ABSTRACT Background: Patellofemoral pain syndrome (PFPS) is commonly seen in athletes and common symptoms are for example pain and stiffness, and difficulty in climbing stairs. Physiotherapy exercise interventions aim to increase the range of motion, strength, knee stability, balance, and functional ability. Shaping knowledge with patient education is a behaviour change technique that has proven important in musculoskeletal pain. How patient education can contribute to positive outcomes for physiotherapy exercise interventions in PFPS is unknown. Aim: To describe the effects of physiotherapy exercise interventions including patient education for adult and adolescent athletes with patellofemoral pain syndrome. Method: In a systematic literature review, only randomized controlled trials, on patients with a primary diagnosis of PFPS, published in English, were included. The data search was conducted by PICO in Pubmed and CINAHL. The methodological quality of the included studies was assessed by using the SBU checklist. Results: Six randomized controlled studies were included. According to the quality assessment the included studies had moderate to high quality and the outcome measures of the included studies were reliable and valid for measuring pain intensity, health-related quality of life, physical function, isometric muscle strength, and fear of movement. The results showed that physiotherapy interventions including patient education led to improved symptoms, functional ability, and health-related quality of life (HRQoL) for patients with patellofemoral pain syndrome in adult and adolescent athletes. Conclusion: Physiotherapy exercise interventions including patient education appear to increase physical function, muscle strength, and health-related quality of life and decrease pain and fear of movement for adult and adolescent athletes with patellofemoral pain syndrome. The conclusions are tentative as the review of the study quality for the included studies implied that four studies had a moderate risk of bias.

Bakgrund: Graviditetsrelaterad bäcken- och/eller ländryggssmärta drabbar många kvinnor och ett stort antal har kvarstående besvär postpartum. Många kvinnor tenderar dessutom att bli fysiskt inaktiva under och efter graviditet. Fysioterapeutiska åtgärder som avser att minska besvär och optimera rörelseförmåga hos denna patientgrupp ges främst ur ett biomedicinskt perspektiv. Nya studier har dock indikerat att fysioterapeutiska åtgärder som beaktar bio-psyko-sociala faktorer är värdefullt. Syfte: Syftet med studien är att undersöka hur kvinnor med graviditetsrelaterad bäcken- och/eller ländryggssmärta postpartum upplever att deras fysiska aktivitetsnivå påverkats av fysioterapeutiska åtgärder. Metod: Studien genomfördes med en kvalitativ, deskriptiv design och data samlades in under sju semistrukturerade intervjuer. Data analyserades genom en kvalitativ innehållsanalys med induktiv ansats. Resultat: Analysen resulterade i fem kategorier: Åtgärder som minskar fysiska besvär ökar förmågan till aktivitet, Individanpassade åtgärder betydelsefullt för ökad aktivitet, Fysioterapeutens kompetens avgörande för aktivitet, Fysioterapeutens bemötande och attityd påverkar behandlingsupplevelsen samt Förståelse för hur aktivitet påverkar besvär främjar rörelse. Slutsats: Resultatet i studien indikerar att fysioterapeutiska åtgärder som integrerar ett bio-psyko-socialt förhållningssätt gynnar ökad fysisk aktivitet hos kvinnor med bäcken- och/eller ländryggssmärta postpartum. Kvinnorna uppgav vidare att fysioterapeutens kompetens samt bemötande och attityd påverkar aktivitetsnivå och huruvida besvären förbättras eller inte. / Background: Pregnancy-related pelvic and/or low back pain affects many women, and a significant number of women have persistent pain postpartum. A lot of women tend to become physically inactive during and after pregnancy. Physiotherapeutic interventions that aim to decrease discomfort and optimize mobility are given foremost from a biomedical approach for this patient group. However, recent studies have indicated that physical therapy interventions that consider a bio-psycho-social approach are valuable. Objective: The purpose of this study is to investigate how women with pregnancy-related pelvic and/or low back pain postpartum experience that their level of physical activity is affected by physiotherapeutic interventions. Method: The study was conducted with a qualitative, descriptive design and data was collected through seven semi-structured interviews. Data were analyzed through a qualitative content analysis with an inductive approach. Results: The analysis resulted in five categories: Interventions to decrease physical discomfort increase the ability to become more active, Individual constructed interventions important for increased activity, The physiotherapist competence is decisive for activity, The physiotherapist approach and attitude affects treatment experience and Understanding how activity affect discomfort promotes movement. Conclusion: This study indicates that physiotherapeutic interventions that integrate a biopsychosocial approach promote increased level of physical activity in women with pregnancy-related pelvic and/or low back pain postpartum. The women further stated that the physiotherapist's competence as well as approach and attitude affect the level of activity and if the discomfort improves or not.

A few scholars have argued that the Internet is a valuable channel for social marketing, and that practitioners need to rethink how they engage with target audiences online. However, there is little evidence that online social marketing interventions can significantly influence behaviours, while there are few evidence-based guidelines to aid online intervention design. This thesis assesses the efficacy of online interventions suitable for social marketing applications, presents a model to integrate behavioural change research, and examines psychological principles that may aid the design of online behavioural change interventions.The primary research project used meta-analytical techniques to assess the impact of interventions targeting voluntary behaviours, and examined psychological design and adherence correlations. The study found that many online interventions demonstrated the capacity to help people achieve voluntary lifestyle changes. Compared to waitlist control conditions, the interventions demonstrated advantages, while compared to print materials they offered similar impacts, but with the advantages of lower costs and broader reach. A secondary research project surveyed users across an international public mobilization campaign and used structural equation modelling to assess the relationships between website credibility, active trust, and behavioural impacts. This study found that website credibility and active trust were factors in behavioural influence, while active trust mediated the effects of website credibility on behaviour. The two research projects demonstrated that online interventions can influence an individual’s offline behaviours. Effective interventions were primarily goal-orientated: they informed people about the consequences of their behaviour, encouraged them to set goals, offered skills-building support, and tracked their progress. People who received more exposure to interventions generally achieved greater behavioural outcomes. Many of these interventions could be incorporated into social marketing campaigns, and offer individually tailored support capable of scaling to massive public audiences. Communication theory was used to harmonize influence taxonomies and techniques; this proved to be an effective way to organize a diversity of persuasion, therapy, and behavioural change research. Additionally, website credibility and users’ active trust could offer a way to mitigate the negative impacts of online risks and competition.

<p>This thesis deals with clinical pain intervention research from a behavioural medicine perspective. The general aim was to develop and evaluate an individually tailored treatment protocol focused on pain management in everyday life in people who experience persistent musculoskeletal pain. Another aim was to develop and incorporate an idiographic outcome measure for behavioural goal assessment in the formal evaluation of the clinical significance of treatment outcomes. </p><p>The studies were conducted in a primary health care setting demonstrating a contribution from physical therapists in the field of behavioural medicine. Two separate samples of patients with musculoskeletal pain with a duration exceeding one month, n = 197 (Study I, descriptive and correlational design), and n = 97/82 (Study III/IV, randomized group-study) were included. In addition, four women were recruited for a series of experimental single-case studies (Study II).</p><p>The treatment protocol that was individually tailored to each participant’s behavioural treatment goals and assumed determinants of pain-related disability was more effective in reducing pain-related disability, pain intensity, fear-avoidance, and in increasing pain control when compared to an intervention including physical exercises. The individually tailored treatment was generally more beneficial for resumption of everyday life activity, increasing satisfaction, fulfilling pre-treatment expectations, and in preparing individuals for self-management of pain. The Patient Goal Priority Questionnaire that was elaborated over the course of the project can be used to a) identify and assess behavioural treatment goals, b) elaborate individual functional behavioural analyses relevant for everyday life functioning, and c) determine the clinical significance of treatment outcomes – that is, whether interventions produce outcomes of relevance for each individual’s everyday life. The inclusion of idiographic outcome measures in clinical pain intervention research is necessary and improves the ecological validity of the evaluation of clinical significance. </p>

This thesis deals with clinical pain intervention research from a behavioural medicine perspective. The general aim was to develop and evaluate an individually tailored treatment protocol focused on pain management in everyday life in people who experience persistent musculoskeletal pain. Another aim was to develop and incorporate an idiographic outcome measure for behavioural goal assessment in the formal evaluation of the clinical significance of treatment outcomes. The studies were conducted in a primary health care setting demonstrating a contribution from physical therapists in the field of behavioural medicine. Two separate samples of patients with musculoskeletal pain with a duration exceeding one month, n = 197 (Study I, descriptive and correlational design), and n = 97/82 (Study III/IV, randomized group-study) were included. In addition, four women were recruited for a series of experimental single-case studies (Study II). The treatment protocol that was individually tailored to each participant’s behavioural treatment goals and assumed determinants of pain-related disability was more effective in reducing pain-related disability, pain intensity, fear-avoidance, and in increasing pain control when compared to an intervention including physical exercises. The individually tailored treatment was generally more beneficial for resumption of everyday life activity, increasing satisfaction, fulfilling pre-treatment expectations, and in preparing individuals for self-management of pain. The Patient Goal Priority Questionnaire that was elaborated over the course of the project can be used to a) identify and assess behavioural treatment goals, b) elaborate individual functional behavioural analyses relevant for everyday life functioning, and c) determine the clinical significance of treatment outcomes – that is, whether interventions produce outcomes of relevance for each individual’s everyday life. The inclusion of idiographic outcome measures in clinical pain intervention research is necessary and improves the ecological validity of the evaluation of clinical significance.

Psychosocial oncology is well established in Europe and in America. Similar initiatives are, however, rare in Africa. On the African continent, psychosocial services are scarce and often a luxury although the importance of psychosocial variables as mediators in the paediatric cancer outcomes have been widely recognised. The apartheid system in South Africa was instrumental in causing major disparities in health, education and socioeconomic status. In order to provide a more holistic service it becomes imperative to assess not only the psychosocial needs and resources of both children and parents who endure the disease but also the influence of socio-demographic variables such as race, educational level and socioeconomic status. This research was limited to collecting baseline information on how parents and children communicate about the illness, emotional responses and the psychological resources that they utilise to deal with the childhood cancer trajectory. The study group consisted of 100 children between the ages of 5 and 16 years who had been diagnosed with cancer and one or both parents of those children. Data was collected through semi-structured interviews and standardised self-report measures. The results of the study indicate that both parents and children did not suffer disabling psychopathology, but certainly evidenced symptoms of depression and anxiety indicative of adjustment difficulties. Communicating about the illness was generally limited to physiological aspects of the disease and medically related matters, while emotional issues were rarely articulated. Children, parents and their siblings relied heavily on medical staff for their information needs. The age of the child was a significant factor with reference to amount and complexity of information imparted to children: adolescents were given more information about the treatment and prognosis; while younger children were given a limited amount of information. Race, socioeconomic status and educational levels of parents not only influenced the meanings and beliefs families developed around the cancer experience, but also the manner in which they expressed their emotions and the coping strategies that they employed. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2004.

Bakgrund och syfte: Huvudvärk av spänningstyp (HST) är vanligt förekommande. Det finns oklarheter avseende både dess patofysiologi och olika behandlingars effekt. Syftet med denna studie var att beskriva och utvärdera effekten av en individuellt anpassad beteendemedicinsk behandling i fysioterapi för patienter med HST. Metod: En single-case studie med A1-A2-B-A3-design av tre patienter med HST genomfördes. Utfallsvariabler var huvudvärksfrekvens (antal dagar med huvudvärk), huvudvärksindex (medelintensitet), konsumtion av smärtlindrande medicin, tro på sin förmåga avseende kontroll av huvudvärken, samt upplevd påverkan av huvudvärken på funktion i vardagsaktiviteter och på glädje i aktiviteter med familj och vänner. Resultat: Tro på sin förmåga avseende kontroll av huvudvärken ökade markant för 2 av 3 patienter. Huvudvärksfrekvens och huvudvärksindex minskade markant för en av patienterna. En av patienterna svarade först inte alls på behandlingen, men blev mycket bättre inför den sista uppföljningen avseende huvudvärksindex och funktion och glädje i aktiviteter. Diskussion och konklusion: Ett beteendemedicinskt förhållningssätt i behandling som grundar sig på funktionell beteendeanalys kan vara ett sätt att som fysioterapeut hantera patienter med HST. HST är en vid diagnosgrupp och det verkar då logiskt att behandlingen bör anpassas individuellt för att få bästa effekt. / Background and aim: Tension-type headache (TTH) is common. There are uncertainties regarding both the pathophysiology and the effect of treatments. The aim of this study was to describe and evaluate the effect of an individually tailored behavioural medicine treatment in physiotherapy, based on a functional behavioural analysis. Method: A single-case study with A1-A2-B-A3-design of three patients with TTH was performed. Outcome variables were headache frequency (days with headache), headache index (mean intensity), consumption of analgesics, headache management self-efficacy (HMSE), disability and feelings of loss of happiness in activities with family and friends. Results: HMSE increased markedly for 2 of 3 patients. Headache frequency and headache index decreased for one of the patients. One of the tree patients did not first respond to treatment but was much better before the last follow-up regarding headache index, disability and loss of happiness. Discussion and conclusion: A behavioural medicine treatment in physiotherapy based on a functional behavioural analysis can be a way for physiotherapists to handle patients with TTH. Since the diagnosis TTH is heterogenic it seems logical that the treatment should be individually tailored.

Einleitung: Für Patienten mit chronischen Schmerzen wird eine interdisziplinäre Versorgung gefordert. In der Praxis arbeiten Spezialdisziplinen jedoch häufig nebeneinander, ohne dass es zu fallbezogener Zusammenarbeit kommt. Unsere Studie zeigt, wie sich der Übergang vom psychosomatischen Konsil- zum Liaisonsystem und die Vernetzung mit einer Psychosomatischen Fachklinik sowie krankengymnastischen Praxen auf Diagnostik und Therapie in einer interdisziplinären Schmerzambulanz auswirkt. Patienten und Methoden: In einer retrospektiven Erhebung wurden alle innerhalb von 6 Monaten vor (N = 165) und nach (N = 277) dem Übergang vom Konsil- zum Liaisonsystem in der Schmerzambulanz gesehenen Patienten erfasst. Aus den Krankenakten wurden medizinische Diagnosen, anästhesistische Therapie, Indikation zum psychotherapeutischen Erstgespräch (Depressivität, somatische Beschwerden) und dessen Ergebnis erhoben. Patienten, bei denen ein psychotherapeutisches Erstgespräch vorgesehen war (N = 94), wurden schriftlich und telefonisch nachbefragt. Ergebnisse: Im Liaisonsystem wurde signifikant häufiger als im Konsildienst psychotherapeutische Diagnostik angefordert (25,6% vs. 13,9%) und durchgeführt (63,3% vs. 30,4%). Der Anteil interdisziplinär betreuter Patienten stieg von 4,2% auf 16,2%. Der Anteil an Patienten, die eine empfohlene Psychotherapie durchführten, blieb mit über 80% konstant hoch. Häufigste indizierte Therapieform war die Verhaltenstherapie (72,7%), häufig kombiniert mit einem körpertherapeutischen Verfahren (32,7%). Von den Therapien wurden 66,8% ambulant, 16,6% stationär und 16,6% als ambulant/ stationäre Kombination durchgeführt. Schlussfolgerung: Im Liaisonsystem wurden signifikant mehr Patienten interdisziplinär betreut als im Konsilsystem. Die gleichbleibend hohe Akzeptanz der vorgeschlagenen Psychotherapie zeigt, dass Patienten die einer Psychotherapie zunächst ambivalent oder ablehnend gegenüberstehen, dazu motiviert werden können. Die enge Kooperation verschiedener Versorgungsstrukturen führte zu einem hohen Anteil interdisziplinär und methodenübergreifend durchgeführter Behandlungen. / Introduction: The effectiveness of multidisciplinary treatment of chronic pain with an emphasis on a cognitive behavioural approach is clearly shown by randomised controlled trials. However, it is difficult to motivate patients with chronic pain for this type of treatment. We compared the effectiveness of a consultation model and a liaison model of co-operation between an outpatient pain clinic and a psychosomatic department in creating motivation for psychotherapy. Patients and Methods: In a retrospective design we collected data of all patients seen in the pain clinic during 6 months before (N = 165) and 6 months after (N = 277) changing from a consultation to a liaison model. Clinical data were documented by the Multiaxial Pain Classification (MPC). Level of depression was assessed by Depression-Scale (DS), somatic complaints by list of complaints (BL). Results: In the liaison model diagnostic sessions with the consulting psychotherapist were significantly more often recommended by physicians in the pain clinic (25,6% vs. 13,9%) and accepted by patients (63,3% vs. 30,4%) compared to the consultation model. In either system 80% of the patients accepted the recommended psychotherapy. After changing to the liaison type of co-operation, there was a significant decrease in prescription of opioid and benzodiazepine drugs. Conclusion: The liaison model of co-operation was significantly more effective in enhancing physician’s and patient’s motivation for a psychosomatic approach in the management of chronic pain. Psychotherapy is better accepted by patients suffering from chronic pain if it is offered in a multidisciplinary context and in the familiar surroundings of the pain clinic. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Einleitung: Für Patienten mit chronischen Schmerzen wird eine interdisziplinäre Versorgung gefordert. In der Praxis arbeiten Spezialdisziplinen jedoch häufig nebeneinander, ohne dass es zu fallbezogener Zusammenarbeit kommt. Unsere Studie zeigt, wie sich der Übergang vom psychosomatischen Konsil- zum Liaisonsystem und die Vernetzung mit einer Psychosomatischen Fachklinik sowie krankengymnastischen Praxen auf Diagnostik und Therapie in einer interdisziplinären Schmerzambulanz auswirkt. Patienten und Methoden: In einer retrospektiven Erhebung wurden alle innerhalb von 6 Monaten vor (N = 165) und nach (N = 277) dem Übergang vom Konsil- zum Liaisonsystem in der Schmerzambulanz gesehenen Patienten erfasst. Aus den Krankenakten wurden medizinische Diagnosen, anästhesistische Therapie, Indikation zum psychotherapeutischen Erstgespräch (Depressivität, somatische Beschwerden) und dessen Ergebnis erhoben. Patienten, bei denen ein psychotherapeutisches Erstgespräch vorgesehen war (N = 94), wurden schriftlich und telefonisch nachbefragt. Ergebnisse: Im Liaisonsystem wurde signifikant häufiger als im Konsildienst psychotherapeutische Diagnostik angefordert (25,6% vs. 13,9%) und durchgeführt (63,3% vs. 30,4%). Der Anteil interdisziplinär betreuter Patienten stieg von 4,2% auf 16,2%. Der Anteil an Patienten, die eine empfohlene Psychotherapie durchführten, blieb mit über 80% konstant hoch. Häufigste indizierte Therapieform war die Verhaltenstherapie (72,7%), häufig kombiniert mit einem körpertherapeutischen Verfahren (32,7%). Von den Therapien wurden 66,8% ambulant, 16,6% stationär und 16,6% als ambulant/ stationäre Kombination durchgeführt. Schlussfolgerung: Im Liaisonsystem wurden signifikant mehr Patienten interdisziplinär betreut als im Konsilsystem. Die gleichbleibend hohe Akzeptanz der vorgeschlagenen Psychotherapie zeigt, dass Patienten die einer Psychotherapie zunächst ambivalent oder ablehnend gegenüberstehen, dazu motiviert werden können. Die enge Kooperation verschiedener Versorgungsstrukturen führte zu einem hohen Anteil interdisziplinär und methodenübergreifend durchgeführter Behandlungen. / Introduction: The effectiveness of multidisciplinary treatment of chronic pain with an emphasis on a cognitive behavioural approach is clearly shown by randomised controlled trials. However, it is difficult to motivate patients with chronic pain for this type of treatment. We compared the effectiveness of a consultation model and a liaison model of co-operation between an outpatient pain clinic and a psychosomatic department in creating motivation for psychotherapy. Patients and Methods: In a retrospective design we collected data of all patients seen in the pain clinic during 6 months before (N = 165) and 6 months after (N = 277) changing from a consultation to a liaison model. Clinical data were documented by the Multiaxial Pain Classification (MPC). Level of depression was assessed by Depression-Scale (DS), somatic complaints by list of complaints (BL). Results: In the liaison model diagnostic sessions with the consulting psychotherapist were significantly more often recommended by physicians in the pain clinic (25,6% vs. 13,9%) and accepted by patients (63,3% vs. 30,4%) compared to the consultation model. In either system 80% of the patients accepted the recommended psychotherapy. After changing to the liaison type of co-operation, there was a significant decrease in prescription of opioid and benzodiazepine drugs. Conclusion: The liaison model of co-operation was significantly more effective in enhancing physician’s and patient’s motivation for a psychosomatic approach in the management of chronic pain. Psychotherapy is better accepted by patients suffering from chronic pain if it is offered in a multidisciplinary context and in the familiar surroundings of the pain clinic. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

This thesis is comprised of four studies and concerns haemodialysis patients’ confidence in being able to manage fluid intake between treatment sessions, and whether the fluid intake is influenced by certain modifiable characteristics of the persons in question. The overall aim was to study aspects of excessive fluid overload and haemodialysis patients’ self-regulation of fluid allotment from a bio-psychosocial and behavioural medicine perspective. The extent of non-adherence to fluid allotment was described in Study I. National registry data were used. Three out of ten Swedish haemodialysis patients had excessive fluid overload and one out of five was at risk for treatment related complications due to too rapid ultrafiltration rate. The objective in Study II was to develop and psychometrically evaluate a self-administered scale to measure situation-specific self-efficacy to low fluid intake. The measure (the Fluid Intake Appraisal Inventory) was found to be reliable and valid in haemodialysis settings. Subgroups based on individual profiles of self-efficacy, attentional style and depressive symptoms were explored in Study III using a cluster analytic approach. Three distinct subgroups were found and the subgroup structure was validated for clinical relevance. The individuals’ profile concerning self-efficacy, attentional style and depressive symptoms has to be taken into account in nursing interventions designed to reduce haemodialysis patients’ fluid intake. In Study IV, an intervention designed to reduce haemodialysis patients’ fluid intake was introduced and its acceptability, feasibility and efficacy were evaluated and discussed. Acceptability of such an intervention was confirmed. Addressing beliefs, behaviours, emotions and physical feelings is clinically feasible and may reduce haemodialysis patient’s excessive fluid overload. This thesis indicates that there is a potential for improvement in the fluid management care of haemodialysis patients. Behavioural nursing strategies that aim to assist patients to achieve fluid control should be applied more extensively. Cognitive profiles of the patients should be taken into account when targeted nursing intervention aiming to encourage and maintain the patient’s fluid control is introduced.