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  • 1. Asenlof, Pernilla
    et al.
    Denison, Eva
    Lindberg, Per
    Mälardalen University, School of Health, Care and Social Welfare.
    Long-term follow-up of tailored behavioural treatment and exercise based physical therapy in persistent musculoskeletal pain: A randomized controlled trial in primary care2009In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 13, no 10, 1080-1088 p.Article in journal (Refereed)
    Abstract [en]

    This study examined long-term effects of a tailored behavioural treatment protocol (TBT), as compared with an exercise based physical therapy protocol (EBT). One-hundred and twenty-two patients who, due to persistent musculoskeletal pain, consulted physical therapists in primary care were originally randomized to either of the two conditions. Follow-up assessments two-year post-treatment were completed by 65 participants. According to per-protocol analyses, short-term effects were maintained in both groups for the primary outcome, pain-related disability. The TBT-group reported lower disability levels compared with the EBT-group. Intention-to-treat analyses (ITT) conveyed similar results. Secondary outcomes of pain intensity, pain control, and functional self-efficacy were maintained over the 2-year post-treatment, but previous group differences were levelled out according to the most conservative method of ITT. Fear of movement/(re)injury increased in the EBT-group, and EBT participants reported higher fear of movement/(re)injury two years post-treatment compared to TBT. The study supports tailoring of treatments in concordance with patients' needs and preferences of activity goals and functional behavioural analyses including predictors of pain-related disability, for successful immediate outcomes and their maintenance in the long run. Exercise-based treatments resulted in somewhat smaller immediate treatment effects but had similar maintenance of effects over the 2-year follow-up period.

  • 2.
    Asenlöf, Pernilla
    et al.
    Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University, Uppsala.
    Denison, Eva
    Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University, Uppsala.
    Lindberg, Per
    Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University, Uppsala.
    Idiographic outcome analyses of the clinical significance of two interventions for patients with musculoskeletal pain.2006In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 44, no 7, 947-65 p.Article in journal (Refereed)
    Abstract [en]

    This study adopted a perspective of the individual to define domains of everyday life for the analysis of clinically meaningful change. The purpose was to compare the clinical significance of two interventions for patients with musculoskeletal pain, applying an idiographic outcome measure, The Patient Goal Priority Questionnaire, in combination with the Jacobson and Truax methodology [(1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 67 (3), 300-307] for determination of clinical significance. The concurrent validity of the outcome variables behavioral performance, satisfaction with behavioral performance, and fulfilled pre-treatment expectations was also studied. Eighty-two patients, randomized to either individually tailored behavioral medicine treatment (experimental group) or physical exercise therapy (control group) were evaluated at baseline and 3 months post-treatment regarding behavioral treatment goals. The experimental intervention had high impact on participants' performance of their highest ranked everyday life activities, and resulted in larger proportions of clinically significant outcomes compared with controls. The concurrent validity of the outcomes was high for those reporting clinically significant changes, but more generally, there was a moderate agreement across outcome categories. The individual should be the unit for analyses of clinical significance to enhance the ecological validity of the construct. Further development of idiographic outcome measures is necessary, as is the inclusion in pain intervention research.

  • 3.
    Asenlöf, Pernilla
    et al.
    Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University, Uppsala.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Lindberg, Per
    Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University, Uppsala.
    Individually tailored treatment targeting activity, motor behavior, and cognition reduces pain-related disability: a randomized controlled trial in patients with musculoskeletal pain.2005In: Journal of Pain, ISSN 1526-5900, E-ISSN 1528-8447, Vol. 6, no 9, 588-603 p.Article in journal (Refereed)
    Abstract [en]

    This study compares the outcomes of an individually tailored behavioral medicine intervention (experimental) with physical exercise therapy (control). The experimental intervention was systematically individualized according to each participant's behavioral treatment goals and functional behavioral analyses. One hundred twenty-two patients seeking care at 3 primary health care clinics because of musculoskeletal pain were randomized. Ninety-seven completed the trial. Data were collected at baseline, immediately after treatment, and at a 3-month follow-up. Analyses of data from completers, as well as intention-to-treat analyses, showed that the experimental group experienced lower levels of disability (P = .01), lower maximum pain intensity (P = .02), higher levels of pain control (P = .001), and lower fear of movement (P = .022) as a result of treatment condition. Self-efficacy (P = .0001) and physical performance (P = .0001) increased over time for both groups. Participants in the experimental group generally reported more positive effects after treatment. Treatment fidelity was maintained during the course of the study. Activity can be resumed and pain might be managed by the patients themselves if treatment incorporates the biopsychosocial explanatory model of pain and strategies are tailored according to individual's priorities of everyday life activities and empirically derived determinants of pain-related disability. PERSPECTIVE: This study shows that the biomedical and the psychosocial perspectives of the experiences and consequences of pain complement rather than contradict each other. Primary health care patients with persistent musculoskeletal pain benefit more from a systematic tailoring of treatments according to biopsychosocial factors than from a physically based exercise intervention.

  • 4.
    Asenlöf, Pernilla
    et al.
    Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University, Uppsala.
    Denison, Eva
    Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University, Uppsala.
    Lindberg, Per
    Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University, Uppsala.
    Individually tailored treatment targeting motor behavior, cognition, and disability: 2 experimental single-case studies of patients with recurrent and persistent musculoskeletal pain in primary health care.2005In: Physical Therapy, ISSN 0031-9023, E-ISSN 1538-6724, Vol. 85, no 10, 1061-77 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: This article introduces an individually tailored intervention targeting motor behavior, cognition, and disability in patients managed by physical therapists in primary health care. Effects on self-rated disability, pain intensity, and pain control are described. SUBJECTS: Two women with recurrent or persistent disabling musculoskeletal pain were selected. METHODS: Two experimental single-subject A(1)-B-C-A(2) studies with multiple baselines across situations were used. Principal outcome data were collected daily with patient-specific continuous measures for 3 weeks before intervention, continuously during intervention, and for 2 weeks during each of the 1-, 4-, 6-, and 12-month follow-up examinations. RESULTS: Disability and pain intensity decreased, and pain control increased in both subjects. The results were maintained at the follow-up examinations. DISCUSSION AND CONCLUSION: Positive outcomes of the intervention were reported from 2 subjects with recurrent and persistent disabling pain. Procedures for systematic tailoring of treatment to behavioral goals and individual patient characteristics are available as a result of the successful application. The results need to be replicated in future clinical controlled group studies.

  • 5.
    Berglund, K M
    et al.
    Uppsala University.
    Persson, B H
    Uppsala University.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare. Uppsala University.
    Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain2008In: Manual therapy, ISSN 1532-2769, Vol. 13, no 4, 295-299 p.Article in journal (Refereed)
    Abstract [en]

    The purpose of this study was to survey the prevalence of pain in the cervical and thoracic spine (C2-T7) in persons with and without lateral elbow pain. Thirty-one subjects with lateral elbow pain and 31 healthy controls participated in the study. The assessment comprised a pain drawing, provocation tests of the cervical and thoracic spine, a neurodynamic test of the radial nerve, and active cervical range of motion. Seventy percent of the subjects with lateral elbow pain indicated pain in the cervical or thoracic spine, as compared to 16% in the control group (p<0.001). The frequency of pain responses to the provocation tests of the cervical and thoracic spine was significantly higher (p<0.05) in the lateral elbow pain (LEP) group, as was the frequency of pain responses to the neurodynamic test of the radial nerve (p<0.001). Cervical flexion and extension range of motion was significantly lower (p<0.01) in the LEP group. The results indicate a relation between lateral elbow pain and pain in the vertebral spine (C2-T7). The cervical and thoracic spine should be included in the assessment of patients with lateral elbow pain.

  • 6.
    Cederbom, S.
    et al.
    Oslo and Akershus University College of Applied Sciences, Oslo, Norway.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Bergland, A.
    Oslo and Akershus University College of Applied Sciences, Oslo, Norway.
    A behavioral medicine intervention for community-dwelling older adults with chronic musculoskeletal pain: Protocol for a randomized controlled trial2017In: Journal of Pain Research, ISSN 1178-7090, E-ISSN 1178-7090, Vol. 10, 845-853 p.Article in journal (Refereed)
    Abstract [en]

    Background: Chronic musculoskeletal pain is a major health problem among older adults, particularly those who live alone and/or those who are dependent on formal care. Chronic pain is associated with mobility problems, falls, fear of falling, catastrophizing thoughts, and a lower quality of life. Research shows that physical therapy interventions based on behavioral medicine approaches are beneficial for middle-aged adults with chronic pain. However, there appears to be no previous randomized controlled trials (RCTs) based on this theoretical framework that have examined the effect on older adults with chronic musculoskeletal pain who live alone at home and are dependent on formal care to manage their everyday lives. The aim of the planned study is to evaluate the effect of an individually tailored integrated physical therapy intervention based on a behavioral medicine approach compared with the effect of standard care. Methods/design: The planned study is an RCT that will include one intervention and one control group involving a total of 150 adults aged ≥75 years with chronic musculoskeletal pain who live alone at home and are dependent on formal care to manage their everyday lives. The intervention will involve a 12-week home-based individually tailored intervention that will be designed to enhance the participants’ ability to perform everyday activities by improving physical function and reducing pain-related disability and beliefs. The control group will be given standard care, including general advice about physical activity. The participants will be assessed at baseline and at 3 and 6 months after baseline. The primary outcome will be pain-related disability and physical performance. Discussion: The intervention, if effective, will have the potential to be the basis of the first evidence-based guidelines for physical therapists who work with older adults with chronic musculoskeletal pain. 

  • 7.
    Cederbom, Sara
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Rydwik, Elisabeth
    Jakobsbergs Hosp, Sweden.
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Frandin, Kerstin
    Karolinska Inst, Sweden.
    Petra, von Heideken Wågert
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    A behavioral medicine intervention for older women living alone with chronic pain - a feasibility study2014In: Clinical Interventions in Aging, ISSN 1176-9092, E-ISSN 1178-1998, Vol. 9, 1383-1397 p.Article in journal (Refereed)
    Abstract [en]

    Background: To be an older woman, live alone, have chronic pain, and be dependent on support are all factors that may have an impact on daily life. One way to promote ability in everyday activities in people with pain-related conditions is to use individualized, integrated behavioral medicine in physical therapy interventions. How this kind of intervention works for older women living alone at home, with chronic pain, and dependent on formal care to manage their everyday lives has not been studied. The aim was to explore the feasibility of a study and to evaluate an individually tailored integrated behavioral medicine in physical therapy intervention for the target group of women. Materials and methods: The study was a 12-week randomized trial with two-group design. Primary effect outcomes were pain-related disability and morale. Secondary effect outcomes focused on pain-related beliefs, self-efficacy for exercise, concerns of falling, physical activity, and physical performance. Results: In total, 23 women agreed to participate in the study and 16 women completed the intervention. The results showed that the behavioral medicine in physical therapy intervention was feasible. No effects were seen on the primary effect outcomes. The experimental intervention seemed to improve the level of physical activity and self-efficacy for exercise. Some of the participants in both groups perceived that they could manage their everyday life in a better way after participation in the study. Conclusion: Results from this study are encouraging, but the study procedure and interventions have to be refined and tested in a larger feasibility study to be able to evaluate the effects of these kinds of interventions on pain-related disability, pain-related beliefs, self-efficacy in everyday activities, and morale in the target group. Further research is also needed to refine and evaluate effects from individualized reminder routines, support to collect self-report data, safety procedures for balance training, and training of personnel to enhance self-efficacy.

  • 8.
    Cederbom, Sara
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    von Heideken Wågert, Petra
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Chronic pain among older women living alone. A study focusing on disability and morale.2014In: European Journal of Physiotherapy, ISSN 2167-9169, E-ISSN 2167-9177, Vol. 16, no 3, 139-150 p.Article in journal (Refereed)
    Abstract [en]

    Purpose: To investigate 1)how older women who are living alone perceive chronic musculoskeletal pain,Activities of Daily Living (ADL), physical activity, affective distress,pain-related beliefs, pain management, and rate pain-related disability andmorale,  2) the relationships betweendemographic variables, ADL, physical activity, affective distress, pain-relatedbeliefs, and pain management with pain-related disability and morale.Method: The study had across-sectional and correlational design. Sixty women, living alone with chronicpain and community support aged ≥65 years were included.Results: The women were on average 81 years old and had lived with pain forabout 21.5 years. They reported low scores of affective distress,catastrophizing thoughts and self-efficacy, high scores of fear of movement,low degrees of pain-related disability, and low levels of  morale. The multiple regression analysisshowed that only catastrophizing thoughts significantlyexplained the variation in pain-related disability, and both affective distress and catastrophizing thoughtssignificantly explained the variation in morale. Conclusion: These older women livingalone with chronic pain reported similar prevalence ofchronic pain and pain-related disability but lower morale when comparingthe results with similar studies about older people in the same age group orolder people who are in need of help to manage their daily life. The only variable that was independely associated to bothpain-related disability and morale was catastrophizing. Further researchshould focus on identifying catastrophizing thougts,and also on developing a rehabilitation program based on a biopsychosocialperspective with the goal to decrease catastrophizing, pain-relateddisability, and increase morale for this target group

  • 9.
    Cederbom, Sara
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. Karolinska Institutet, Huddinge, Sweden; The Unit for Rehabilitation in the municipality of Eskilstuna, Sweden.
    Thunborg, Charlotta
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Söderlund, Anne
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    von Heideken Wågert, Petra
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Home Help Service Staffs' Descriptions of Their Role in Promoting Everyday Activities Among Older People in Sweden Who Are Dependent on Formal Care.2017In: Journal of Applied Gerontology, ISSN 0733-4648, E-ISSN 1552-4523, Vol. 36, no 8, 971-992 p.Article in journal (Refereed)
    Abstract [en]

    The study aimed to explore how home help service staff described their role in improving the abilities of older people, in particular, older women with chronic pain who are dependent on formal care, to perform everyday activities. Three focus group interviews were conducted, and a qualitative inductive thematic content analysis was used. The analysis resulted in one theme: struggling to improve the care recipients' opportunities for independence but being inhibited by complex environmental factors. By encouraging the care recipients to perform everyday activities, the staff perceived themselves to both maintain and improve their care recipients' independence and quality of life. An important goal for society and health care professionals is to improve older people's abilities to "age in place" and to enable them to age independently while maintaining their quality of life. A key resource is home help service staff, and this resource should be utilized in the best possible way.

  • 10.
    Demmelmaier, Ingrid
    et al.
    Uppsala University.
    Lindberg, Per
    Uppsala University.
    Åsenlöf, Pernilla
    Uppsala University.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare.
    The associations between pain intensity, psychosocial variables, and pain duration/recurrence in a large sample of persons with nonspecific spinal pain.2008In: The Clinical journal of pain, ISSN 1536-5409, Vol. 24, no 7, 611-619 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The aims of this study were: (1) to describe and compare pain intensity, disability, cognitive, physical, behavioral, and environmental variables in 4 predefined categories, on the basis of duration and recurrence of nonspecific spinal pain; and (2) to compare disability, cognitive, physical, behavioral, and environmental variables in these 4 predefined categories, after controlling for pain intensity. METHODS: Postal questionnaires were sent to a random sample of 5000 persons, aged 20 to 50 years, in Sweden. The response rate was 39%. One thousand and twenty-four participants reporting spinal pain were divided into 4 predefined categories (n=100, 215, 172, and 537) based on duration and recurrence of pain. Multivariate analyses of variance and covariance were performed to investigate differences between the 4 pain duration/recurrence groups. RESULTS: The first analyses revealed that the 4 pain duration/recurrence groups differed in pain intensity, disability, 7 cognitive variables, and perceived social support. After controlling for pain intensity, small but significant group differences were identified in depression, catastrophizing, pain expectations, and perceived social support. Higher levels of catastrophizing and pain expectations and lower levels of perceived social support were seen in groups with longer duration of pain. DISCUSSION: After controlling for pain intensity, categories based on pain duration/recurrence differed in 3 cognitive variables and perceived social support. Pain expectations, catastrophizing and perceived social support were related to longer duration of pain. Between-group differences were small and pain duration/recurrence was not an important explanatory factor.

  • 11.
    Denison, Eva
    et al.
    Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala University.
    Asenlöf, P
    Lindberg, P
    Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care.2004In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 111, no 3, 245-52 p.Article in journal (Refereed)
    Abstract [en]

    This study examined the relations between disability, as measured by the Pain Disability Index (PDI) and self-efficacy, fear avoidance variables (kinesiophobia and catastrophizing), and pain intensity, using a prospective design. Two primary health care samples (n(1)=210; n(2)=161) of patients with subacute, chronic or recurring musculoskeletal pain completed sets of questionnaires at the beginning of a physiotherapy treatment period. Multiple hierarchial regression analyses showed that self-efficacy explained a considerably larger proportion of the variance in disability scores than the fear avoidance variables in the first sample. This finding was replicated in the second sample. Pain intensity explained a small, but significant proportion of the variance in disability scores in one sample only. Gender, age, and pain duration were not related to disability. These findings suggest that self-efficacy beliefs are more important determinants of disability than fear avoidance beliefs in primary health care patients with musculoskeletal pain. The findings also suggest that pain-related beliefs, such as self-efficacy and fear avoidance, in turn, are more important determinants of disability than pain intensity and pain duration in these patients.

  • 12.
    Denison, Eva
    et al.
    Mälardalen University, School of Health, Care and Social Welfare.
    Asenlöf, Pernilla
    Uppsala University, Uppsala, Sweden.
    Sandborgh, Maria
    Mälardalen University, School of Health, Care and Social Welfare. Uppsala University, Uppsala, Sweden.
    Lindberg, Per
    Uppsala University, Uppsala, Sweden.
    Musculoskeletal pain in primary health care: subgroups based on pain intensity, disability, self-efficacy, and fear-avoidance variables2007In: Journal of Pain, ISSN 1526-5900, E-ISSN 1528-8447, Vol. 8, no 1, 67-74 p.Article in journal (Refereed)
    Abstract [en]

    The purpose of this study was to identify and describe subgroup profiles based on self-reported pain intensity, disability, self-efficacy, fear of movement/(re)injury, and catastrophizing in patients with musculoskeletal pain. Two primary health care samples (n = 215 and n = 161) were used. Self-report questionnaires were completed at the start of physical therapy treatment. Cluster analysis was used to generate subgroups. Three subgroups were identified in sample 1 and replicated in sample 2. These were labeled "High self-efficacy-Low fear-avoidance," "Low self-efficacy-Low fear-avoidance," and "Low self-efficacy-High fear-avoidance." The subgroups differed significantly in work-status in both samples (P < .001), but not in age, gender, or duration of pain. The results show the presence of subgroups based on pain intensity, disability, self-efficacy, fear of movement/(re)injury, and catastrophizing. The profile patterns suggest that different management strategies may be relevant in each subgroup. PERSPECTIVE: This article presents subgroups of patients with musculoskeletal pain with different profiles in pain intensity, disability, and psychosocial variables possible to modify by physical therapy management. The results could potentially aid clinicians in tailoring assessment and treatment approaches to each subgroup.

  • 13.
    Emilson, C.
    et al.
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    Demmelmaier, I.
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    Bergman, S.
    Research and Development Center Spenshult, Halmstad, Sweden.
    Lindberg, P.
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Åsenlöf, P.
    Department of Public Health, and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    A 10-year follow-up of tailored behavioural treatment and exercise-based physiotherapy for persistent musculoskeletal pain2017In: Clinical Rehabilitation, ISSN 0269-2155, E-ISSN 1477-0873, Vol. 31, no 2, 186-196 p.Article in journal (Refereed)
    Abstract [en]

    Objective: To study the long-term outcomes of two interventions targeting patients with sub-acute and persistent pain in a primary care physiotherapy setting. Design: A 10-year follow-up of a two-armed randomised controlled trial, initially including 97 participants. Interventions: Tailored behavioural medicine treatment, applied in a physiotherapy context (experimental condition), and exercise-based physiotherapy (control condition). Main measures: Pain-related disability was the primary outcome. The maximum pain intensity, pain control, fear of movement, sickness-related absence (register data) and perceived benefit and confidence in coping with future pain problems were the secondary outcomes. Results: Forty-three (44%) participants responded to the follow-up survey, 20 in the tailored behavioural medicine treatment group and 23 in the exercise-based physiotherapy group. The groups did not differ in terms of the change in the scores for the primary outcome (p=0.17) of pain-related disability between the experimental group (median: 2.5, Q1-Q3: -2.5-14.25), and the control group (median: 0, Q1-Q3: -5-6). Further, there were also no significant differences found for the secondary outcomes except for sickness-related absence, where the exercise-based physiotherapy group had more days of sickness-related absence three months before treatment (p= 0.02), and at the 10-year follow-up (p=0.03). Discussion: The beneficial effects favouring tailored behavioural medicine treatment that observed post-treatment and at the two-year follow-up were not maintained 10 years after treatment.

  • 14.
    Hammer, C.
    et al.
    PrimärvårdsRehab Södra, Rehab Årsta, Årsta, Sweden.
    Degerfeldt, L.
    tockholm Norr sjukgymnastik, Åkersberga, Sweden.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Mechanical diagnosis and therapy in back pain: Compliance and social cognitive theory2007In: Advances in Physiotherapy, ISSN 1403-8196, E-ISSN 1651-1948, Vol. 9, no 4, 190-197 p.Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to describe social cognitive theory (SCT) constructs and exercise compliance, and to explore relations between SCT variables and exercise compliance in patients with lumbar derangement syndrome during mechanical diagnosis and therapy (MDT) treatment. Fifty-eight subjects completed the study. The data collection included measures relevant to SCT constructs and compliance: outcome expectations and expectancies, self-efficacy expectations, behavioural capability, and self-reported frequency of exercise occasions, as well as treatment outcomes regarding pain intensity and disability. Data were collected at five occasions during treatment and during a 2-month follow-up period. The subjects received a mean of three movements (range one to five) as home exercises. The mean number of weeks with these exercises was 4 (range 1-6). High median scores were found in all variables related to SCT. The median compliance rates varied between 79% (week 1) and 91% (week 3) during treatment. During the first follow-up month, the compliance rate was 79% and during the second month of follow-up 62%. Pain intensity and disability decreased during treatment. Although there were no significant correlations between the SCT variables and exercise compliance, the descriptive data are in line with SCT.

  • 15. Nilsagård ., Y.
    et al.
    Denison, Eva
    Mälardalen University, Department of Caring and Public Health Sciences.
    Gunnarsson, LG.
    Evaluating a single session with cooling garment for persons with multiple sclerosis –: a randomised trial.2006In: Disability and Rehabilitation: Assistive Technology, ISSN 1748-3107, E-ISSN 1748-3115, Vol. 1, 225-233 p.Article in journal (Refereed)
  • 16.
    Nilsagård, Y.
    et al.
    Örebro University Hospital, Sweden.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Gunnarsson, L. -G
    Örebro University Hospital, Sweden.
    Evaluation of a single session with cooling garment for persons with multiple sclerosis-a randomized trial2006In: Disability and Rehabilitation: Assistive Technology, ISSN 1748-3107, E-ISSN 1748-3115, Vol. 1, no 4, 225-233 p.Article in journal (Refereed)
    Abstract [en]

    Purpose. This research investigates the objective and subjective effects of wearing the Rehband® cooling garment. Method. A multi-centre, randomized crossover study was conducted regarding 43 heat-sensitive persons with multiple sclerosis (MS), comparing active treatment with placebo. Subjects were tested immediately before and after intervention. Ten- (10TW) and 30-metre timed walk (30TW), oral temperature, spasticity, standing balance and timed up and go (TUG) and nine-hole peg test (NHPT) performance were measured. A study-specific questionnaire was used to evaluate subjective experiences. Results. Active treatment produced statistically significant objective improvement in 10TW, 30TW, one-legged stance, tandem stance (right) and TUG; statistically significant subjective improvement was also found in fatigue, spasticity, weakness, balance, gait, transfers, ability to think clearly and time to recover. The coherence between the objective and subjective results indicates clinical relevance from the subjects' perspective. There were no statistically significant differences between treatments in terms of oral temperature, spasticity (measured by the modified Ashworth scale), tandem stance (left), step test or NHPT, or subjective signs such as difficulty in dressing, dysarthria or pain. Conclusions. Active cooling with a Rehband® vest is likely to have a positive effect on everyday life in heat-sensitive persons with MS.

  • 17.
    Nilsagård, Y.
    et al.
    Örebro University Hospital, Örebro, Sweden.
    Gunnarsson, L. -G
    Örebro University Hospital, Örebro, Sweden.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Self-perceived limitations of gait in persons with multiple sclerosis2007In: Advances in Physiotherapy, ISSN 1403-8196, E-ISSN 1651-1948, Vol. 9, no 3, 136-143 p.Article in journal (Refereed)
    Abstract [en]

    This study aimed to describe the self-perceived walking limitations of those with multiple sclerosis (MS) using the Swedish translation of the 12-item MS Walking Scale [MSWS-12 (S)], and to investigate it for concurrent validity and internal consistency. Eighty-one persons, recruited from five centres in Sweden, were tested using the Four Square Step Test (FSST), the Timed Up and Go cognitive (TUGcog) and the Berg Balance Scale (BBS) in randomized order, besides filling in the MSWS-12 (S). Perceived limitations were reported in 89-96% of the sample, i.e. performance of activities related to standing or walking, decreased speed and distance, and qualitative aspects; and self-perception regarding the ability to run being most extremely affected. Correlations between the MSWS-12 (S) and the objective tests were low, as were correlations between items in the MSWS-12 (S) and the BBS or time taken to complete the TUGcog or the FSST. The internal consistency was acceptable for nine of the 12 items (0.7-0.84). The majority of the sample experienced limitations in several aspects of their walking ability. Concurrent validity was not established between the MSWS-12 (S) and the other tests. There may be a discrepancy in self- perception of disability and objective measures. The use of subjective, as well as objective measures is recommended.

  • 18.
    Nilsagård, Y
    et al.
    Örebro universitet.
    Lundholm, C
    Karolinska Institutet.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare.
    Gunnarsson, L-G
    Örebro universitetssjukhus.
    Predicting accidental falls in people with multiple sclerosis: a longitudinal study2009In: Clinical Rehabilitation, ISSN 0269-2155, E-ISSN 1477-0873, Vol. 23, no 3, 259-269 p.Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate accidental falls and near fall incidents in people with multiple sclerosis with respect to clinical variables and the predictive values of four tests. Design: A longitudinal, multi-centred cohort study with prospectively collected falls. Procedures: Self-reported incidents during the three months following a standardized test procedure. Subjects: Seventy-six people with multiple sclerosis and an Expanded Disability Status Scale score between 3.5 and 6.0. Main outcome measures: Berg Balance Scale, Timed Up and Go cognitive, Four Square Step Test (FSST) and 12-item Multiple Sclerosis Walking Scale. Results: Forty-eight people (63%) registered 270 falls. Most falls occurred indoors during activities of daily life. We found a correlation of r(s) = 0.57 between near falls and falls, and of r(s) = 0.82 between registered and retrospectively recalled falls. Fallers and non-fallers differed significantly regarding Expanded Disability Status Score (odds ratio (OR) 1.99, 95% confidence interval (0) 1.22; 3.40), spasticity (OR 1.14, CI 1.02; 1.31), proprioception (OR 2.50, CI 1.36; 5.12) and use of walking aids (OR 2.27, Cl 1.23; 4.37). Reported use of walking aids both indoors and outdoors increased the odds of falling fivefold while disturbed proprioception increased the odds 2.5-15.6 times depending on severity. The odds of falling were doubled for each degree of increased Expanded Disability Status Score and more than doubled for each degree of increased spasticity. The Berg Balance Scale, use of walking aids and Timed Up and Go cognitive best identified fallers (73-94%) and proprioception, Expanded Disability Status Score, 12-item Multiple Sclerosis Walking Scale and Four Square Step Test best identified non-fallers (75-93%). Conclusions: In clinical practice, looking at the use of walking aids, investigating proprioception and spasticity, rating Expanded Disability Status Score and using Berg Balance Scale or Timed Up and Go cognitive all contribute when identifying fallers

  • 19.
    Nilsson, A.
    et al.
    Uppsala University.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare.
    Lindberg, P.
    Uppsala University.
    Life values as predictors of pain, disability and sick leave among Swedish registered nurses: A longitudinal study2011In: BMC Nursing, ISSN 1472-6955, E-ISSN 1472-6955, BMC Nursing, Vol. 10, no art nr 17Article in journal (Refereed)
    Abstract [en]

    Background: Prospective studies on high-risk populations, such as subgroups of health care staff, are limited, especially prospective studies among staff not on sick-leave. This paper is a report of a longitudinal study conducted to describe and compare the importance and consistency of life domains among registered nurses (RNs) working in a Swedish hospital and evaluate a model based on the consistency of valued life domains for prediction of pain, disability and sick leave.Method: Importance and consistency ratings of life values, in 9 domains, were collected during 2003 and 2006 from 196 RNs using the Valued Living Questionnaire (VLQ). Logistic regression analyses were used for prediction of pain, disability and sick leave at the three-year follow-up. The predictors family relations, marriage couples/intimate relations, parenting, friends/social life, work, education, leisure time, psychological well-being, and physical self-care were used at baseline.Results: RNs rated life values regarding parenting as most important and with the highest consistency both at baseline and at follow-up. No significant differences were found between RNs' ratings of importance and consistency over the three-year period, except for friends/social relations that revealed a significant decrease in importance at follow-up. The explanatory models for pain, disability and sick leave significantly predicted pain and disability at follow-up. The odds of having pain were significantly increased by one consistency rating (psychological well-being), while the odds were significantly decreased by physical self-care. In the model predicting disability, consistency in psychological well-being and education significantly increased the odds of being disabled, while consistency in physical self-care significantly decreased the odds.Conclusion: The results suggest that there might be a link between intra-individual factors reflecting different aspects of appraised life values and musculoskeletal pain (MSP).

  • 20.
    Nilsson, A.
    et al.
    Uppsala University.
    Lindberg, P.
    Uppsala University.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare.
    Predicting of pain, disability, and sick leave regarding a non-clinical sample among Swedish nurses2010In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 1, no 3, 160-166 p.Article in journal (Refereed)
    Abstract [en]

    Objectives: Health care providers, especially registered nurses (RNs), are a professional group with a high risk of musculoskeletal pain (MSP). This longitudinal study contributes to the literature by describing the prevalence and change in MSP, work-related factors, personal factors, self-reported pain, disability and sick leave (>7 days) among RNs working in a Swedish hospital over a 3-year period. Further, results concerning prediction of pain, disability and sick leave from baseline to a 3-year follow-up are reported. Method: In 2003, a convenience sample of 278 RNs (97.5% women, mean age 43 years) completed a questionnaire. In 2006, 244 RNs (88% of the original sample) were located, and 200 (82%) of these completed a second questionnaire. Results: Logistic regression analyses revealed that pain, disability and sick leave at baseline best predicted pain, disability, and sick leave at follow-up. The personal factors self-rated health and sleep quality during the last week predicted pain at follow-up, while age, self-rated health, and considering yourself as optimist or pessimist predicted disability at follow-up, however weakly. None of the work-related factors contributed significantly to the regression solution. Conclusions: The results support earlier studies showing that a history of pain and disability is predictive of future pain and disability. Attention to individual factors such as personal values may be needed in further research. 

  • 21. Nilsson, A.
    et al.
    Sjödén, P-O.
    Dahl, J.
    Denison, Eva
    Mälardalen University, Department of Caring and Public Health Sciences.
    Factors related to long-duration pain and sick-leave among Swedish staff working in the public health service.2005In: Scandinavian Journal of Caring Sciences, ISSN 1471-6712, no 19, 419-426 p.Article in journal (Refereed)
  • 22.
    Nilsson, Annika
    et al.
    Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala University, Uppsala; Department of Caring Sciences and Sociology, University of Gävle.
    Sjödén, Per-Olow
    Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala University.
    Dahl, Joanne
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare. epartment of Caring Sciences and Sociology, University of Gävle.
    Factors related to long-duration pain and sick leave among Swedish staff working in the public health service.2005In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 19, no 4, 419-26 p.Article in journal (Refereed)
    Abstract [en]

    The aim of the present study was to provide information about factors related to long-duration pain (LDP) (>3 months), sick leave (SL) and long sick leave (LSL) (>3 months) among staff in the community health services. The specific research question was: To what extent do data on activity, physical function, pain severity, psychological/cognitive factors, expectations of LDP, expectations to be working within 6 months and work satisfaction predict LDP, SL and LSL respectively? Logistic regression analyses were used to test predicted membership in the groups LDP, SL and LSL. In this context prediction refers to statistical prediction only, due to the cross-sectional design. Staff (n = 914) in the public health services in a medium-sized Swedish city completed a questionnaire during the spring of 2000. The results show that musculoskeletal pain and SL for this occupational group are common. Pain severity, expectations of LDP and fear-avoidance increased the odds of being in the LDP group, while kinesiophobia decreased the odds. Pain severity and kinesiophobia increased the odds of being in the SL group, while expectations to be working in 6 months decreased the odds. Only expectations to be working in 6 months predicted membership in the LSL group, decreasing the odds. Although some caution is warranted concerning the representativity of the sample, the results indicate that expectations about pain duration and ability to work are important psychosocial factors in LDP and LSL.

  • 23.
    Overmeer, Thomas
    et al.
    Örebro Universitet, Sweden.
    Boersma, Katja
    Örebro Universitet, Sweden.
    Denison, Eva
    Norwegian Knowledge Center for the Health Services, Oslo, Norway..
    Linton, Steven
    Örebro Universitet, Sweden.
    Does teaching physical therapists to deliver a biopsychosocial treatment program result in better patient outcomes?: A randomized controlled trial2011In: Physical Therapy, ISSN 0031-9023, E-ISSN 1538-6724, Vol. 91, no 5, 804-819 p.Article in journal (Refereed)
    Abstract [en]

    Background. Psychosocial prognostic factors are important in the development of chronic pain, but treatment providers often lack knowledge and skills to assess and address these risk factors. Objective. The aim of this study was to examine the effects on outcomes (pain and disability) in patients of a course about psychosocial prognostic factors for physical therapists. Design. This study was a randomized, controlled trial. Setting. The setting was primary care practice. Participants. Forty-two primary care physical therapists attended an 8-day university course (over 8 weeks) aimed at identifying and addressing psychosocial risk factors. Intervention. The physical therapists were randomly assigned to either the course or a waiting list. They treated consecutive patients with acute and subacute musculoskeletal pain both before and after the course. Measurements. We measured physical therapists' attitudes and beliefs about psychosocial factors, knowledge, and skills before and after the course. We measured patients' pain, disability, catastrophizing, and mood at the start of treatment and at a 6-month follow-up. Methods. The physical therapists were randomly assigned to either the course or a waiting list. They treated consecutive patients with acute and subacute musculoskeletal pain both before and after the course. Results. Pain and disability outcomes in all patients of physical therapists who had participated in the course or in patients at risk of developing long-term disability who had higher levels of catastrophizing or depression were not significantly different from those outcomes in patients of physical therapists who had not participated in the course. Pain and disability outcomes in patients with a low risk of developing long-term disability-and pain outcomes in patients with a high risk of developing long-term disability-were not dependent upon whether the attitudes and beliefs of their physical therapists changed during the course. However, disability outcomes in patients with a high risk of developing long-term disability may have been influenced by whether the attitudes and beliefs of their physical therapists changed. Limitations. A limitation of this study was that actual practice behavior was not measured. Conclusions. An 8-day university course for physical therapists did not improve outcomes in a group of patients as a whole or in patients with a risk of developing long-term disability. However, patients who had a risk of developing long-term disability and had higher levels of catastrophizing or depression may have shown greater reductions in disability if the attitudes and beliefs of their physical therapists changed during the course.

  • 24.
    Sandborgh, Maria
    et al.
    Mälardalen University, School of Health, Care and Social Welfare. Uppsala Universitet, Sweden.
    Lindberg, Per
    Uppsala Universitet, Sweden.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare. Uppsala Universitet, Sweden.
    Pain belief screening instrument: Development and preliminary validation of a screening instrument for disabling persistent pain2007In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 39, no 6, 461-466 p.Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To develop and test the ability of a screening instrument to identify subgroups among primary healthcare patients with musculoskeletal pain. The Pain Belief Screening Instrument covers pain intensity, disability, self-efficacy, fear avoidance and catastrophizing. DESIGN: Cross-sectional, correlational and comparative study. SUBJECTS: Patients in primary healthcare (n1 = 215; n2 = 93) with a pain duration of 4 weeks or more were included. METHODS: Items for the Pain Belief Screening Instrument were derived from principal component analyses of: the Self-efficacy Scale, the Tampa Scale of Kinesiophobia and the Catastrophizing subscale in the Coping Strategies Questionnaire. Cluster solutions of scores on the screening instrument and the original instruments were cross-tabulated. The reliability of items in the Pain Belief Screening Instrument was examined. RESULTS: The screening instrument identified 2 groups: high- or low-risk profile for pain-related disability. Validity was in-between moderate and substantial (kappa = 0.61, p < 0.001). The reliability of each item in the Pain Belief Screening Instrument in relation to the corresponding item in the original instruments was moderate to high (rs 0.50-0.80, p < 0.01). CONCLUSION: The screening instrument fairly well replicated subgroups identified by the original instruments. The reliability of items in the screening instrument was acceptable. Further testing of predictive validity for a primary healthcare population is needed..

  • 25.
    Sandborgh, Maria
    et al.
    Uppsala University, Uppsala, Sweden.
    Lindberg, Per
    Uppsala University, Uppsala, Sweden.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare. Uppsala University, Uppsala, Sweden.
    The Pain Belief Screening Instrument (PBSI): predictive validity for disability status in persistent musculoskeletal pain2008In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 30, no 15, 1123-30 p.Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To evaluate the predictive validity of a screening instrument measuring disability, self-efficacy, fear of movement and catastrophizing, for disability status in patients with musculoskeletal pain in primary health care physical therapy. Development over time of pain-related disability, pain intensity, self-reported work capacity and overall daily function for subgroups of patients was also investigated. METHOD: Prospective and correlational study, where patients (n = 168) with a pain-duration of 4 weeks or more completed the questionnaires and their cases were followed for 8 months to assess the variables of interest. For predictive validity of the screening instrument discriminant analyses were conducted. The development over time for subgroups was analysed by comparing scores at the first and second measurement. RESULTS: The PBSI correctly classified 72% of the subjects as High-disabled (n = 33) or Low-disabled (n = 110), as measured with the Pain Disability Index (Wilks' lambda = 0.848, p < 0.005). For pain intensity, self-reported changes in work capacity and overall daily function the discriminant analyses were not significant. The High-disability group had increased disability, unchanged pain intensity and decreased work capacity and daily function after 8 months. CONCLUSION: The predictive validity of the PBSI for disability was confirmed. In clinical use the PBSI could serve as a mean to obtain supplementary and clinically useful information.

  • 26.
    Sandborgh, Maria
    et al.
    Uppsala University, Uppsala, Sweden.
    Lindberg, Per
    Uppsala University, Uppsala, Sweden.
    Åsenlöf, Pernilla
    Uppsala University, Uppsala, Sweden.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare. Uppsala University, Uppsala, Sweden.
    Implementing behavioural medicine in physiotherapy treatment: Part I: Clinical trial2010In: Advances in Physiotherapy, ISSN 1403-8196, E-ISSN 1651-1948, Vol. 12, no 1, 2-12 p.Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate the capacity of the Pain Belief Screening Instrument (PBSI) to discriminate between subgroups for targeting of treatment, investigate effects of treatment tailored to patients' individual and functional goals, and identify a suitable treatment dosage for patients with low risk of disability. Explorative study, Part I. Design: Randomized, controlled clinical trial with four treatment conditions. Methods: Patients in primary healthcare (n=45) with musculoskeletal pain for ≥4 weeks were included. PBSI-identified subgroups were validated by comparing scores on four established instruments. Measures of disability and patients' ratings of global outcome were used to examine treatment effect. Results: PBSI data adequately defined patients with either high or low risk of disability. Patients in the tailored treatment rated global outcome as better than in the non-tailored treatment. No differences were found on disability measures. For the low-risk group, the brief tailored treatment was as effective as the non-targeted control treatment. Conclusion: The PBSI adequately defined subgroups. Tailored treatment was partially superior to physical exercise treatment. Targeting by treatment dosage was effective for low-risk patients but remains to be investigated for high-risk patients. Treatment integrity for tailored treatments was compromised and is to be further explored in the following study.

  • 27.
    Sandborgh, Maria
    et al.
    Uppsala University, Uppsala, Sweden.
    Åsenlöf, Pernilla
    Uppsala University, Uppsala, Sweden.
    Lindberg, Per
    Uppsala University, Uppsala, Sweden.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare. Uppsala University, Uppsala, Sweden.
    Implementing behavioural medicine in physiotherapy treatment: Part II: Adherence to treatment protocol2010In: Advances in Physiotherapy, ISSN 1403-8196, E-ISSN 1651-1948, Vol. 12, no 1, 13-23 p.Article in journal (Refereed)
    Abstract [en]

    Objectives: In a controlled clinical trial, targeted and tailored treatment strategies, based on cognitive–behavioural treatment principles were investigated. The intervention was aimed at patients with persistent musculoskeletal pain in primary healthcare. A preliminary examination indicated low treatment integrity for the tailored treatment. Therefore, the aim in this study was to evaluate physiotherapists' treatment adherence to a treatment tailored to physical, cognitive and behavioural factors of importance for the performance of patients' prioritized activities. Explorative study, Part II. Materials and Methods: Treatment documents for 18 patients, treated by four specially trained physiotherapists, were utilized for assessment of treatment adherence. A treatment integrity measure was developed, tested and used for evaluation of adherence to the treatment protocol. Results: Physiotherapists' adherence to the treatment manual was low concerning treatment components and the overall sequencing of the treatment. Intrapersonal physical and cognitive factors, and situational variations tied to the performance of prioritized activities targeted in treatment, were rarely found or specified in treatment documents. Statements about functional and causal relationships between determinants for activity performance were not documented or unspecified. Conclusion: The physiotherapists' adherence to the treatment protocol was low despite the pre-intervention training programme and supervision during the intervention period.

  • 28.
    Söderlund, Anne
    et al.
    Mälardalen University, School of Health, Care and Social Welfare, Health and Welfare.
    Denison, Eva
    Mälardalen University, School of Health, Care and Social Welfare. Uppsala University, Sweden.
    Classification of patients with whiplash associated disorders (WAD): reliable and valid subgroups based on the Multidimensional Pain Inventory (MPI-S).2006In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 10, no 2, 113-119 p.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Classification of patients with chronic whiplash associated disorders (WAD) into homogenous subgroups is an important objective in order to tailor interventions and to control for subgroup differences when evaluating treatment outcome. AIMS: The aims of this study were to investigate if it was possible to replicate and describe the three cluster solution and profiles found in other pain groups and describe cluster profiles based on self-reported Multidimensional Pain Inventory-scores for patients with WAD three months after the injury, describe characteristics of the clusters in relation to disability, self-efficacy and coping at the same point in time and to validate the cluster solution by comparing clusters in disability, self-efficacy and coping over time. METHODS: Ninety-one WAD-patients three months after the accident took part in the study. The measures used were the Multidimensional Pain Inventory-Swedish version (MPI-S), The Self-Efficacy Scale, The Coping Strategies Questionnaire and The Pain Disability Index. Cluster analysis was conducted for the total sample MPI-S subscale scores. RESULTS: The adaptive copers cluster represented 42% of the sample, dysfunctional 34% of the sample, and interpersonally distressed 24% of the sample. The external validation of cluster solution showed that there were several significant differences between clusters in self-efficacy, disability and coping measures. There was also a significant interaction effect (clusterxtime) in disability (PDI). Patients in dysfunctional cluster reported a decreased disability over time. CONCLUSIONS: These results support the presence of different subgroups among patients with whiplash associated disorders. This classification can be seen as a complement to a classification based on medical condition.

  • 29. Åsenlöf, P,
    et al.
    Denison, Eva
    Mälardalen University, Department of Caring and Public Health Sciences.
    Lindberg, P,
    Individually tailored treatment targeting activity, motor behaviour, and cognitions reduces pain-related disability: a randomized controlled trial in patients with musculoskeletal pain.2005In: The Journal of Pain, no 6, 588-603 p.Article in journal (Refereed)
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