low-back, neck, or shoulder diagnoses. Material and methods: An eleven-year prospective cohort study of all individuals who, in 1985, were aged 25–34 years, lived in the municipality of Linköping, Sweden, and had a sick-leave spell ≥ 28 days with low-back, neck, or shoulder diagnoses (n = 213, 61% women). The following information was obtained from registers: number of sick-leave days and spells in 1982–1984; diagnosis and demographical data in 1985 (age, sex, occupation, citizenship, marital status, and income); data on each sick-leave period (date, full/part time), disability pension (date, diagnoses, temporary/permanent, full/part time); emigration (date), and death (date, cause) from 1985 to 1 September 1996. In 1996, a questionnaire was sent to members of the cohort (response rate 73%). Different measures were used to analyse sickness absence and disability pension over the eleven-year period, possible risk factors for disability pension were tested by Cox regression, and possible factors predicting future low levels of sickness absence were tested by logistic regression. Based on the questionnaire perceptions of encounters with rehabilitation professionals were analysed with factor analyses and linear regression, and the so called health-line (a method to collect data on self-rated health over time) was tested, and the results were compared with data on sickness absence and disability ension. Results: The members of the cohort turned out to be a high-risk group for disability pension. After 11 years, 26% of the women and 14% of the men had been granted such benefits, mainly due to musculoskeletal diagnoses, but also with psychiatric diagnoses for half of the men and 17% of the women. Full-time pension was granted more often to men than to women. The women had higher levels of sickness absence. An extended Cox regression model proved suitable for prediction of disability pension. Taking citizenship and long-term sickness absence into consideration, the women had a 1.9 times higher risk of being granted disability pension than the men. Predictors for future low levels of sickness absence were a history of low sickness absence, having a white-collar job, and being married. These associations were not discerned when a pathogenic approach was used, which implies that factors other than the opposite risk factor for disability pension are associated with future low sickness absence. Three dimensions of the individuals’ contacts with professionals were identified: supportive treatment, distant treatment, and empowering treatment. Women perceived both social insurance officers and health care professionals as more supportive than the men did. Contact with social insurance officers was experienced as more supportive and empowering by persons on disability pension than by those not receiving such benefits. Data collected using the health-line (i.e., self-rated health from 1985 to 1995) was correlated with data on annual mean number of sick-leave days and days on disability pension. No tendency to recall bias was noted. Conclusions: Additional research is needed to elucidate the situation of women on sick leave with low-back, neck, and shoulder diagnoses. Further testing and practical application of statistical and epidemiological models for analysing sickness absence and disability pension data should be carried out to ascertain the validity and usefulness of such models. / On the day of the public defence the status of the article I was: Submitted; article III was: Accepted; article IV was: Submitted and article V was: In press.

Stress-related diseases and burnout have increased in Sweden during the last decades. In 2006, the most common diagnoses for new cases of sickness compensation were mental and behavioural disorders in both women and men. In spite of the large group of people seeking care for and on long-term sickness absence due to stress-related diseases and burnout, there is no agreement on which treatment they should be offered. The overall aim of this thesis was to describe patients on longterm sick leave because of burnout and to evaluate rehabilitation programs for this patient group. Two patient samples were recruited from the Stress Clinic at the University Hospital in Umeå, Sweden: REST (Rehabilitation for stressrelated disease and burnout; n=136) and QIST (Qigong for stress-related disease and burnout; n=82). A general population sample was from the 2004 Northern Sweden MONICA survey (n=573). Patients in REST were randomised into a 1-year rehabilitation program to either program A (Cognitively-oriented Behavioural Rehabilitation (CBR) and Qigong), or to program B (Qigong alone). In Paper I, baseline data were compared with data from the MONICA sample. In paper II, programs A and B were compared regarding effects on psychological variables and sick leave rates, and in Paper III, 18 patients from program A and B were interviewed to explore subjective experiences of the rehabilitation programs. Patients in QIST were allocated to an intervention with Qigong twice a week for 12 weeks or a control group. Psychological and physical measurements were assessed in QIST. Data were collected by questionnaires, physical measurements, the register on sick leave, and interviews. Patients with burnout reported a more restricted social network and higher work demands than the general population. In relation to women from a general population, women with burnout more often worked “with people”, reported high job strain, a more sedentary work situation and less emotional support. A per-protocol analysis showed no significant differences in treatment effect between program A and B in REST or between the intervention and control group in QIST. All groups improved significantly over time with reduced levels of burnout, anxiety, depression, and fatigue. In REST, lower scores on obsessive-compulsive symptoms, stress behaviour, and sick leave rates were found in both programs and in QIST both groups increased dynamic balance and physical capacity. In an intention-to-treat analysis, patients in program A in REST had significantly fewer obsessive-compulsive symptoms, and larger effect sizes in stress behaviour and obsessive-compulsive symptoms compared to patients in program B. Patients in both REST programs perceived that the 1-year rehabilitation program gave them specific tools to use in secondary prevention. They also emphasised that the good encounters, affirmation and group cohesiveness they perceived during the 8 rehabilitation was a necessary basis for initiation of a behavioural change leading to recovery. In conclusion, compared to a general population, patients with burnout perceived more demands at work and less social support. Lack of emotional support seemed to be more associated with burnout among women. There were no differences in effect between CBR and Qigong compared to Qigong alone, or between a 12 week Qigong intervention compared to a control condition. Improvements were found in all groups in the rehabilitation programs. CBR combined with Qigong have some advantages compared to Qigong alone. An environment with good encounters and affirmation of the patients was experiences as important by the patients and group rehabilitation had advantages as recognition and support from the group. Early rehabilitation measures are important to prevent long-term sickness absence. In future rehabilitation programs it might be necessary to have a more individualized approach and choose treatments preferred by the patient.

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.

Background The psychosocial work environment affects our health (e.g., sick leave and mortality rates). Research on psychosocial work factors and burnout has focused on specific workplaces or occupations and rarely evaluated in the general population or used longitudinal designs. In Sweden, the diagnosis of exhaustion disorder (closely related to burnout) is a common cause for sick leave. The effects of psychosocial work environments on the process of returning to work has not been studied in this specific patient group. The overall aims of this thesis were to (1) assess the level of burnout in a working general population and investigate the importance of psychosocial work factors and sex on burnout, and (2) study reduction of sick leave and experiences of returning to work in burnout patients, with special attention towards psychosocial work factors. Methods An occupationally active subset (n=1000) of the 2004 Northern Sweden MONICA survey was used in a cross-sectional study. A five-year follow-up of this population was also performed (n=626). Level of burnout was measured using the Shirom Melamed Burnout Questionnaire (SMBQ). Burnout patients were studied for the second thesis aim. A cohort of 117 patients from the REST project was investigated using a baseline questionnaire and sick leave data at two-year follow-up. Grounded Theory was used for an in-depth interview and analysis of 12 employed patients. Results Cross-sectional results from the working general population showed that women have higher levels of burnout than men. In both sexes, work demands, work control, and job insecurity were associated with burnout levels. Among women, education, socioeconomic position, work object, and working hours were also important. Work factors in combination with situational life factors explained about half the difference in burnout level between women and men. Longitudinal results show that burnout levels decrease with age in both sexes, although the changes occur at an earlier age for men. A constant job strain, increased job insecurity, and a worsened economic situation are related to an increase in burnout level. When studying risk factor accumulation, each additional risk factor exposure increases the burnout level. In burnout patients, low work control and use of covert coping towards supervisors and workmates predicts unchanged sick leave levels after a twoyear period. Borderline significance was found between work overcommitment and reduced sick leave. Both personal resources and external support are described as important factors when regaining the ability to work. Perceived validation, insights into the situation and adaptive coping skills increase the chance of regaining the ability to work. External support, particularly from the workplace, is also important. Conclusion There are links between psychosocial work factors and burnout levels in a working general population and sick leave levels in burnout patients. Socioeconomic position and working conditions are important for the level of burnout among working women. In the working population, age differences occur between the sexes; women reduce their burnout levels later in life than men. In the burnout patient population, coping patterns and control at work predict sick leave levels after two years. Both internal resources and external support are important when burnout patients describe the process of regaining the ability to work. The workplace and the work environment are important in preventing working people from becoming burned out and in easeing return to work after sick leave. A person’s coping pattern is also important in reduction of sick leave.

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.

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.

The present thesis is based on four empirical studies concerning risk factors related to musculoskeletal pain (MSP), disability, and sick leave among three non-clinical samples of health care staff. Initially, in Study I, cognitive, behavioural and environmental factors related to MSP of nurses' aides<b> </b>were explored. An experimental design including baseline, intervention and follow-ups among 29 nurses' aides<b> </b>working in a home for the elderly was used to evaluate effects of a workplace intervention based on cognitive behaviour (CB)- and conventional, symptom reduction principles. In Study II, a cross-sectional and correlational design was applied. A self-administered questionnaire was used to describe and investigate the relationship between risk factors and development of persistent pain, sick leave and long sick leave among 914 municipal health care staff. In Study III and IV, a longitudinal design was used among 200 registered nurses (RN) working in a county hospital to describe and predict pain, disability and sick leave. Data collection involved two self-administered questionnaires covering: 1) work and personal factors, pain, disability and sick leave at baseline and 2) valued life dimensions at baseline. The results showed that MSP was common among the staff. Study I showed positive effects among nurses' aides<b> </b>receiving the CB principles related to MSP compared with nurses' aides receiving the conventional principles. In Study II, pain severity and expectations to be working in 6 months were associated with persistent MSP and sick leave, respectively. In Study III, pain, disability and sick leave at baseline were the strongest predictors of pain, disability and sick leave at the three-year follow-up. In Study IV, the findings support the notion that individual values in different life domains are possible predictors of pain and disability.

Objectives The aim of this thesis was to assess the importance of general practitioners (GP) and patient related factors for the GPs’ decision to sick certify or not to sick certify the patients. Study population and methods The data were obtained from a cross-sectional questionnaire study of GP-patient consultations. 65 GPs responded to one questionnaire about themselves and one questionnaire about each of the altogether 642 consultations. The patients responded to a questionnaire about themselves and the consultation, altogether 521 consultations. Various combinations of the three questionnaires were used in the four papers on which this thesis is based. Results Among GPs, long experience of family medicine and working part-time were significant determinants for issuing more sick leave certificates. Complaints perceived as clearly somatic by the physician decreased the chance of sick certifications, and complaints resulting in severe limitation of occupational work capacity, as assessed by the patient as well as the physician, increased the chance of sick certification, as did appointments for loco-motor complaints. Among work related factors, high ‘authority over decisions’ and high ‘social support’ were associated with reduced sickness certification probability. Worrying about illness or injury risks from work increased sickness certification. GPs and their patients took a fairly similar view to statements on health related and insurance system related matters. GPs’ opinions seem to have a greater impact than patients’ on the GPs’ decision to sickness certify a patient or not. Conclusions A number of patient and GP related factors were associated with the probability of getting sick certified. The patient’s own judgement of impaired work ability was important for sickness certification, but a shared judgement and decision between the GP and the patient appears probable in most cases. / Försäkringsmedicin

Vi har gjort en fallstudie av hur rehabiliteringen har fungerat för två kvinnor anställda i en svensk kommun. Syftet med denna studie har varit att ta reda på om rehabilitering tillbaka till arbetslivet skiljer sig åt mellan två kvinnor med liknande medicinska besvär i denna kommun. Kvinnor i vårdyrket får ofta förslitningsskador och som följd blir många sjukskrivna. Vi vet av tidigare forskning att det är yngre män i städer som återgår till arbete i högre grad än kvinnor. På landsbyggden kommer sällan kvinnor tillbaka till arbetslivet efter sjukskrivning. Vi har i denna studie intervjuat två kvinnor med ryggbesvär som arbetar inom äldreomsorgen  och en arbetsledare (AL). Vi har studerat kvinnornas väg tillbaka till arbete från sjukskrivning. Vi har jämfört likheter och olikheter i deras process. Vi använde oss av en kvalitativ insamlingsmetod och fallstudie som undersökningsmetod. Det vi kom fram till var att för en kvinna gick det fort att komma tillbaka till arbete och för den andra tog det längre tid trotts likartade förutsättningar. Olikheter fanns i kontakten med arbetsledaren (AL). I ett fall var Försäkringskassan (FK) drivand att kvinnan skulle pensioneras och i det andra fallet att kvinnan skulle åter till arbete.