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  • 1.
    Calner, Tommy
    et al.
    Luleå University of Technology, Department of Health Sciences, Health and Rehabilitation.
    Nordin, Catharina
    Luleå University of Technology, Department of Health Sciences, Health and Rehabilitation.
    Eriksson, Margareta K.
    Department of Public Health, Norrbotten County Council, Luleå.
    Nyberg, Lars
    Luleå University of Technology, Department of Health Sciences, Health and Rehabilitation.
    Gard, Gunvor
    Luleå University of Technology, Department of Health Sciences, Health and Rehabilitation.
    Michaelson, Peter
    Luleå University of Technology, Department of Health Sciences, Health and Rehabilitation.
    Effects of a self-guided, web-based activity programme for patients with persistent musculoskeletal pain in primary healthcare: A randomized controlled trial2017In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 21, no 6, p. 1110-1120Article in journal (Refereed)
    Abstract [en]

    BACKGROUNDWeb-based interventions for pain management are increasingly used with possible benefits, but never used in addition to multimodal rehabilitation (MMR). MMR is recommended treatment for persistent pain in Sweden. The aim was to evaluate the effects of a self-guided, web-based programme added to MMR for work ability, pain, disability and health-related quality of life.METHODSWe included 99 participants with persistent musculoskeletal pain in a randomized study with two intervention arms: (1) MMR and web-based intervention, and (2) MMR. Data was collected at baseline, 4 and 12 months. Outcome measures were work ability, working percentage, average pain intensity, pain-related disability, and health-related quality of life.RESULTSThere were no significant effects of adding the web-based intervention to MMR regarding any of the outcome variables.CONCLUSIONSThis trial provides no support for adding a self-guided, web-based activity programme to MMR for patients with persistent musculoskeletal pain.SIGNIFICANCEThe comprehensive self-guided, web-based programme for activity, Web-BCPA, added to multimodal treatment in primary health care had no effect on work ability, pain, disability or health-related quality of life. Future web-based interventions should be tailored to patients' individual needs and expectations

  • 2.
    Gard, Gunvor
    et al.
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    Zingmark, Karin
    Luleå University of Technology, Department of Health Sciences, Nursing Care.
    Nyberg, Lars
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    Eriksson, Margareta K.
    Department of Public Health, Norrbotten County Council, Luleå.
    Michaelson, Peter
    Luleå University of Technology, Department of Health Sciences, Health and Rehab. peter.michaelson@ltu.se .
    Nordin, Catharina
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    Calner, Tommy
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    Multimodal pain rehabilitation (MMR) with additional tailored web-based pain rehabilitation: an RCT study2014Conference paper (Other academic)
  • 3.
    Nordin, Catharina
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    Patient participation in and treatment effects of multimodal rehabilitation and the web Behaviour Change Program for Activity2016Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The overall aim was to explore experiences of patient participation in pain rehabilitation among patients with persistent musculoskeletal pain, and investigate effects of multimodal rehabilitation (MMR) and a self-guided web-based intervention. Qualitative interviews were conducted with women and men (between 23 to 60 years) with persistent musculoskeletal pain. Their experiences of patient participation prior to MMR, within MMR, and withinMMR in combination with the web Behaviour Change Program for Activity (web-BCPA) were analysed with qualitative content analysis (study I – III). A randomized controlled trial with two intervention arms: 1) MMR in combination with the web-BCPA (MMR+WEB), and 2) MMR, was performed in the primary healthcare to investigate treatment effects of pain intensity (Visual Analogue Scale), self-efficacy to control pain and other symptoms (ArthritisSelf-Efficacy Scale), general self-efficacy (General Self-Efficacy Scale), coping (Two-item Coping Strategies Questionnaire), and patient participation. Adherence, feasibility and satisfaction with treatment were also evaluated. The patients were 85 women and 14 men (mean age 43 years) with persistent musculoskeletal pain for 6.5 years (m) (study IV). The findings showed that patient participation can be understood as complex and individualized (I – III). Patients’ emotional and cognitive resources and restrictions, as well ashealthcare professionals’ attitudes and behaviours were important to patient participation (I, II, III). Experiences of patient participation prior to MMR indicated a search for recognition and an alienation from the healthcare system (I). Patients experienced satisfying patient participation within MMR (II) and within MMR in combination with the web-BCPA (III). Patient participation was to take part in a structured and flexible rehabilitation frameworkcharacterized by co-operation with healthcare professionals (II, III), and solitary work in the web-BCPA (III). Being confirmed in the interaction with healthcare professionals in MMR (II, III), and in interaction with the web-BCPA (III) was fundamental to patient participation. Being confirmed included to be recognized as a patient and as a person (II, III), as well as to perceive trustworthiness and to be able to identify one-self in the rehabilitation (III).Situations of mistrust and disrespect in contacts with the healthcare professionals were experienced as restrained patient participation (I, II, III). Patient participation included various experiences of knowledge and insights: the patients’ knowledge not being acknowledged (I), experiencing a lack of knowledge (II), and experiences of acquiring knowledge and insights (III). Behaviour change was included in patients’ experiences of patient participation (III). Further, the findings showed that MMR in combination with the web-BCPA decreased patients’ catastrophic thinking about their pain (p = .003) over time, compared to MMR (IV). Also, patients in the MMR+WEB group were more satisfied with their multimodal rehabilitation, at 4 (p = .000) and 12 months (p = .003) (IV).There were no differences between the MMR+WEB group and the MMR group regarding the other six subscales of the Two-item Coping Strategies Questionnaire. Nor were there any differences between thegroups for pain intensity, self-efficacy, and patient participation. However, there were significant decrease of average pain (p = .000) over time in the whole study group (MMR+WEB and MMR) (IV). The web-BCPA adherence was 304 minutes (m), with range between 0 to 1142 minutes, and the patients opened in average 5.1 modules out of eight (IV). Patients rated feasibility and satisfaction with the web-BCPA acceptable to excellent (62 to 93/ 100). Due to the large variation of time spent in the web-BCPA a sub-group analysis oflower (LQ) and upper quartile (UQ) of time spent was performed. The study groups were small (fourteen patients in each group) but the results showed a trend that the UQ had higher scores regarding web-BCPA feasibility and satisfaction, and LQ had lower scores. In conclusion, patients’ emotions and cognitions were in focus in patient participation. Experiences of patient participation prior to MMR were understood as a search forrecognition in the healthcare system. In contrast, patients experienced satisfying patientparticipation and being confirmed within MMR and within MMR in combination with the web-BCPA. Patients in MMR in combination with the self-guided web-BCPA decreased their catastrophic thinking about pain. Also, they were more satisfied with their multimodal rehabilitation.

  • 4.
    Nordin, Catharina
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    Patients’ experiences of patient participation prior to and within multimodal pain rehabilitation2013Licentiate thesis, comprehensive summary (Other academic)
    Abstract [en]

    Patient participation is a concept used to describe the patients’ involvement in their healthcare. The aim of this licentiate thesis was to explore primary healthcare patients’ experiences of patient participation prior to and within multimodal pain rehabilitation. Qualitative interviews were conducted with seventeen patients, 14 women and 3 men, who had completed multimodal pain rehabilitation for persistent pain. Data was analyzed using qualitative content analysis.The findings show that patient participation can be understood as a complex and individualized interaction between the patient and the healthcare professionals. There were both positive and negative experiences of patient participation prior to, as well as within the multimodal rehabilitation. Experiences prior to the multimodal pain rehabilitation indicated a lack of patient participation including a search of recognition and an alienation from the healthcare system. Patients experienced satisfying patient participation within the multimodal rehabilitation, which was described as a continuous exchange of emotions and cognitions between the patients and the healthcare professionals. Patients’ emotions and cognitions were important in the patient – healthcare interaction and for patient participation. A confidence-inspiring alliance with the healthcare professionals, built on mutual trust and respect, was experienced as a basis for patient participation. The patients experienced unfulfilled medical needs, being unconfirmed, and having their point of view disregarded by healthcare professionals, to limit patient participation. Insufficient communication with the healthcare professionals was also perceived restricting patient participation. The patients emphasized that healthcare professionals needed to play an active role to include the patients in dialogue and to build common ground in the interaction. The healthcare professionals’ expertise, empathy and personal qualities were important for patient participation.In conclusion, patients with persistent pain had experiences of poor patient participation from encounters with healthcare professionals prior to multimodal pain rehabilitation. In contrast, these patients then experienced satisfying patient participation within the multimodal pain rehabilitation. Healthcare professionals need to play an active role in developing a relationship and finding common ground, through confirmation and dialogue, to increase patient participation in rehabilitation planning and decision-making.

  • 5.
    Nordin, Catharina
    et al.
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    Fjellman-Wiklund, Anncristine
    Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University.
    Gard, Gunvor
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    In search of recognition: patients’ experiences of patient participation prior to multimodal pain rehabilitation2014In: European Journal of Physiotherapy, ISSN 2167-9169, E-ISSN 2167-9177, Vol. 16, no 1, p. 49-57Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to explore primary healthcare patients’ experiences of patient participation prior to multimodal pain rehabilitation. Data was collected from interviews with 17 patients, aged 23–59 years, after completing multimodal rehabilitation. Data was analysed using qualitative content analysis. The theme, In search of recognition, depicted patient participation prior to the multimodal pain rehabilitation as a lack of recognition in the healthcare system. A demand for medical help and the healthcare professionals’ preferential right to interpret the patients’ condition formed the category Need for medical affirmation. In the category Emotional and cognitive alienation, patients emphasized distress when being unconfirmed. This entailed an emotional and cognitive distance between the patients and the healthcare professionals. Situational factors, together with patients’ emotional and cognitive prerequisites and patients’ strategies to be included in dialogue represented the category Need to communicate, which influenced the opportunities to participate. For healthcare professionals, it is important to understand that patients in multimodal pain rehabilitation may have experiences of a clinician-centred behaviour in the past. Patients may have been unconfirmed and their point of view disregarded. For the future, greater effort for dialogue and patients’ involvement in decision-making and rehabilitation planning is needed.

  • 6.
    Nordin, Catharina
    et al.
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    Gard, Gunvor
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    Fjellman-Wiklund, Anncristine
    Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University.
    Being in an exchange process: experiences of patient participation in multimodal pain rehabilitation2013In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 45, no 6, p. 580-586Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To explore primary healthcare patients’ experiences of patients participation in multimodal pain rehabilitation. Patients and methods: A total of 17 patients who had completed multimodal rehabilitation for persistent pain were interviewed. The interviews were analysed using qualitative content analysis. RESULTS: One theme, Being in an exchange process, and 4 categories emerged. The theme depicted patient participation as a continuous exchange of emotions, thoughts and knowledge. The category Fruitful encounters represented the basic prerequisites for patient participation through dialogue and platforms to meet. Patients’ emotional and cognitive resources and restrictions, as well as knowledge gaps, were conditions influencing patient participation in the category Inequality in co-operation. Mutual trust and respect were crucial conditions in patient’s personal relationships with the health professionals, forming the category Confidence-inspiring alliance. In the category Competent health professionals, the health professionals’ expertise, empathy and personal qualities, were emphasized to favour patient participation. CONCLUSION: Patient participation can be understood as complex and individualized. A confidence-inspiring alliance enables a trusting relationship to be formed between patients and health professionals. Patients emphasized that health professionals need to play an active role in building common ground in the interaction. Understanding each patient’s needs in the participation process may favour patient participation.

  • 7.
    Nordin, Catharina
    et al.
    Luleå University of Technology, Department of Health Sciences, Health and Rehabilitation. Department of Primary Health Care, Region Norrbotten, Piteå.
    Michaelson, Peter
    Luleå University of Technology, Department of Health Sciences, Health and Rehabilitation.
    Eriksson, Margareta K.
    Luleå University of Technology, Department of Health Sciences, Health and Rehabilitation. Department of Public Health, Norrbotten County Council, Luleå.
    Gard, Gunvor
    Luleå University of Technology, Department of Health Sciences, Health and Rehabilitation.
    It's about me: patients’ Experiences of Patient Participation in the Web Behavior Change Program for Activity in Combination With Multimodal Pain Rehabilitation2017In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 19, no 1, p. 62-72, article id e22Article in journal (Refereed)
    Abstract [en]

    Background

    Patients’ participation in their health care is recognized as a key component in high-quality health care. Persons with persistent pain are recommended treatments with a cognitive approach from a biopsychosocial explanation of pain, in which a patient’s active participation in their rehabilitation is in focus. Web-based interventions for pain management have the potential to increase patient participation by enabling persons to play a more active role in rehabilitation. However, little is known about patients’ experiences of patient participation in Web-based interventions in clinical practice.

    Objective

    The objective of our study was to explore patients’ experiences of patient participation in a Web Behavior Change Program for Activity (Web-BCPA) in combination with multimodal rehabilitation (MMR) among patients with persistent pain in primary health care.

    Methods

    Qualitative interviews were conducted with 15 women and 4 men, with a mean age of 45 years. Data were analyzed with qualitative content analysis.

    Results

    One theme, “It’s about me,” and 4 categories, “Take part in a flexible framework of own priority,” “Acquire knowledge and insights,” “Ways toward change,” and “Personal and environmental conditions influencing participation,” were developed. Patient participation was depicted as being confirmed in an individualized and structured rehabilitation framework of one’s own choice. Being confirmed was fundamental to patient participation in the interaction with the Web-BCPA and with the health care professionals in MMR. To acquire knowledge and insights about pain and their life situation, through self-reflection in the solitary work in the Web-BCPA and through feedback from the health care professionals in MMR, was experienced as patient participation by the participants. Patient participation was described as structured ways to reach their goals of behavior change, which included analyzing resources and restrictions, problem solving, and evaluation. The individual’s emotional and cognitive resources and restrictions, as well as health care professionals and significant others’ attitudes and behavior influenced patient participation in the rehabilitation. To some extent there were experiences of restrained patient participation through the great content of the Web-BCPA.

    Conclusions

    Patient participation was satisfactory in the Web-BCPA in combination with MMR. The combined treatment was experienced to increase patient participation in the rehabilitation. Being confirmed through self-identification and finding the content of the Web-BCPA trustworthy was emphasized. Patient participation was experienced as a learning process leading to new knowledge and insights. Higher user control regarding the timing of the Web-BCPA and therapist guidance of the content may further increase patient participation in the combined treatment.

  • 8.
    Nordin, Catharina
    et al.
    Luleå University of Technology, Department of Health Sciences, Health and Rehab. Department of Primary Health Care, Norrbotten County Council.
    Michaelson, Peter
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    Gard, Gunvor
    Luleå University of Technology, Department of Health Sciences, Health and Rehab.
    Eriksson, Margareta K.
    Luleå University of Technology, Department of Health Sciences, Health and Rehab. Department of Primary Health Care, Norrbotten County Council.
    Effects of the Web Behavior Change Program for Activity and Multimodal Pain Rehabilitation: Randomized Controlled Trial2016In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 18, no 10, p. 24-41, article id 265Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Web-based interventions with a focus on behavior change have been used for pain management, but studies of Web-based interventions integrated in clinical practice are lacking. To emphasize the development of cognitive skills and behavior, and to increase activity and self-care in rehabilitation, the Web Behavior Change Program for Activity (Web-BCPA) was developed and added to multimodal pain rehabilitation (MMR).

    OBJECTIVE:

    The objective of our study was to evaluate the effects of MMR in combination with the Web-BCPA compared with MMR among persons with persistent musculoskeletal pain in primary health care on pain intensity, self-efficacy, and copying, as part of a larger collection of data. Web-BCPA adherence and feasibility, as well as treatment satisfaction, were also investigated.

    METHODS:

    A total of 109 participants, mean age 43 (SD 11) years, with persistent pain in the back, neck, shoulder, and/or generalized pain were recruited to a randomized controlled trial with two intervention arms: (1) MMR+WEB (n=60) and (2) MMR (n=49). Participants in the MMR+WEB group self-guided through the eight modules of the Web-BCPA: pain, activity, behavior, stress and thoughts, sleep and negative thoughts, communication and self-esteem, solutions, and maintenance and progress. Data were collected with a questionnaire at baseline and at 4 and 12 months. Outcome measures were pain intensity (Visual Analog Scale), self-efficacy to control pain and to control other symptoms (Arthritis Self-Efficacy Scale), general self-efficacy (General Self-Efficacy Scale), and coping (two-item Coping Strategies Questionnaire; CSQ). Web-BCPA adherence was measured as minutes spent in the program. Satisfaction and Web-BCPA feasibility were assessed by a set of items.

    RESULTS:

    Of 109 participants, 99 received the allocated intervention (MMR+WEB: n=55; MMR: n=44); 88 of 99 (82%) completed the baseline and follow-up questionnaires. Intention-to-treat analyses were performed with a sample size of 99. The MMR+WEB intervention was effective over time (time*group) compared to MMR for the two-item CSQ catastrophizing subscale (P=.003), with an effect size of 0.61 (Cohen d) at 12 months. There were no significant between-group differences over time (time*group) regarding pain intensity, self-efficacy (pain, other symptoms, and general), or regarding six subscales of the two-item CSQ. Improvements over time (time) for the whole study group were found regarding mean (P<.001) and maximum (P=.002) pain intensity. The mean time spent in the Web-based program was 304 minutes (range 0-1142). Participants rated the items of Web-BCPA feasibility between 68/100 and 90/100. Participants in the MMR+WEB group were more satisfied with their MMR at 4 months (P<.001) and at 12 months (P=.003).

    CONCLUSIONS:

    Adding a self-guided Web-based intervention with a focus on behavioral change for activity to MMR can reduce catastrophizing and increase satisfaction with MMR. Patients in MMR may need more supportive coaching to increase adherence in the Web-BCPA to find it valuable.

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