Musculoskeletal pain in primary health care:
A biopsychosocial perspective for assessment and treatment
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To my beloved grandchildren
Lucas, Julia, David, Tilda and Märta
Hold fast to dreams
For if dreams die
Life is like a broken-winged bird
That cannot fly
Hold fast to dreams
For when dreams go
Life is a barren field
Frozen with snow
Langston Hughes 1902-1967
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Örebro Studies in Medicine 40
Anders Westman
Musculoskeletal pain in primary health care:
A biopsychosocial perspective for assessment
and treatment
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© Anders Westman, 2010
Title: Musculoskeletal pain in primary health care:
A biopsychosocial perspective for assessment and treatment
Publisher: Örebro University 2010
www.publications.oru.se
Editor: Heinz Merten
[email protected]
Printer: intellecta infolog, Kållered 02/2010
issn 1652-4063
isbn 978-91-7668-716-1
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ABSTRACT
Westman, A (2010): Musculoskeletal pain in primary health care:
A biopsychosocial perspective for assessment and treatment.
Long-term musculoskeletal pain is a large public health problem with serious consequences for both the individual and society. Psychosocial factors have been shown to be
good predictors of long-term disability and play an important role in the transition from
acute to chronic pain. Early identification and intervention of those that run the risk of
developing long-term disability would offer a great opportunity for reducing costs and
personal suffering. The overall aim of this thesis was to assess a biopsychosocial
approach to the assessment and management of musculoskeletal pain patients in primary health care.
To this end, biopsychosocial assessment and treatment methods were tested in two
different populations of primary care patients suffering pain. Results indicated that
improvements in quality of life and work capacity one year after early multimodal
rehabilitation were basically maintained after five years. The most salient prognostic
factors determining return to work were educational level and the individual’s perceived
health (Study I). Psychosocial factors as measured by the Örebro Musculoskeletal Pain
Screening Questionnaire (ÖMPSQ) were related to disability and perceived health three
years after treatment for non-acute pain problems (Study II). The experimental group in
the controlled multimodal pain rehabilitation programme had lower health care utilization and a reduced risk of using large amounts of medication after three years compared
with the participants in the control group. However, there were no significant differences between the groups on variables such as work capacity, function, catastrophizing
and pain (Study III). Distinct profiles of catastrophizing, fear-avoidance beliefs, and
distress were extracted and meaningfully related to future sick leave and dysfunction
(Study IV).
Our findings provide support for the biopsychosocial model and highlight the importance of psychosocial factors in long-term outcome. The results underscore the need
for early identification of patients at risk. Further, multimodal treatment that covers not
only biological but also psychosocial factors seems to be a key to successful treatment,
and ideally this intervention should be matched to the patients’ needs.
Keywords: musculoskeletal pain, biopsychosocial, multimodal, fear-avoidance,
catastrophizing, distress, sick leave, function.
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PUBLICATIONS
This thesis is based upon the following papers, which are referred to in the text by the
corresponding Roman numerals:
I. Westman A, Linton S J, Theorell T, Öhrvik J, Wahlén P, Leppert J.
Quality of life and maintenance of improvements after early multimodal rehabilitation:
A 5-year follow-up.
Disabil Rehabil, 2006. 28(7): 437-446.
II. Westman A, Linton S J, Öhrvik J, Wahlén P, Leppert J.
Do psychosocial factors predict disability and health at a 3-year follow-up for patients
with non-acute musculoskeletal pain? A validation of the Örebro Musculoskeletal Pain
Screening Questionnaire.
Eur J Pain, 2008. (12):641-649.
III. Westman A, Linton S J, Theorell T, Öhrvik J, Wahlén P, Leppert J.
Controlled 3-year follow-up of a multidisciplinary pain rehabilitation programme in
primary health care.
Disabil Rehabil, 2010. 32(4): 307-316.
IV. Westman A, Boersma K, Leppert J, Linton S J.
Avoidance beliefs, catastrophizing and distress – a longitudinal subgroup analysis
on patients with musculoskeletal pain (MSP).
Submitted to the Clinical Journal of Pain.
The articles are reprinted in this dissertation with the kind permission of the publishers.
ABBREVIATIONS
ADL
Activities of daily living
BPS
Biopsychosocial
CBT
Cognitive behavioural therapy
CHAMP
The Center for Health and Medical Psychology
CNS
Central nerve system
CKF
Centre for Clinical Research
CSQ
Coping Strategies Questionnaire
CI
Confidence interval
DRI
Disability Rating Index
EPM
Psychosomatic Medicine Clinic
GCT
Gate control theory
GLM
General Linear Model
GP
General practitioner
HPA
Health profile assessment
HAD
HAD Hospital Anxiety and Depression
IASP
International Association for the Study of Pain
MSP
Musculoskeletal pain
OR
Odds ratio
QL
Quality of life
PCS
Pain Catastrohizing Scale
PHC
Primary health care
ROC
Receiver operator characteristic
RCT
Randomized controlled trial
SD
Standarad deviation
SPSS
Statistical Package for the Social Sciences
SF-36
Medical Outcomes Study Short-Form Health Survey 36
TSK
Tampa Scale for Kinesiophobia
TSK-SV
Tampa Scale for Kinesiophobia-Swedish Version
ULF
National Living Survey
VAS
Visual analogue scale
ÖMPSQ
Örebro Musculoskeletal Pain Screening Questionnaire
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Contents
Preface .................................................................................................11
Introduction ......................................................................................... 13
Pain from a historical perspective ......................................................... 13
The biomedical model ........................................................................... 13
Defi nitions and classifications ............................................................... 13
Gender differences and musculoskeletal pain .......................................14
Musculoskeletal pain and disability in primary health care ..................14
Biopsychosocial models......................................................................... 16
Modern / current advances in the BPS model ........................................18
The neuromatrix theory of pain ...........................................................18
Psychosomatic medicine ....................................................................... 19
Behavioural medicine ........................................................................... 19
Psychosocial risk factors .......................................................................20
Stress and pain ......................................................................................20
Fear-avoidance .....................................................................................20
Catastrophizing ....................................................................................21
Distress .................................................................................................21
Coping ..................................................................................................22
Early identification................................................................................23
Multidisciplinary / interdisciplinary team .............................................24
Multidisciplinary / multimodal rehabilitation .......................................24
Aims......................................................................................................27
Materials and methods ........................................................................29
Study populations .................................................................................30
Ethics .................................................................................................... 31
Inclusion and exclusion criteria .............................................................32
Measures...............................................................................................32
Background ..........................................................................................32
Sick leave/return to work......................................................................32
Intensity and frequency of pain ............................................................ 33
Function ............................................................................................... 33
Inclination towards anxiety and depression ......................................... 33
Perceived health / Quality of life (QL)..................................................34
Job strain ..............................................................................................34
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Health profile assessment (HPA) ..........................................................34
Patient satisfaction ............................................................................... 35
The Örebro Musculoskeletal Pain Screening
Questionnaire (ÖMPSQ) ..................................................................... 35
Coping .................................................................................................. 35
Life events ............................................................................................36
Health care utilization ..........................................................................36
Drug consumption ...............................................................................36
Psychosomatic symptoms .....................................................................36
Fear-avoidance beliefs ..........................................................................36
Catastrophizing ....................................................................................36
Distress .................................................................................................37
Statistics ................................................................................................37
Study I ..................................................................................................37
Study II .................................................................................................37
Study III ...............................................................................................38
Study IV ...............................................................................................38
Results..................................................................................................41
Quality of life and maintenance of improvements after early
multimodal rehabilitation: A 5-year follow-up (Study I) .......................41
Do psychosocial factors predict disability and health at a 3-year
follow-up for patients with non-acute musculoskeletal pain?
A validation of the Örebro Musculoskeletal Pain Screening
Questionnaire (Study II) ....................................................................... 43
Controlled 3-year follow-up of a multidisciplinary pain rehabilitation
program in primary health care (Study III) ........................................... 45
Avoidance beliefs, catastrophizing and distress: A longitudinal
subgroup analysis on patients with musculoskeletal pain, (MSP),
(Study IV). ............................................................................................47
General discussion ............................................................................... 53
Limitations and strengths .....................................................................57
Clinical implications .............................................................................59
Future implication ................................................................................60
Conclusions ..........................................................................................63
Acknowledgments .................................................................................65
References .............................................................................................69
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PREFACE
As a physician in family medicine, occupational health and, subsequently psychosomatic medicine, when thinking of the “stream” of patients I have met over the years I
have become increasingly amazed at the close connection between body and mind.
The geneses to a patient’s problems are often multifactorial, and there are continuous
ongoing interactions between these various factors in the processes of illness, recovery
and the preservation of health. There remain, however, influences of dualism and reductionism in the health care system which obstruct the possibility of meeting patients
needs in an optimal manner. This thesis has grown from a personal desire to propose a
more holistic approach towards the management of pain patients in primary health care.
An old oriental metaphor describes a human being as a carriage consisting of a
horse, a cart, a driver and a passenger.
Image adapted from Mobilus Professional
This image distinguishes between two bodily elements: the material body (the “corpse”
in us) and the physiological processes (the life in us). The two mental elements represent the psychological functions (thoughts, feelings) and the spiritual spark of selfawareness (the “I am” in us). In this picture, the material body is symbolized by the cart
and the living processes by the horse, pulling the cart. The psychological functions are
seen as the driver leading the horse. The passenger, sitting in the centre, aware of the
whole carriage but also the surroundings, directs the driver who carries out his orders.
The passenger is the self-awareness of “I am” and the whole carriage, e.g. the human
being, is an indivisible unit [31].
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INTRODUCTION
“The assessment and treatment of chronic and frequently recurring pain conditions are
one of the most difficult areas of medicine………There are few areas in which a holistic
approach is as important as when it comes to helping people with chronic pain…..”
National Board of Health and Welfare, 1994.
Pain from a historical perspective
Given the universal nature of pain, various scholars have attempted to understand and
explain its experience throughout history. Plato (ca 427-347 BC) believed that the heart
and liver were centres for the appreciations of all sensation, and that pain arose not only
from peripheral sensation but as an emotional response in the soul, which resided in the
heart. Hippocrates (ca 460-370 BC) considered the mind and body as one unit but
asserted that pain was the result of an imbalance in vital fluids. Aristotle (ca 384-322
BC), on the other hand, asserted that pain was due to the gods and evil spirits which
entered the body via an injury. The brain was not believed to have any direct influence
and, for years, the heart was considered to be the centre of pain sensation.
The biomedical model
René Descartes (1596-1650), the foremost philosopher of the Renaissance, offered a
dualistic view of mind and body. The pain model of Descartes, commonly known as
Cartesian or the biomedical model, is the one on which our modern health care system
is built. The model is mechanistic, with the underlying message that pain is the direct
product of a noxious stimulus activating a dedicated pathway from the skin along nerve
fibres, to the centre of the brain where it activates a mechanical behaviour response. The
biomedical model, with its strong emphasis on biology, has serious limitations and its
character is to a great extent reductionistic. The school medicine is mainly influenced by
this dualistic model, and physicians and other medical personnel are still educated
within this reductionistic paradigm. Primary care physicians are working daily to relieve
patient symptoms for which they cannot determine an exact pathoanatomical diagnosis.
Moreover, treatment routines usually have a biomedical approach and, in many cases, it
is difficult to tailor treatment to the needs of the individual patient.
Definitions and classifications
The established definition of pain according to IASP (the International Association
for the Study of Pain) is “an unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms of such damage”. This
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definition underscores both the subjectivity of pain and the importance of emotional as
well as sensory factors. Thus, pain is recognized to have many dimensions. It includes
psychological as well as biological factors and is truly a multidimensional phenomenon.
It is worth considering that pain is always a personal and subjective experience which,
taken as a whole, makes it unquestionable. As a consequence, our ability to measure
pain with obvious objective methods is restricted.
Chronic pain has been defined as “that which persists beyond the normal time of
healing” and three months is considered “the most convenient point of division between
acute and chronic pain, but for research purposes six months will be preferred” IASP
(1994). Persistent pain is defined as pain that was present “most of the time for a period
of six months or more during the prior year” [51].
Gender differences and musculoskeletal pain
Average life expectancy in Sweden, as in many western countries, is higher for women
than for men. Women, however, are seeking care at higher rates than men and musculoskeletal pain problems are more common among women [8, 47, 110, 153]. Furthermore, a women’s pain is classified as medically unexplained more often then a man’s
[142, 168]. The reason for the difference is probably complex, including both biological
and social mechanisms. Genus, rather than sex, may be an important factor for how pain
is perceived and interpreted and for which consequences pain may have [37, 165].
Musculoskeletal pain and disability in primary health care
Over the last few decades many disciplines have contributed to the development of a
multidimensional understanding of causality in chronic pain. Pain is the most common
symptom in health care but, despite this, perhaps one of the least understood. Although
many pain problems are acute and short-lived, as is most often the case, pain may be
ongoing with chronic illnesses. Chronic pain is often difficult to diagnose and treat
because it is simultaneously “subjective” and “objective” and arises as a consequence of
interactions between physical, emotional, cognitive, and behavioural variables [84].
Pain is a symptom which originates from a great number of conditions and is not
equivalent with either diagnosis or disease. The current view is that no causal relationships exist between pathophysiology or tissue damage on one hand and subjectively
reported pain on the other hand. [155]. There is a consensus today that chronic pain
cannot be considered as a purely biomedical phenomenon but nor can it be regarded
solely as a result of psychological factors and conditions.
Epidemical studies from Sweden have shown pain prevalence rates of 35-65% [2, 8,
19, 47] with musculoskeletal pain representing the majority of persistent pain. Statistics
taken from Sweden's Survey of Living Conditions (ULF) for 2002-03 show that 57% of
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men and 68% of women stated that they had persistent aches and pain in the back, neck,
shoulders, elbows, legs or knees. Persistent aches and pain, however, have become more
common since the early 1980s, particularly among women and young people [119]. The
point prevalence of back disorders (i.e. the percentage who report back problems when
asked) has been found to vary in Europe from a low of 14-15% in Great Britain and
Denmark to a high of 31% in Sweden, Finland and Germany [160, 164]. The majority
of patients presenting, for example, acute low back pain (LBP) have at least one recurrence of it in the following year and most patients continue to have episodes of significant pain and disability [118]. International surveys of LBP report a lifetime prevalence
of about 60-70% [111].
Musculoskeletal symptoms of various types are a major reason for consultation in
primary care. In Scandinavia, 20-40% of visits to general practitioners (GPs) consist of
pain problems [55, 94, 124]. Long-lasting pain problems are associated with an
increased utilization of health care; a Swedish study showed that about 40% of patients
with chronic pain have consulted a GP during the last three months [3, 13]. On an individual level, persistent musculoskeletal pain significantly affects a patient’s quality of
life, e.g. the pain is usually continuous and impairs a variety of functions. Not all
patients, however, develop chronic problems and only a small percentage (3-10%) experience a long-term absence from work. This small number of patients nevertheless
consume about 75-85% of the available resources [162].
In many cases involving musculoskeletal pain, it is a problem to establish a specific
diagnosis and the origin of a patients’ symptoms remain unknown. International epidemiological studies have shown that a substantial proportion of patients in primary care
complain of physical symptoms not attributable to any known conventionally defined
disorder, i.e. they suffer from medically unexplained or functional somatic symptoms
[38, 127]. Clinical experience and recent research has shown that our highly specialized
health care systems often have a problem handling these types of patients successfully[113, 129, 143]. For the individual patient and the health care provider this is often
frustrating and frequently the patient will be sent on an almost endless pursuit of
medical interventions [82]. Furthermore, patients with an unclear diagnosis experience
negative treatments, insufficient contact with clinicians and distrust throughout the
consultation process [69]. On the other hand, the physicians themselves may experience
an “angry helplessness” towards their patients leading to feelings of low satisfaction
with themselves and of a deficiency to communicate with their clients [96].
Pain and disability are obviously related to each other and, in clinical practice, they
are often treated as being equivalent. They are not equivalent, however, and it is important to make this distinction. Epidemiological research indicates that whereas 40%
of people in the community report having chronic pain a much smaller portion in the
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population reports significant levels of disability due to pain [14]. Disability used to be
defined as restricted activity [163], but having pain and being disabled is not the same
thing. Consequently, both pain and disability is related to a patient’s own subjective
experience.
Although differences can be observed between individual countries, it is documented that chronic pain is a major health care problem in Europe that needs to be taken
more seriously [20]. According to a report by the Swedish Council on Technology
Assessment in Healthcare (SBU) entitled “Methods of treating chronic pain: a systematic review” (2006), the total cost of persistent pain for Swedish society was estimated
to be € 8.2 billion (87.5 billion Swedish Crowns (SEK)) a year [131]. In Sweden
musculoskeletal pain disorders represent one of the most common causes of both shortand long-term sick leave and the awarding of disability pensions.
Biopsychosocial models
Melzack & Wall proposed the original gate control theory (GCT) of pain in 1965 [105].
This theory marked a turning point in our understanding of pain and formed the physiological basis of the biopsychosocial (BPS) model of pain. Briefly, it states that pain can
no longer be regarded as merely a physical sensation of noxious stimulus and disease.
After the nerve is stimulated the impulse is sent to the spinal cord where “gating” takes
place. This occurs in the dorsal horn of the spinal cord and constitutes the first synapse,
i.e. where one nerve transmits the signal to the next one. Each particular pain experience
results from the integration of purely sensory information with cognitive and affective
information in the central nervous system. Psychological processes can thus influence
and modulate reactions to painful sensations. The major conceptual contribution of the
gate control theory is that it replaces the Cartesian mind-body dichotomy and allows for
the complexity of the pain phenomena. It explains how psychological and social influences may modulate an individual perception of and response to pain. Pain involves the
entire biological system that is regulated by the brain in reaction to environmental
stimuli. All sensations, thoughts, feeling and behaviour have a biological counterpart.
This complexity demonstrates the need for methods that capture the biopsychosocial
function available in the assessment and treatment of pain patients.
Engel was one of the first to call for a new approach to the traditional biomedical
and reductionistic philosophy that had dominated the field of medicine since the
Renaissance. In 1977 he proposed the BPS model which provides “a blueprint for
research, a framework for teaching, and a design for action in the real world of health
care”. This model, in contrast to the biomedical, enabled within its framework a place
for the social, psychological and behavioural dimensions of illness [35]. The last few
decades have been a challenging period in mental and physical health research resulting
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in a major paradigm shift from a biomedical reductionism approach to a more heuristic
and comprehensive biopsychosocial model. One consequence of this is that emphasis is
now placed on the unique interactions among biological, psychological, and social
factors [43]. Indeed, to fully understand an individual’s perception and response to pain
and illness, the interrelationship among biological changes, psychological factors, social, cultural, and existential context have to be considered (Figure 1).
Figure 1. A conceptual model of the biopsychosocial interactive processes involved in health
and illness. (taken from “Comorbidity of Chronic Mental and Physical Health Conditions: The
Biopsychosocial Perspective” by R. J. Gatchel. American Psychologist, 04, 795-805. Copyright
of the American Psychological Association, 2004).
BIO
• PSYCHO •
Biological
Cognitive
SOCIAL
Activities of Daily Living
Environmental Stressors
Interpersonal Relationschips
Somatic
Affective
Efferent Feedback
Family Enviroment
Social Support / Isolation
Afferent Feedback
Social Expectations
Cultural Factors
Autonomic
Endocrine
Immune Systems
Medicolegal / Insurance Issues
Previous Treatment Experiences
Work History
The BPS model focuses on both disease and illness, the distinction between the two,
being crucial to understanding chronic pain. Disease is generally defined as “an objective biological event” involving the disruption of specific body structures or organ systems caused by anatomical, pathological or physiological changes. In contrast to this
customary view of physical disease, illness is defined as a “subjective experience or
self-attribution” that a disease is present; it yields physical discomfort, emotional distress, behavioural limitations and psychosocial disruption. [158]. Under this model it is
possible for a person to be diseased without being ill (to have an objectively definable
medical condition), and to be ill without being diseased (such as perceiving a normal
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experience as a medical condition or medicalizing a non-disease situation) [34]. The
distinction between disease and illness is analogous to the distinction that can be made
between nociception and pain. Nociception is defined as “the neural processes of encoding and processing noxious stimuli”. In contrast, pain is the subjective perception that
results from the transduction, transmission, and modulation of sensory information.
In 1980 Loeser formulated a model describing four dimensions associated to the
concept of pain: 1) nociception refers to mechanical or other stimuli that could cause
tissue damage, 2) pain is the perception of the sensation of pain, 3) suffering is the
unpleasant emotional response (suffering, however, is not unique to pain and pain can
exist without suffering and suffering without pain), 4) pain behaviour includes any act
or behaviour engaged in to control pain, or that communicates pain to others [89].
Figure 2. Biopsychosocial models of pain and illness.(adapted from American Psychologist,
November 2004).
ENGEL’S
LOESER’S
CONCEPTUAL MODEL OF ILLNESS
CONCEPTUAL MODEL OF PAIN
Physical
problem
Nociception
Modern / current advances in the BPS model
The neuromatrix theory of pain
The neuromatrix theory of pain proposes that pain is a multidimensional experience
produced by characteristic “neurosignature” patterns of nerve impulses generated by a
widely distributed neural network – the “body-self neuromatrix”- in the brain. These
neurosignature patterns may be triggered by sensory inputs, but they may also be generated independently of them. The theory proposes that the output patterns of the
neuromatrix engage perceptual, behavioural and homeostatic systems in response
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to injury and chronic stress [103]. Pain is the consequence of the output of a widely
distributed brain neural network rather than a direct response to sensory input following
tissue injury, inflammation, and other pathologies [104].
Psychosomatic medicine
The biopsychosocial approach is now widely accepted as bringing a heuristic perspective to the understanding of chronic pain, with the model viewing chronic pain as the
result of a dynamic interaction between physiological, psychological, and social factors.
A further development within this model has been the creation of the discipline of
psychosomatic medicine which incorporates an integrative approach to disease and
health, and is a link between medicine and psychology. This discipline includes an
approach and clinical ability to interpret symptoms and illness as expressing manifestations and consequences of interacting systems: psychological, biological, social, and
existential [97]. Each patient’s story is always “psychosomatic”, expressed simultaneously through both sensory-physical somatic and symbolic-verbal psychic signs and
messages. “The patient will not be content -cured -until the story makes full cognitive,
physical, and emotional sense, and is in accordance with the patient’s whole self and
with the environment as perceived and lived by the patient” [137, 138]. To work from a
comprehensive point of view is to realize that a human being, at every single moment, is
a thinking, feeling and acting individual. Body and mind are two aspects of life and
there is a constant interplay between the two.
Behavioural medicine
Behavioural medicine can be defined as the interdisciplinary field concerned with the
development and integration of psychosocial, behavioural and biomedical knowledge
relevant to health and illness and the application of this knowledge to prevention,
etiology, diagnosis, treatment and rehabilitation. A particular hallmark of this integrated
perspective is to apply this knowledge to health promotion, disease prevention and
rehabilitation [64].
As its name suggests, focus is placed upon behavioural principles (i.e. that behaviour results from learning through classical or operant conditioning). These underlying
principles are applied in preventions and treatments. Behavioural medicine also includes
emotions such as fear, anxiety and emotional distress, although it is not concerned with
the mental health problems in itself [109, 133]. Cognitive behavioural therapy (CBT) is
a psychotherapeutic approach that aims to solve problems concerning dysfunctional
emotions, behaviours and cognitions through a goal-oriented systematic procedure.
CBT for pain management is based upon a cognitive-behavioural model of pain
[157].The hallmark of this model is the notion that pain is a complex experience that is
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not only influenced by underlying pathophysiology, but also by an individual’s cognitions, affects, and behaviour [71].
Psychosocial risk factors
Psychosocial factors have been shown to be good predictors of long-term disability and
play an important role in the transition from acute to chronic pain [121, 156]. Significant psychological risk factors include stress, fear- avoidance beliefs, catastrophizing,
emotional distress, depression, anxiety, coping strategies and socio-cultural factors.
Stress and pain
Acute pain activates the HPA (hypothalamus-pituitary-adrenal) axis and the sympathetic nervous system. The physiology of stress is very complex and consists of central
nerve system (CNS) and peripheral components, including both the HPA axis and the
autonomic (sympathetic) system. Chronic pain is a stressor that, in itself, will load the
stress system, and a prolonged activation of the stress regulation system may generate
breakdowns of muscle, bone, and neural tissue that, in turn, will cause pain and may
produce a vicious cycle of pain-stress-reactivity [43, 102]. Stress and anxiety per se
appear to influence pain perception. It is becoming clear that a variety of stressors may
lead to pain, that pain may lead to stress, and that there is not a simple unidirectional
relationship between changes in stress response function and pain [25].
A great number of studies, both cross sectional and prospective, have shown associations between psychosocial stress at work and a high incidence of musculoskeletal
pain disorders [11, 18, 79]. Stress or strain at work could be caused by a combination of
high demands and low control [152], by under-stimulation [40], and by high effort
combined with low reward [136]. Path analysis has shown general distress to be an important predictor of return visits for low back pain patients and a mediator of job stress
and ergonomic demands [36]. McEwen proposed a model called the allostatic load
model, which predicts under what conditions physiological stress responses are adaptive
and when they lead to health problems [100]. Important in this model is the striving
towards a balance between activation and rest/recovery.
Fear-avoidance
To prevent chronic disability, it is important to discover the factors that influence
its development and to understand how they influence it. In this regard, the “fearavoidance model” has received increasing interest because of the way it explains how
acute pain can develop into chronic pain. Clinicians working with chronic pain
patients are aware that patients who have similar pain histories may differ greatly in
their beliefs about their pain. A breakthrough within the framework of the BPS model
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was the introduction of the fear-avoidance model, which presents a plausible explanation for how individuals become trapped in a downward spiral of increasing avoidance,
disability and pain. This model incorporates several risk factors known to be associated
with pain. It is based on ideas originating with the work of Lethem et al.(1983), Philips
(1987) [80, 120] and was expanded by Vlaeyen et al. (1995, 2000) [172, 173]. The fearavoidance model is a cognitive and behavioural framework explaining how pain-related
fear can develop into persistent disability. The role of pain-related fear is of great interest in a biopsychosocial approach, as it is hypothesized to impact upon behaviour
(avoiding activity and movement), cognition (hypervigilance) and emotion (distress).
Many studies have shown the specific importance of psychological factors such as fearavoidance beliefs, catastrophizing and emotional distress in the development of chronic
pain and disability. Among the most powerful cognitive and behavioural risk factors are
fear-avoidance beliefs, pain-related fear, distress, and the avoidance of activity [15, 16,
41, 72, 78, 83, 121, 145, 171, 173].
Catastrophizing
If pain, possibly caused by an injury, is interpreted as threatening (pain catastrophizing),
pain related fear evolves. This may lead to avoidance behaviours, followed by disability, disuse, and depression. The latter maintains the experience of pain and thereby fuels
the vicious circle of increasing fear and avoidance [78]. In non-catastrophizing patients,
normal fear that serves as a “warning signal” occurs, but the individual soon begins to
confront the pain by resuming movement. This enhances the recovery of mobility and
daily activities, leading to recovery. Catastrophizing has been defined as an exaggerated
orientation toward pain stimuli and pain experience [145]. Furthermore, individuals
who appraise bodily sensations as dangerous are thought to be more likely to scan the
body for threatening sensations. Hypervigilance emerges when patients experience intensive pain, have catastrophic thoughts about pain, and become fearful of it [23, 28,
48]. There are several earlier studies that have demonstrated a relationship between
catastrophizing and low perceived health-related quality of life [74, 123]. Additionally,
there is a high level of consistency to the relationship between catastrophizing and pain.
Catastrophizing has been associated with heightened pain and several studies have reported that women catastrophize more than men [146].
Distress
It is well-known that living with chronic pain contributes to elevated rates of depression
[30]. The prevalence of depression in Sweden is estimated at 4-10 % (SBU). In a literature review by Bair et al. in 2003, the mean (range) prevalence rates for concurrent
major depression in pain patients were 52% (1,5-100%) in pain clinics and
Musculoskeletal pain in primary health care… ✍
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anders westman I 21
27% (5,9-46%) in primary care clinics [4, 106]. The lifetime prevalence of major depressive disorder is at least 10%, with the risk in woman being twice that in men [81].
Depressed mood and pain are imminently linked and chronic pain patients often report
depressive symptoms, but these are not always severe enough to meet the criteria for
depression. “Affective distress” has been suggested as a better term than depression as it
incorporates a wider range of emotions such as anger, frustration, fear, and sadness
[122] and most patients with chronic pain have to some extent depressive symptoms
[115, 174]. Several studies have found that emotional distress is common among patients with musculoskeletal pain in primary care [21, 70, 90]. Moreover, depressive
mood or “distress” is a well-known risk factor for the development of chronic disability
[46, 121]. The relationship between chronic pain and depressive mood is complex and
although we know that depressive mood may intensify pain it is also well known that
suffering chronic pain could affect mood negatively. However the interrelationships
between depressive mood, fear avoidance beliefs, catastrophizing and pain might be
different for different pain patients.
Figure 3. Fear-avoidance model, (adapted from Pain, 85 (3), 317-32, April 2000).
Dysfunction
Depression
Avoidance
Fear
Injury
Pain
Vigilance and
tension
Threat
Catastrophizing
Recovery
Confronting
Normal fear
“Warning”
Coping
Coping entails any method a patient employs to deal with or adjust to their pain [128].
Similarity, a later definition states that coping is the term used to describe the strategies
that a patient uses to deal with their pain [76]. People cope with stress, adversity or
pain in many different ways. Coping strategies may be active/problem-focused
(exercising, ignoring pain, etc) or passive/maladaptive (withdrawal, rest, analgesics etc)
[141]. Active coping strategies help to reduce pain, disability and depression whereas
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22 I anders westman ✍ Musculoskeletal pain in primary health care…
passive/maladaptive strategies are associated with the opposite. Catastrophizing is generally believed to be the most unfavourable coping strategy in pain patients [92].
Early identification
As a result of the extensive cost involved in treating musculoskeletal pain patients, the
need for an early intervention as a means of secondary prevention has been pointed out
[111]. Today, there is strong evidence which indicates that psychosocial factors have a
greater impact on disability than biomechanical or biomedical factors [83, 156].
Research over the last few decades has shown a link between psychosocial factors and
the development of chronic pain and disability by the important role that psychosocial
risk factors play in the transition from acute to chronic pain [83, 121, 156]. Despite
increasing knowledge about the importance of psychosocial factors importance in the
field of musculoskeletal pain there is a lack of implementation in clinical practice. In a
recently published Swedish study, 26% of physicians in primary care did not inquire
about or discuss psychosocial factors with back pain patients. More than a quarter of
physicians responded that they did not provide patients with a clear explanation of what
caused their complaints. Furthermore, a relatively large proportion of clinicians were
unfamiliar with the content of evidence-based guidelines [117].
Because a large number of people seek care for musculoskeletal pain problems but
only a minority develop a persistent problem, early identification would offer the advantage of being able to concentrate resources on those most in need. For the general practitioner who often meets many patients with a variety of symptoms it is a demanding task
to identify those at risk of developing long-term problems. The prevention of the
development of persistent musculoskeletal pain would be greatly enhanced if the patients most in need of treatment and rehabilitation could be identified at an early point in
time. Usually the routine treatments have a bio-medical approach and it is in the early
stages often difficult to decide when there is a risk for long-term problems. A particular
problem has been the lack of matching between risk factors and the different interventions available [135].
Early identification often involves screening procedures and multiple questionnaires
are available for the assessment of chronic pain and disability [32, 45, 57, 61, 62, 86,
99, 161, 169]. Taken as a whole, the evidence shows a relationship between psychosocial factors and future outcome. However, while these factors may be relevant at a
group level, they may not be reliable at an individual one. An important question is
whether our knowledge about psychosocial risk factors can be applied to individual
cases in clinical practice.
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Multidisciplinary / interdisciplinary team
Two characteristics make primary care unique in comparison with other sorts of medical
practice: general practitioners provide the “first line” of medical care for almost all categories of patients, and they provide care that is continuous over time. The fact that pain
patients are heterogeneous, often with a multifactorial genesis, has posited the need for
multidisciplinary teams in primary health (in this thesis multidisciplinary is used
synonymously with interdisciplinary). It is well known that sharing responsibility and
knowledge with other professionals in multidisciplinary teams could be of great value
and a way to meet new challenges and demands in primary care [65, 125]. The team
work requires that the “units” that constitute assessments and treatments are highly
integrated, having the same overall goal, and that the team members share a similar
“ideology” regarding the rehabilitation process. A well-functioning team is characterized by respect for the competences of the other health care professionals and by the
realization that no one has a preferential right of interpretation. Many evaluations of
teamwork in primary health care have been undertaken over the last few decades,
although generally with disappointing results. It has, for example, been found to be
especially difficult to engage doctors in the teamwork process [60], probably as a consequence of several factors. It has been reported that one of these factors, in the case of
GPs, could be the latent threat of loosing the leading role [6, 26]. In a recently published
Swedish study it was concluded that, if teamwork is to be successfully introduced into
primary health care, the self-perception of a GP has to be taken into consideration. Furthermore, new roles will be created for all team members in the team and they have to
be thoroughly discussed under professional supervision. Otherwise there is an
obvious risk that doctors remain outside the development of new working methods [54].
Multidisciplinary / multimodal rehabilitation
Intervention and pain rehabilitation approaches have typically been discussed in terms
of primary, secondary or tertiary prevention. Primary prevention programmes aim
to prevent the onset of disability, while secondary programmes aim to prevent the
progression from an acute condition to chronic disability, and tertiary programmes aim
to prevent the development of further disability in someone whose condition has
evolved into a chronic state of disability [44]. Secondary and tertiary prevention is the
primary focus of this thesis. The traditional biomedical model, which solely focuses on
structural or biomechanical abnormities, has been increasingly replaced with the
biopsychosocial model of pain and disability, which emphasizes the role of psychological and social factors in the development and maintenance of symptoms. Since musculoskeletal pain occurs so frequently, however, it would be costly and unnecessary to
provide every patient with secondary preventive interventions. Furthermore, a
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24 I anders westman ✍ Musculoskeletal pain in primary health care…
biopsychosocial understanding of the multifactorial challenge in rehabilitation is of little
use to the patient unless the complex approach can be shaped into a form that is clinically applicable. In many musculoskeletal pain cases there is a polysymptomatic picture
with a multi-factor genesis in which both the diagnosis and the rehabilitation potential
are unclear. Because of this multifactorial background these patients are considered
suitable to undergo a multi-professional integrated assessment with a holistic approach
[7, 49, 52, 53, 132, 139, 170].
The prevalence of musculoskeletal symptoms and the costs they incur in the general
population and in primary health care highlight the need for the development of
appropriate interventions. As early as 1973, Fordyce et al. described a multidisciplinary
treatment programme for patients with chronic non-malignant pain [39]. Since then, this
approach has achieved acceptance and support by many medical care providers. Multidisciplinary/multimodal programmes are usually conducted in a group format and
involve physicians, physiotherapists, occupational therapists, nurses and psychologists
or social workers. The treatment aims to: improve the perceived quality of life despite
the experience of persistent pain symptoms, to enable the patient to cope with pain in a
better way, and to enhance daily functioning in normal life activities.
Comprehensive pain programmes are predominantly based on the BPS model and
allow a better understanding of different factors that influence pain [159]. In a Cochrane
Review (2004), Guzmán et al. concluded that intensive multidisciplinary biopsychosocial rehabilitation with a functional restorative approach decreases pain and improves
function in patients with chronic back pain. Less intensive interventions did not show
improvements in clinically relevant outcome measures [52, 53]. The Swedish Council
on Technology Assessment in Health Care (SBU) published in 2006 a systematic
review of the literature on the treatment of chronic pain according to which the scientific evidence supports multidisciplinary rehabilitation programmes for chronic pain of
musculoskeletal origin [131]. In a 2008 review of all currently available randomized
controlled trials (RTCs), Scascighini et al. showed moderate evidence of higher
effectiveness for multidisciplinary interventions. In contrast to no treatment or standard
medical treatment, strong evidence was detected in favour of multidisciplinary treatments [132].
In this connection, it could be worth mentioning that RCT studies are almost always
carried out in a rehabilitation context and not in primary health care. This means that it
is actually unknown to what extent investigations works in primary health care settings.
There are crucial differences between the conditions in rehabilitation clinics and in
primary health care. For example, the patient groups in primary care are more heterogeneous (not only chronic pain) and there is less time available for each patient.
Furthermore, the composition and education of the personnel and the way of working
Musculoskeletal pain in primary health care… ✍
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differ to that of clinics.
Although all these programmes successfully improve physical function their ability
to facilitate return to work varies. Indeed, their superiority over other rehabilitation
programmes has been questioned [149]. Several studies do not show any differences in
outcome between multidisciplinary rehabilitation programmes and traditional treatment
[33, 140]. Jellema et al. (2005) compared the effects of an intervention strategy aimed at
assessment and modification of psychosocial prognostic factors and of routine care for
treatment of (sub-) acute low back pain in general practice. No significant differences
between the groups on any outcome measure during 12 months of follow-up were
demonstrated [66].
Despite successful outcomes of many multidisciplinary rehabilitation programmes
there remain patients who do not benefit from them or who may profit just as well from
less costly and comprehensive interventions. For the GP there is often a challenge in
deciding which assessment to use and in knowing which patients risk long-term problems. One problem is that the pain intervention programmes themselves differ a great
deal in both content and designs, resulting in difficulties of interpretation and evaluation
The programmes often contain a combination of different psychological and physical
assessments e.g. (stress and pain management, life style, physical training, coping, body
awareness etc). This necessitates a better matching of patient characteristics with treatment strategies. Furthermore, assessments may work and lead to an increased knowledge about important underlying psychological factors but the clinicians remain with no
resource at their disposal, for example access to personnel with a psychosocial competence. In a focus group interview with the multidisciplinary teams in one of the mentioned rehabilitation projects in this thesis it was obvious that the clinicians felt unsure
of how to assess and select treatment for patients with chronic pain resulting in two
things. First, frustration with the patients since they do not get better and no options
seem available. Second, in considerable negative affect because the clinicians feel
inadequate and drained by such cases.
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26 I anders westman ✍ Musculoskeletal pain in primary health care…
AIMS
The overall aim of this thesis is to assess a biopsychosocial approach to the assessment
and management of musculoskeletal pain patients in primary health care. The specific
aims of the individual studies are:
•
To assess quality of life and long-term effectiveness of early multimodal rehabilitation on patients with musculoskeletal pain and disability. (Study I).
•
To determine prognostic variables predicting return to work (Study I).
•
To evaluate the predicting value of the Örebro Musculoskeletal Pain Screening
Questionnaire (ÖMPSQ) for patients with non-acute pain problems in primary care
(e.g. 1-6 months sick leave) and compare it with other relevant questionnaires
(Study II).
•
To evaluate a multidisciplinary model for the assessment and treatment of patients
with musculoskeletal pain problems (Study III).
•
To describe profiles of catastrophizing, fear avoidance beliefs and emotional
distress among musculoskeletal pain patients over a 3-year period and to explore the
relationships between psychological risk profiles for pain, function and sick leave
(Study IV).
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28 I anders westman ✍ Musculoskeletal pain in primary health care…
MATERIALS AND METHODS
The four papers in this thesis are based on data from two separate multimodal rehabilitation projects in primary health care:
•
Paper I was based on data from the first project, assessing quality of life and
maintenance of improvements five years after early multimodal rehabilitation.
•
Paper II was based on data from the second rehabilitation project and was conducted
to validate the predicting value of the Örebro Musculoskeletal Pain Screening
Questionnaire for patients with non-acute musculoskeletal pain problems (e.g.1-6
months of sick leave).
•
Paper III was based on data from the second rehabilitation project and assessed the
long- term effects (three years) of a primary health care multimodal rehabilitation
programme.
•
Paper IV was based on data from the second project and assessed to describe
profiles of catastrophising, avoidance beliefs and distress among musculoskeletal
pain patients. A further intention was to explore the relationship of psychological
risk profiles for pain, function and sick leave over a 3-year period.
Table 1. Studies, and their design, number of patients, data collection and main
outcome measures.
Study
Type of study
No. of
patients
Data
collection
Main outcome measures
I
Long-term (5 years)
evaluation
91
Questionnaire
Sick leave, pain, function, anxiety
and depression, job strain, quality
of life, perceived health, psychosomatic symptoms
II
Validation of screening
questionnaire
158
Questionnaire
Prediction of sick leave, perceived
physical and mental health
III
Controlled trial
158
Questionnaire
Sick leave, health care utilization,
analgesic consumption, fearavoidance, catastrophizing,
coping, quality of life, perceived
health, life events, job strain,
psychosomatic symptoms
IV
Longitudinal pattern
oriented subgroup analysis
110
Questionnaire
Sick leave, function, pain
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Study populations
The studies included in this thesis are based on two samples of patients with musculoskeletal pain and disability who were referred to multimodal rehabilitation
programmes in primary health care. The first sample consists of 91 patients (Table 2).
At 1-year follow-up there were eight dropouts and at the 5-year follow-up an additional
11. The second sample consists of 158 patients, 89 experiments and 69 controls (Table
3). At the 3-year year follow-up there were 10 dropouts. One hundred and ten subjects
from sample two were included and analyzed in study IV.
Table 2. Study I, baseline characteristics (n = 91). Continuous variables are expressed as mean
and standard deviation (SD) and categorical variables as numbers and percentage (%) if not
otherwise stated.
Study I
Age
Gender (male/female)
41.5 (Range 21-59)
27/54
(30/70)
Educational level
Elementary school only
High school
University
45
40
6
(49)
(44)
(7)
66
16
(80)
(20)
82
9
25
(90)
(10)
(31)
47
33
1
10
(52)
(36)
(1)
(11)
2
10
0
78
(2)
(11)
(0)
(87)
39
36
(52)
(48)
Mean
2.0
(SD)
(0.8)
48
26
(20)
(23)
Occupation
Heavy physical work
Light physical work
Occupational status
Employed
Unemployed
Smokers (>10 cigarettes/day, n=80)
Primary pain site
Neck/shoulder, upper extremities
Back
Leg/lower extremities
Other
Sick leave degree at start
25%
50%
75%
100%
Previous sick leave for the same problem (n=75)
Yes
No
Duration of the ongoing sick leave period before
the programme (months, n=84)
Average pain intensity at baseline, (VAS, n=85)
Accepted pain level at baseline (VAS, n=77)
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30 I anders westman ✍ Musculoskeletal pain in primary health care…
Table 3. Study III, baseline characteristics (n = 158). Continuous variables are expressed as
mean and standard deviation (SD) and categorical variables as numbers and percentage (%)
if not otherwise stated.
Study III
Age
Gender (male / female)
Educational level
Elementary school only
High school
University
Occupational status
Employed
Unemployed
Students
Other
Primary pain site
Neck
Shoulder/ shoulder-joint
Back upper part
Back lower part
Leg
Other symptoms
Pain duration (weeks)
0 -11 weeks
12-23 weeks
24-52 weeks
> 52 weeks
Sick leave at baseline
25 % sick leave
50 % sick leave
75 % sick leave
100 % sick leave
Missing
Consumption of analgesics
“High consumers”
“Low consumers”
Disability benefits at baseline
Duration of sick leave
(days during previous 12 months)
Pain score (past week)
Pain score (past three months)
Visits to general practitioner last
12 months, median (inter-quartile range)
Visits to physiotherapist
last 12 months, median (inter-quartile range)
Visits to naprapath/chiropractor last
12 months, median (inter-quartile range)
Experiment
Group
(n=89)
Control
Group
(n=69)
46
(10.3)
25/64 (28/72
47
23/46
(9.3)
(33/67
50
32
7
(56)
(36)
(8)
26
36
7
(38)
(52)
(10)
64
19
1
4
(73)
(22)
1)
(4)
51
10
3
5
(74)
(15)
(4)
(7)
60
64
28
45
30
33
(68)
(73)
(32)
(52)
(35)
(39)
37
41
20
40
25
24
(54)
(59)
(29)
(58)
(36)
(35)
16
14
16
42
75
2
10
1
60
16
(18)
(16)
(18)
(48)
(84)
(3)
(14)
(1)
(82)
8
9
8
44
50
3
5
3
38
20
(12)
(13)
(12)
(64)
(73)
(6)
(10)
(6)
(78)
46
40
7
(54)
(47)
(8)
42
27
9
(61)
(39)
(14)
67
(51)
67.5
(63)
6.6
7.2
(1.9)
(1.9)
6.6
6.9
(2.0)
(1.5)
3.0
(2.0-4.0)
3.0
(3.0-5.0)
3.0
(0.0-9.0)
1.5 (0.0-10.3)
0.0
(0.0-0.0)
2.0
(0.0-8.8)
Ethics
Participation in the studies was voluntary. The participants were given written as well
as verbal information and an assurance that they could decline to participate at
anytime without providing an explanation. The Human Research Ethics Committee at
the University of Uppsala, Sweden approved the studies (Dnr 96326 and Dnr 98496).
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Inclusion and exclusion criteria
Inclusion criteria for the first rehabilitation programme were: patients on sick leave
(ranging ≥ 30 days ≤ 90) days referred with musculoskeletal pain and disability, and
who had not been on sick leave for more than 180 cumulative days during the previous
two years. This was expanded during the second year of the project to sick leave
ranging ≥ 30days ≤ 180 days with a maximum of 12 months during the previous two
years. The subjects were either in permanent employment or were at the disposal of the
labour market.
In the second rehabilitation programme, the inclusion criteria were: patients with
musculoskeletal pain between 18 and 65 years old, on sick leave ≥ 28 days ≤ 180 days
and/or had consulted the doctor about the same problem ≥ 3 times in the previous 12
months according to information from the referring physicians. In both projects, patients
with a need for orthopaedic surgery and those with a psychiatric disorder or a tendency
to abuse were excluded. Furthermore, participants had to be able to speak Swedish
sufficiently well to be able to describe their symptoms and understand the information
given.
Measures
Background
Background questions concerning age, gender, educational level, occupational
status, and nationality were taken from the Örebro Musculoskeletal Pain Screening
Questionnaire [86]. (Studies I-IV)
Sick leave/return to work
In study I, sick leave information was obtained from the registers at the time of the
baseline visit and at 1-year follow-up. At the 5-year follow-up patients reported their
own current sick-leave. Previous research has shown that patients’ ratings are highly
correlated to register data from the National Social Insurance office [56, 87]. The term
active “active worker” is defined as a person who has decreased his or her sick leave
level at follow-up. The term “non-active worker” is a worker who maintains or
increases his or her sick leave level at follow-up. All patients were on sick leave full- or
part-time at baseline. In studies II-IV information was obtained from the patients` own
reports. “Improved” is defined as a patient who has decreased his/her sick leave level.
“Impaired” is defined as a patient who maintains or increases his/her sick leave level at
the follow-up. (Studies II-IV)
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Intensity and frequency of pain
The pain frequency instrument contains five items pertaining to the frequency of pain,
with extremes ranging from “never free from pain” to “almost free from pain”, “can be
totally free some weeks”. Intensity of pain was assessed by means of a 100-mm visual
analogue scale (VAS) with 0 indicating no pain and 100 indicating unbearable pain. The
VAS has been validated as a measure of chronic and experimental pain [50] (Study I).
The two questions concerning pain: “How would you rate the pain that you experienced during the past week”? (Studies III-IV) and “In the past three months, on average, how intensive was your pain”? (Study III) were taken from the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ). The item scores range from
0 (“no pain at all”) to 10 (“unbearable pain”) [32, 86].
Function
In Study I, function was measured with the Disability Rating Index (DRI). This instrument is constructed as a self-administered tool where patients mark on a 100-mm VAS
their presumed ability to perform the daily physical activities in question (0 representing
“without any difficulty” and 100 representing “cannot perform at all”). The items are
divided into three categories: items 1-4 refer to common daily activities, items 5-8
pertain to more demanding daily physical activities and items 9-12 concern workrelated or more vigorous activities [130](Study I).
In Study IV, function was measured by one item from the SF-36 questionnaire and
four questions about activities of daily living (ADL) from the Örebro Musculoskeletal
Pain Screening Questionnaire (ÖMPSQ) [86, 101, 166].
The SF-36 item consists of ten questions about function ability: vigorous activities;
moderate activities; lifting or carrying groceries; climbing several flights of stairs;
climbing one flight of stairs; bending, kneeling or stooping; walking more than a mile;
walking several blocks; walking one block and bathing or dressing yourself. There are
three possible answers: Yes, limited a lot; Yes, limited a little; No, not limited at all
(0-100) with higher scores reflecting a better self reported function.
The ADL items “I can do light work for an hour; I can walk for an hour; I can do
ordinary household chores; I can do weekly shopping” are scored on a scale of 0-10.
The items are added together to form a composite score (0-40) with low scores
indicating good function.
Inclination towards anxiety and depression
The Hospital Anxiety and Depression (HAD) scale, is a brief self-rating scale that was
specially designed for patients with physical illness. It consists of 14 items, seven for
the depression subscale and seven for the anxiety subscale, both with a score range
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of 0-21. The instrument is widely used in both clinical practice and research. In this
study we used both subscales [12, 175] (Study I).
Perceived health / Quality of life (QL)
The QL instrument is intended to explore levels of life satisfaction. The questionnaire
contains 10 items that are rated on a 6-point scale. The score range is from 1-6, with
higher scores corresponding to higher levels of life satisfaction [42](Study I).
The Short Form-36 Health Survey (SF-36) generic measure was developed in the
United States. It covers both functioning and well-being and has proved suitable for
clinical research, patient monitoring, and health care planning. The SF-36 is a 36-item
questionnaire that assesses health-related quality of life from the point of view of the
health care recipient. Ware et al. developed the SF-36 as a brief, comprehensive, and
psychometrically sound health outcome measure. It was also designed it to be generic
so that it could be applied to a wide variety of health conditions. The SF-36 describes
both the physical and mental components of health. Eight primary SF-36 scales from
distinct physical and mental health clusters are based on factor analyses. For each of the
eight scales scores range from 0 to 100, with higher scores reflecting better self-reported
health status. Continuous method studies and empirical testing have shown that the
scales in SF-36 can be summed up to two overall health indexes: the physical health
score (PCS) and the mental health score (MCS) [101, 166, 167](Studies II-III).
Job strain
This instrument contains 11 items (graded 1-4) concerning demands and control.
Indices for work demands and control were calculated, with high scores corresponding
to high demands and high control. By dividing demands by control, a measure of job
strain was obtained for each patient [152] (Studies I-III).
Health profile assessment (HPA)
The HPA is a special method aimed at getting the individual take responsibility for her
or his health [1, 93]. It is also a method for screening individuals who are considered to
be at risk and who therefore ought to have a motive for revising their way of life. The
HPA begins with a conversation (patient/nurse) based on a questionnaire, which is then
followed up by skeletal measurements, blood pressure determination and a submaximal
work test on an ergometer cycle. The session ends with a discussion about the results.
The questionnaire consists of 11 items on a 5-point ordinal scale, the answers to which
shed light on some important health habits and how the participant considers his or her
state of health. For the items: drug consumption, psychosomatic symptoms, perceived
stress and perceived loneliness the extremes 1-2 (“very often” and “often”) can be seen
as a “health risk”. For the perceived health item, the corresponding extremes “very bad”
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34 I anders westman ✍ Musculoskeletal pain in primary health care…
and “bad” can also be seen as a risk. The second item, leisure activities, is subdivided
into seven steps and is designed to cover leisure activities with the extremes “never” and
“very often”. The answers are summarized in an index providing information about the
respondent’s energy level, social contacts and level of activity. For the exercise item,
the extremes “never” and “occasionally” can also be seen as a risk from a health
perspective (Study I).
Patient satisfaction
The patients’ attitude to the rehabilitation program was assessed using three questions
with dichotomous answers at the 5-year follow-up: “Do you feel that the rehabilitation
project has been helpful?”; “Are you satisfied with the care you received from the
project?”; “ Would you recommend this treatment programme to a friend?” (Study I).
The Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ)
ÖMPSQ was developed as a tool for clinicians to earlier identify individuals at risk of
developing long-term problems. The questionnaire contains 25 items divided into five
groups: function, pain, psychological factors, fear avoidance, and miscellaneous
(i.e. sick leave, age, gender, nationality, monotonous or heavy work, job satisfaction).
Twenty-one of the 25 items are scored on a scale of 0-10, yielding a total score range of
0- 210. Scores are tallied to form a total score. The actual experience of pain itself is
explored through several questions about site, intensity, duration, and frequency. Ability
to perform daily activities is assessed with five items. Participants rate their current
ability to carry out light work, walk for an hour, perform household chores, complete
the weekly shopping, and sleep. Perceived ability to cope with pain and perceived job
satisfaction are appraised with two single items. Fear-avoidance beliefs are estimated
with three assertions where the patient rates the degree to which he/she agrees. The
patient’s own perception of their risk is measured with two items developed especially
for this questionnaire [17, 86] (Studies II-IV).
Coping
The Coping Strategies Questionnaire (CSQ) assesses eight different coping strategies
for pain. Each strategy consists of six different items. On a scale ranging from 0-6
subjects are asked to indicate how often they use a particular item when they experience
pain (0 = never, 6 = always). A total score of thirty-six can be obtained on each of the
eight coping strategies. In this study, we restricted the questionnaire to only assess the
coping strategy coping self-statements, e.g. “Telling oneself that one can cope with
pain, no matter how bad it gets”, “I tell myself to be brave and carry on despite the
pain [67, 128] (Studies II-III).
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anders westman I 35
Life events
A continuous “life events” variable was computed from answers regarding 17 possible
major events which could have occurred during the preceding 12 months (12 negative,
1 positive, 4 neutral) [126, 150] (Studies II-III).
Health care utilization
The extent of health care utilization was assessed by asking the subjects to report how
many times (0-≥10) during the past 12 months they had visited a general practitioner,
physiotherapist, hospital physician, naprapath or chiropractor (Study III).
Drug consumption
Drug consumption was assessed with one item: “Have you during the last month used
drugs against pain (analgesics, sedatives, sleeping pills, natural drugs?)”, with a score
range of 1-6 for each of the four drug groups (“several times every day” to “not at all
the last month”). We defined high analgesic consumption as “several times every day”,
“every day” or “every second day”, and low consumption as “some time every week”,
“more seldom”, “not at all last month” (Study III).
Psychosomatic symptoms
This questionnaire includes 22 different symptoms covering all organ systems.
Each item is provided with a 5-point Likert scale with scoring alternatives ranging from
never to every day. The questionnaire has been used in several studies by the National
Institute of Psychosocial Factors and Health [151] (Study III).
Fear-avoidance beliefs
Fear-avoidance beliefs were assessed with the Swedish translation of the Tampa Scale
for Kinesiophobia (TSK). The instrument was developed by Miller et al. (1991) as a
measure of fear of movement or (re)injury [107]. Each item is provided with a 4-point
Likert scale with scoring alternatives ranking from “strongly disagree” to “strongly
agree”. In this study, we used a 12-item short version. In accordance with the psychometric work carried out by Vlaeyen et al. (1995) five items that loaded poorly in factor
analysis were excluded, and a total score was used [172] (Studies II-IV).
Catastrophizing
The Pain Catastrophizing Scale (PCS) was used to assess subjects´ catastrophizing,
which is characterized by tendencies to engage in negative thinking and worry in
response to pain. Participants were asked to reflect on past painful experiences and to
indicate the degree to which they then experienced each one of 13 thoughts or feelings
36
36 I anders westman ✍ Musculoskeletal pain in primary health care…
on a 5-point scale ranging from 0 (not at all) to 4 (all the time) [116, 147]
(Studies II-IV).
Distress
Distress was measured by a revised subscale of The Short Form-36 Health Survey. Five
questions reflecting a patient’s experience during the previous four weeks were used to
construct a distress scale: Have you been a very nervous person? Have you felt so down
in the dumps that nothing could cheer you up? Have you felt calm and peaceful? Have
you felt downhearted and blue? Have you been a happy person? Each item is provided
with a 6-point scale with scoring alternatives ranking from 1 (all of the time) to 6 (none
of the time), with higher scores reflecting a better self-reported state of mental health
(Study IV).
Statistics
The calculations were performed with SPSS (Statistical Package for Social Science),
11.0 in Studies I and II and version 16.0 in Study IV. In Study III, SPSS 14.1 was used
for all data analysis except the conditional logistic regression which was analyzed using
SAS version 9.2. A two-sided p-value of ≤ 0.05 was considered significant.
Study I
The Wilcoxon signed-rank test or paired t-tests were used to evaluate changes in numerical variables from the baseline assessment to the 1- and 5-year follow-ups, respectively. For categorical variables, McNemar’s test was used to evaluate changes between
baseline and the 1-year and 5-year follow-ups, respectively. The Wilcoxon rank sum
test was used to test for differences in numerical variables between the active and nonactive worker groups. The chi-square test (or Fisher’s exact test if the expected cell
frequencies were too small (<5)) was used with categorical variables to evaluate
differences between the active and non-active worker groups. To determine which
subset of prognostic variables best predicted return to work stepwise logistic regression
was used. In order to control that possible multicollinearity did not affect the model
selection, both forward and backward stepwise regression was used to check that the
same best model was achieved.
Study II
The relationship between sensitivity and specificity was studied by constructing the
Receiver Operator Characteristic (ROC) curve. Principal component analysis was used
for the items in the ÖMPSQ in order to reduce the dimensionality and find relevant
factors. Only factors with an eigenvalue ≥ 1 were used. To assess the predictive power
of different factors on sick leave, stepwise logistic regression was used. Adjustments
Musculoskeletal pain in primary health care… ✍
37
anders westman I 37
were made for the variables age, gender, education level and previous sick leave if their
p-values were less than 0.2. The predictive power of the different factors on perceived
mental and physical health was studied using the General Linear Model (GLM).
Continuous variables were presented as mean and standard deviation, and categorical
data as counts and percentages. Since there were no convincing outcome difference
between the control group and the experimental group the data analyses were conducted
on the whole group.
Study III
Categorical variables were expressed as numbers and percentages. The Pearson
chi-square test was used to assess differences between the control and the experimental
group. Continuous variables were expressed as mean and standard deviation or range.
The Wilcoxon rank sum test was used to test for differences between the control and the
experimental group. Logistic regression analysis was used to study the difference in
analgesic drug consumption between the control and the experimental group at 3-year
follow-up adjusting for baseline drug consumption. Conditional logistic regression for
paired data was used to study the change in analgesic consumption over time.
Study IV
Part 1. Cluster analyses were used to extract subgroups of individuals with similar
scoring patterns on catastrophizing (PCS), fear avoidance beliefs (TSK) and emotional
distress (SF-36, five items). The analyses were done within SLEIPNER, a statistical
package developed for pattern-oriented analyses. The data were analyzed using the
LICUR rationale (LInking of ClUsters after removal of a Residue). Hierarchical cluster
analyses were performed cross-sectionally at baseline, and at 1-and 3-year follow-up
using squared Euclidean distance as the similarity measure and Ward’s method to
minimize within-cluster differences. Cluster solutions that explained two thirds of the
total error sum of squares were selected. Thereafter, k-means cluster analysis was used
to fine-tune the results. This method aims to increase the homogeneity of the clusters by
allowing cases to move to a better fitting cluster if this leads to a reduction in the error
sum of squares of the cluster solution. The cluster solutions were subsequently validated
descriptively against average pain intensity (for the previous week), function (SF-36
subscale and ADL) and sick leave (% on sick leave at baseline, and % improved level of
sick leave at 1-and at 3-year follow-up). Analysis of Variance (with Tukey’s HSD as
post hoc analysis) and chi-square were used to statistically test differences between
clusters on these variables at the three time points. Thereafter, these three separate
cluster solutions were linked across time. The “centroid” procedure was used to
examine the similarity of the cluster solutions from the three different time points by
38
38 I anders westman ✍ Musculoskeletal pain in primary health care…
calculating the average squared Euclidean distance between the centroids of cluster
solutions adjacent in time. The “exacon” procedure was used to examine individual stability and change; this procedure produces contingency tables of the two cluster solutions adjacent in time and examines it with focus on cell-wise analysis of common
pathways: “types” (an overrepresentation of units in a cell). It calculates, among other
things, the one-tailed probability of the observed cell frequency and can in this way
highlight typical individual moves from one cluster to another.
Finally, it was investigated whether treatment had affected developmental pathways
over the three year period. To do this, clusters were reorganised into fewer units
(thereby increasing N per unit, and allowing statistical analysis). One subgroup included
original clusters with “low risk” profiles (average z- scores on all three variables
under 1) and the other subgroup included original clusters with “risk” profiles (one or
more of the variables had an average z-score of 1 or above) at baseline, and at 1- and
3-year follow-up. Possible differences in pathways over time of those who had received
treatment as usual, and those who had received treatment with a biopsychosocial
orientation were compared using log-linear analysis.
Part 2. The relationship of risk profiles with outcome was examined by using the
“risk profile” and “non-risk profile” groups at baseline. By means of t-tests it was investigated whether these subgroups differ on average pain intensity (for the previous past
week), function (SF-36, ADL) and sick leave (% improved during previous year) at the
1- and 3-year follow-ups, respectively.
Table 4. Statistical methods used in studies I-IV
I
II
Paired t-test
*
*
Wilcoxon signed-rank test
*
McNemar’s test
*
Chi-square test
*
Fisher´s exact test
*
Logistic regression
*
*
Principal component analysis
*
General Linear Model
*
Wilcoxon rank sum test
*
III
IV
*
*
*
*
Log-linear analysis
*
Anova
*
Cluster analysis
*
Musculoskeletal pain in primary health care… ✍
39
anders westman I 39
40
40 I anders westman ✍ Musculoskeletal pain in primary health care…
RESULTS
Quality of life and maintenance of improvements after early multimodal rehabilitation: A 5-year follow-up (Study I)
Improvements in pain (p=0.034), perceived health (p=0.002), and psychosomatic
symptoms (p< 0.001) were maintained at 5-year follow-up. In addition, improvements
in function (p=0.020), quality of life (p=0.046) and level of acceptable pain (p=0.049)
were significant in comparison to baseline (Figures 4-5).
At the time of the baseline assessment all patients were on sick leave (13% were on
partial sick leave). Work capacity, as reflected in return to work increased greatly (81%)
at 1-year follow-up and was substantial (58%) at 5-year follow up. Furthermore, the
results show that those working differed significantly from those not working at the
5-year follow-up on almost all variables, indicating that those in work enjoy better
health (Tables 5-6). The most salient prognostic factors for return to work at the time of
the baseline evaluation were perceived health (p=0.010, OR 2.3, 95% CI: 1.2 - 4.3) and
educational level (p=0.033, OR 3.2, 95% CI: 1.1-9.1).
Nearly 80% of patients believed that the project had been helpful and 97% were
satisfied with the care they received. Ninety percent reported that they would recommend the rehabilitation programme to a friend.
Figure 4. Pain intensity, accepted level of pain, Disability Rating Index (DRI) and Quality of
Life Index (QL) at baseline and 1-and 5-year follow-up. The short bracket indicates the
comparison between baseline and 1- year follow-up. The long bracket indicates the comparison
between baseline and 5- year follow-up. Means and 95% confidence intervals of means.
(* = p<0.05, ** = p<0.01, *** = p<0.001).
100
100
Pain intensity
*
*
80
***
***
60
60
40
40
20
20
0
n=
N=
64
64
64
64
Baseline 1-year
100
64
64
0
**
52
52
n=
N=
5-year
52
52
Baseline 1-year
6.0
DRI
52
52
5-year
QL
5.0
80
*
60
4.0
**
3.0
40
2.0
20
0
0
Accepted level of pain
80
n=
1.0
65
65
Baseline
65
65
1-year
65
65
5-year
n=
66
66
66
66
Baseline 1-year
66
66
5-year
Musculoskeletal pain in primary health care… ✍
41
anders westman I 41
Figure 5. Distribution percentage of negative components (“risk”) originating from the health
profile assessment at baseline and 1- and 5-year follow-up. The short bracket indicates the
comparison between baseline and 1-year follow-up. The long bracket indicates the comparison
between baseline and 5-year follow-up. (* = p<0.05, ** = p<0.01, *** = p<0.001)
100
***
***
Baseline
1 year
5 year
80
60
**
40
**
*
20
0
Lack of
exercise
Inadequate
diet
Symptoms
Stress
Loneliness
Poor health
Drugs #
#Tranquillizers, sedatives, pain medication
Table 5. Mean differences between non-active and active workers at 5-year follow-up for all
psychology, pain-related, functional, and work-related measures.
Variables
Non-active
workers
n
Active
workers
n
P-value
Pain frequency
(range 1-5)
1.72
(1.3)
31
3.58
(1.6)
37
<0.001
Average intensity of pain
(VAS range 0-100 mm)
59.2 (24.9)
32
25.6 (23.9)
39
<0.001
Disability Rating Index
(VAS range 0-100 mm)
54
(19.2)
30
21.0 (19.6)
39
<0.001
HAD, anxiety score
(range -0-21)
7.7
(2.9)
32
5.8
(2.7)
40
0.003
HAD, depression score
(range 0-21)
5
(3.8)
31
2.3
(2.9)
40
0.001
Accepted level of pain
(VAS range 0-100 mm)
42
(27.8)
30
25.7 (18.2)
39
0.002
Quality of life score
(1-6)
4.2
(0.9)
32
4.8
39
0.002
42
42 I (0.8)
anders westman ✍ Musculoskeletal pain in primary health care…
Table 6. Frequency and distribution percentage of negative components (“risk”) based
on the health profiles assessment for non-active and active workers at 5-year follow-up.
Risk frequency
non-active
workers
n=32 (%)
Psychosomatic
symptoms
Perceived poor health
Drug consumption
¤
Perceived loneliness
Perceived stress
Lack of exercise
Lack of leisure activities
¤
Risk frequency
active
workers
n=40 (%)
24
(80)
13
11
12
(37)
(41)
0
5
2
7
15
7
(7)
(23)
(54)
(24)
2
9
12
0
P-value
(38%)
<0.001
(15)
<0.001
0.013
(6)
(27)
(35)
0.62
0.88
0.09
0.002
Tranquillizers, sedatives, pain medication
Do psychosocial factors predict disability and health at a 3-year follow-up for
patients with non-acute musculoskeletal pain? A validation of the Örebro
Musculoskeletal Pain Screening Questionnaire (Study II)
The items in the questionnaire were reduced to six disjoint factors by factor analysis:
I) Function, II) Pain, III) Distress, IV) Fear-avoidance, V) Return to work expectancy
and VI) Coping.
Sick leave: adjusting for age and earlier sick leave Factor I (function) and Factor II
(pain) significantly predicted sick leave after three years (p= 0.001 and 0.037,
respectively) (Figure 6).
Figure 6. Increased sick leave or maintained total work disability. Unadjusted odds ratio and
95% C.I. for the different factors.
Musculoskeletal pain in primary health care… ✍
43
anders westman I 43
Factor III (distress) significantly predicted perceived mental health and Factor V
(return to work expectancy) almost significantly predicted perceived mental health
(p< 0.000 and 0.082, respectively), as measured by SF-36 (mental health score)
(Table 7).
Adjusting for age, Factor I (function) and Factor II (pain) significantly predicted
perceived physical health as measured by SF-36 (physical health score) (p< 0.001 and
0,026, respectively). Factor IV (fear-avoidance) was borderline significant (p=0.059)
(Table 8).
Table 7. Prediction of self-reported health (SF-36, mental health score) analyzed using the
General Linear Model.
Regression
coefficient
95% C.I.
P-value
Factor III
(Distress)
-1.509
-2.296 – 0.721
< 0.001
Factor V
(Return to work expectancy)
-0.922
-1.963 – 0.120
0.082
0.241
0.035 – 0.447
0.022
Age
Table 8. Prediction of self-reported health (SF-36, physical health score) analyzed using the
General Linear Model
Regression
coefficient
95% C.I.
P-value
Factor I
(Function)
-2.056
-3.024 – -1.087
< 0.001
Factor II
(Pain)
-1.405
-2.638 – -0.173
0.026
Factor IV
(Fear-Avoidance)
0.963
-0.039 – 1.964
0.059
Age
-0.269
-0.445 – -0.092
0.003
Predictive ability of the overall ÖMPSQ score: a cut-off “at-risk” score of 117 correctly
classified (sensitivity) 78% of the poor outcomes (failed to reduce sick leave) and a
cut-off score of 139 correctly classified 44% of those who failed to reduce their sick
leave. For the same score levels 49% and 89% of those who succeeded in reducing their
sick leave were correctly classified (specificity) (Figure 7).
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44 I anders westman ✍ Musculoskeletal pain in primary health care…
Figure 7. Receiver operator characteristic (ROC ) curve for ÖMPSQ total score’s ability to
predict sick leave status at 3- year follow-up.
Other questionnaires: The questionnaires Job Strain, Coping Strategies Questionnaire
(CSQ), Pain Catastrophizing Scale (PCS), Tampa Scale for Kinesiophobia (TSK)
and Life events, did not significantly predict sick leave or perceived health at 3-year
follow-up.
Controlled 3-year follow-up of a multidisciplinary pain rehabilitation program in
primary health care (Study III)
There was an overall improvement in both the experimental and the control groups at
3-year follow-up but there was no significant difference between the groups with regard
to the Short Form -36 (SF-36), the Coping Strategies Questionnaire (CSQ), the Pain
Catastrophizing Scale (PCS), the Tampa Scale for Kinesiophobia (TSK), negative life
events, job strain and pain (Tables 9 and 11).
Musculoskeletal pain in primary health care… ✍
45
anders westman I 45
Table 9. Score index of the questionnaires at baseline and 3-year follow-up and p-values for
the comparison of differences between the two groups in score index change from baseline
(mean( SD))(Wilcoxon rank sum test).
Experimental group
3 year
Control group
n
Baseline
3 year
n
p-value
Measure
Baseline
SF-36
Physical health score
41.2 (5.1)
38.3 (10.4) 59
40.4 (6.5)
36.5 (10.0) 52
0.68
SF-36
Mental health score
39.6 (8.9)
46.5 (11.8) 59
38.1 (7.8)
43.5 (12.4) 52
0.58
PCS total index
17 (9.1)
15.8 (9.8) 59
20.0 (10.7)
18.1 (11.7) 54
0.68
PCS
Helplessness
7.9 (4.6)
8.2
(4.9) 60
8.8
(5.5)
8.7
(5.5) 56
0.24
PCS
Magnification
3.1 (2.4)
2.9
(2.7) 64
4.3
(2.4)
3.6
(3.0) 58
0.23
PCS
Rumination
6.0 (3.6)
4.9
(3.5) 63
6.7
(3.9)
5.6
(4.1) 58
0.61
CSQ
Self-statement
2.9 (1.2)
3.3
(1.0) 64
3.0
(1.1)
3.3
(1.2) 52
0.79
TSK
24.7 (6.0)
23.7 (6.4) 66
28.2 (6.9)
25.7 (7.7) 58
0.48
Job strain
0.9 (0.3)
0.8
(0.2) 33
0.9
(0.3)
0.8
(0.2) 28
0.37
Psychosomatic
symptoms
1.3 (0.7)
1.4
(0.7) 64
1.4
(0.6)
1.6
(0.6) 60
0.57
Negative life events
1.8 (1.6)
1.6
(1.6) 67
2.6
(1.8)
2.6
(1.8) 58
0.70
Health care utilization: there were fewer primary health care visits at 3-year follow-up
than at baseline in both the experimental and the control groups. This difference was
significant concerning visits to general practitioners and naprapaths/chiropractors in the
experimental group (p=0.047, 0.034) but not to visits to physiotherapists (p=0.308)
(Table10).
Work capacity: there was a slightly higher work capacity in the experimental group after
three years but the difference was not statistically significant (p=0.595).
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46 I anders westman ✍ Musculoskeletal pain in primary health care…
Table 10. Differences in visits to general practitioners (GPs), physiotherapists, and
naprapaths or chiropractors between the experimental and the control groups at 3-year
follow-up (Wilcoxon rank sum test).
Median
Inter-quartile
range
Experimental group (n=73)
1.0
0 – 3.5
Control group (n=62)
3.0
0 – 6.0
P-value
Visits to GP last 12 months
0.047
Visits to physiotherapists last 12 months
Experimental group (n=75)
0.0
0 – 5.0
Control group (n=64)
0.0
0 – 12.0
0.308
Visits to naprapath or chiropractor last 12 months
Experimental group (n=79)
0.0
0–0
Control group (n=61)
0.0
0 – 2.0
0.034
Analgesic consumption: analgesic consumption decreased in both groups during the
3-year follow up. Consumption decreased significantly in the experimental group
(OR 0.39; 95% CI 0.16-0.93; p=0.034) but not in the control group (OR 0.46; 95%
CI 0.18-1.22; p=0.12). The odds ratio of being a “high consumer” in the control group
compared with the experimental group after 3-year follow-up, adjusting for baseline
consumption, was 1.64 (95% CI 0.8-3.4); p=0.18).
Table 11. Score index for the two items concerning pain experience at baseline and at 3- year
follow-up and p-values for the comparison of differences between the two groups for the change
in score index from baseline (mean (SD)). (Wilcoxon rank sum test).
Experimental group
Control group
Measure
Baseline
3 year
n
Baseline
3 year
n
Pain past week
6.6 (1.9)
5.6 (2.5)
Pain past three months
7.2 (1.6)
5.7 (2.5)
79
6.6 (2.0)
5.8 (2.6)
64
0.59
79
6.9 (1.5)
5.8 (2.5)
64
0.32
P-value
Avoidance beliefs, catastrophizing and distress: A longitudinal subgroup analysis
on patients with musculoskeletal pain, (MSP), (Study IV).
In order to identify subgroups of individuals with similar patterns on catastrophizing,
fear-avoidance beliefs and emotional distress a cluster analysis of 110 musculoskeletal
pain patients was used. The number of clusters was determined by the proportion of
explained variance. Using a k-means analysis to fine-tune the results from the
Musculoskeletal pain in primary health care… ✍
47
anders westman I 47
hierarchical procedure, this resulted in three 5-cluster solutions that explained 68%
(baseline), 65% (1-year follow-up) and 69% (3-year follow-up) of the variance.
In Figure 8, the five cluster solutions are graphically displayed horizontally, with
the first column representing clusters extracted at baseline, the second column clusters
extracted from the 1-year follow-up, and the third column clusters extracted from the
3-year follow-up. The five distinct profiles found were: “low scores cluster” (cluster 1),
“high score cluster” (cluster 5), “fear avoidance and catastrophizing cluster”
(cluster 2), “distress only cluster” (cluster 3) and “medium catastrophizing cluster”
(cluster 4).
Figure 8 demonstrates that emerging patterns at 1-year follow-up are very similar to
the cluster solution extracted at baseline. The patterns emerging at 3-year follow-up
show some divergence. All subgroups display relatively high pain intensity, functional
problems, and sick leave rates at baseline, but the differences seem to be more distinctive across time. The analysis of common developmental pathways shows considerable
stability over time. In particular, cluster 1 (“low scores cluster”), cluster 3 (“distress
only cluster”) and cluster 5 (“high scores cluster”) show high rates of individual
stability over time.
To further explore the similarities between the cluster solutions a centroid analysis
was performed. The average squared Euclidian distances between the cluster centroids
at baseline and 1-year follow-up varied between 0.003 (cluster 1) and 0.233 (cluster 5),
while the distances between centroids at 1- and 3-year follow-up varied between 0.007
(cluster 1) and 0.390 (cluster 5). This confirms the relative stability of the cluster
solution across these time periods.
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48 I anders westman ✍ Musculoskeletal pain in primary health care…
Figure 8. Significant longitudinal pathways between baseline and assessments at one and three
years. The graphs depict standardized scores for five similar groups at each time point. An area
with +/- 2 z-scores on the y-axis was used. The number by each arrow shows how many more
times than expected by chance individuals were classified in similar or slightly dissimilar
groups. All paths: p<0.05. Note that the profiles are person-oriented and therefore the number
of participants in each profile is indicated.
BASELINE
1-YEAR FOLLOW UP
3-YEAR FOLLOW UP
2
2
2
1,5
1,5
1,5
1
0,5
0
1
2.3 x
1
2.5x
0,5
0
0,5
0
-0,5
-0,5
-0,5
-1
-1
-1
-1,5
-1,5
-1,5
-2
-2
-2
Cluster 1 (n=37)
Cluster 1 (n=29)
Cluster 1 (n=33)
2
2
2
1,5
1,5
1,5
1
1
1
0,5
0,5
0,5
0
1.9x
0
0
-0,5
-0,5
-0,5
-1
-1
-1
-1,5
-1,5
-1,5
-2
-2
Cluster 2 (n=31)
1.6x
-2
Cluster 2 (n=15)
Cluster 2 (n=26)
2.9x
2
2
2
1,5
1,5
1,5
1
1
1
0,5
0,5
0,5
0
0
-0,5
2.6x
2.6x
-0,5
0
-0,5
-1
-1
-1
-1,5
-1,5
-1,5
-2
-2
Cluster 3 (n=16)
2.3x
-2
Cluster 3 (n=16)
Cluster 3 (n=29)
2
2
2
1,5
1,5
1,5
1
1
1
0,5
0,5
0,5
0
0
-0,5
1.9x
2.1x
-0,5
0
-0,5
-1
-1
-1
-1,5
-1,5
-1,5
-2
-2
Cluster 4 (n=18)
-2
Cluster 4 (n=32)
Cluster 4 (n=10)
1.9x
2
2
2
1,5
1,5
1,5
1
1
1
0,5
0,5
0,5
0
-0,5
-1
-1,5
-2
Cluster 5 (n=8)
= Catastrophizing,
3.1x
0
3.1x
-0,5
0
-0,5
-1
-1
-1,5
-1,5
-2
-2
Cluster 5 (n=18)
= Fear avoidance,
Cluster 5 (n=12)
= Distress
Musculoskeletal pain in primary health care… ✍
49
anders westman I 49
There are significant differences between the clusters in function (SF-36) at baseline, in
pain intensity and function (ADL) at 1-year follow-up, and on the entire set of outcome
variables at 3-year follow-up. The “low scores cluster” and “distress only cluster” seem
to have the most favourable scores on outcome variables (Table 13). A multimodal
treatment programme did not significantly affect the developmental pathways.
The reorganization of clusters into a psychological “risk cluster” and a “non risk
cluster” showed significant differences at 1-and 3-year follow up in functional ability as
well as in decreased sick leave. There were no significant differences between the
groups on average pain ratings at 1- and 3-year follow-up (Table 12).
Table 12. Prediction of outcome based on the “risk” profile at pretreatment baseline
(Mean (SD).
1-year follow-up
Pain
Risk profile
at baseline
(N=55)
Non-risk profile
at baseline
(N=55)
T/ χ²
Function
3-year follow-up
Improved
sick leave
SF-36
ADL
6,0
(2,2)
59,2
(17,7)
19,1
(8,3)
49%
5,6
(2,7)
67,2
(21,7)
16,7
(9,2)
67%
-0,9
(df=107)
2,1*
(df=107)
-1,5
(df=108)
3,7*
Pain
Function
Improved
sick leave
SF-36
ADL
6,0
(2,1)
64,4
(18,5)
19,9
(7,8)
48%
5,2
(3,0)
70,6
(23,4)
16,4
(9,4)
67%
-1,7
(df=104)
1,5
(df=108)
-2,1*
(df=103)
4,1*
*=p<0.05
50
50 I anders westman ✍ Musculoskeletal pain in primary health care…
Baseline
Musculoskeletal pain in primary health care… ✍
1,3
F/
χ² (df=4)
2<1
2,8 *
2,3
51,5 (15,3) 16,5 (9,2)
62,9 (15,3) 18,8 (7,4)
54,4 (20,6) 19,1 (7,4)
* p<0.05, ** p<0.01, ¤ p=0.09
Post hoc
6,6 (1,4)
baseline
Cluster 5
Cluster solution at
7,2 (1,9)
Pain
Cluster 4
Function
6,6 (2,2)
yes)
Cluster 3
Sick leave (%
52,2 (13,8) 22,8 (8,5)
2,8
75%
94%
75%
81%
year follow up
6,7 (2,0)
Cluster solution at 1
Cluster 5
Cluster 4
Cluster 3
Cluster 2
3<5;
1, 3<4
4,6**
6,7 (1,9)
6,7 (1,8)
4,4 (2,6)
6,2 (2,5)
0,9
59,0 (19,3)
63,5 (16,2)
66,9 (22,3)
56,7 (18,9)
66,6 (23,7)
1<4
2,7 *
18,5 (7,8)
21,4 (7,4)
16,4 (9,2)
17,9 (7,3)
3,3
39%
63%
63%
60%
14,4 (10,2) 62%
improved)
Cluster 2
Pain
4,8 (2,9)
Sick leave (%
Cluster 1
Cluster 5
Cluster 4
Cluster 3
Cluster 2
Cluster 1
year follow up
78%
Cluster solution at 3
64,0 (19,3) 17,3 (7,6)
Function
ADL
1<2,4,5;
3<5
6,5**
7,3 (1,7)
7,2 (1,6)
5,0 (2,6)
6,5 (1,9)
4,3 (2,8)
Pain
6,0 (2,0)
SF-36
5<1,3,4;
2<1,3
7,3 **
47,0 (22,2)
70,5 (14,6)
73,3 (17,7)
58,5 (19,3)
76,1 (20,2)
SF-36
1<2 ¤
2,4 *
20,2 (5,7)
22,1 (6,5)
16,8 (8,9)
20,9 (6,2)
51
11,4*
33%
78%
72%
39%
15,1 (10,8) 64%
ADL
Function
ADL
3- year follow up
improved)
Cluster 1
SF-36
1- year follow up
Table 13. Cross-sectional description of cluster solutions at baseline, and at 1-and 3- year follow-up (Mean (SD)).
Sick leave (%
anders westman I 51
52
52 I anders westman ✍ Musculoskeletal pain in primary health care…
GENERAL DISCUSSION
The overall aim of this thesis was to study a biopsychosocial approach to the assessment and treatment of musculoskeletal pain patients in primary health care. Patients
with musculoskeletal pain problems are common visitors to primary care; a heterogeneous patient group with a wide variety of pain sites, pain intensity, comorbidity,
background and geneses. The majority of patients recover with or without routine
conservative care. A small percentage, however, go on to experience long-term problems and this small number of patients consume a large amount of resources [162]. As
musculoskeletal pain occurs so frequently it would be costly and unnecessary to provide every patient with secondary preventive interventions. Furthermore, a biopsychosocial understanding of the multifactorial challenges of rehabilitation is of little use to
the patient unless the complex approach can be shaped into a form that is clinically
applicable. For the GP it is a great challenge to decide which patients are at risk of developing chronicity and to decide which type of treatment to use.
This thesis is based on two multidisciplinary rehabilitation projects in primary
health care. In this research field there is a paucity of long-term evaluations and only a
few studies have examined the results of such treatments when carried out as a part of
usual care by existing personnel, e.g. effectiveness studies. In evaluating the impact of
health care research, the distinction between efficacy and effectiveness studies is
important. Efficacy studies seek to determine the impact of specified interventions, and
the best form for doing this is the randomized controlled trial. Effectiveness studies
emphasize external validity and generalizability and aim to determine whether interventions are feasible and have measurable beneficial effects across broad populations
in real-world settings [5, 108, 112].
The first study was an effectiveness study assessing quality of life and maintenance
of long-term results after a multimodal rehabilitation. Improvements in pain, perceived
health, and psychosomatic symptoms after one year were maintained between the
1-and 5-year follow-ups. In addition, improvements in quality of life, function, and
level of acceptable pain were significant between the baseline assessments and the
5-year follow-up. The most salient prognostic factors determining a patient’s return to
work were the individual’s perceived health and educational level at baseline. Many
studies across different countries have confirmed that self-assessed health is an important predictor of health status in many populations [63]. Self-perceived health is also a
predictive factor in developing chronic pain, and chronic pain itself is related to low
self-related health in the general population [95]. Educational level is known to have
an association with rehabilitation outcomes, disability and bad health status
[27, 29, 148].
Musculoskeletal pain in primary health care… ✍
53
anders westman I 53
Individuals who are working five years after the rehabilitation programme terminated
differed significantly on almost all variables from those not working, indicating that
people with work generally enjoy better health. Even common leisure activities such as
hobbies, joining cultural events, activities associated with clubs and organizations
(religious, political etc) differed and were significantly lower in the “not working
group”. These results add support to the opinion and common experience that sick
leave per see often negatively influences an individual’s perceived health and quality
of life [10].
The fact that the majority of the patients were satisfied with the treatment is appreciative. While satisfaction is a subjective variable, it may nonetheless reflect the
quality of care and may predict important patient behaviour. Patient satisfaction with
treatment has been defined as “the extent to which treatment gratifies the wants,
wishes, and desires of clients” [77], and has become common assessment in medical
patients today. Although patient satisfaction with treatment in general has been widely
researched, most of the research has focused on patients with non-chronic conditions.
In our study, and consistent with earlier research in this field, the care satisfaction
ratings were higher than the satisfaction with improvement ratings. These rating differences suggest that patients distinguish between the quality of the care, which is a more
interpersonal construct, and quality of treatment, which is a more outcomes oriented
construct [58].
Many chronic pain patients are characterized by the feeling that the medical investigations they experience are inadequate and that they have unexplained questions
about their illness. One prominent intention with the rehabilitation projects in this thesis has been to meet every single patient’s specific needs. The rates of patient satisfaction reported in our study might be in line with earlier research in chronic pain showing that a patient’s feeling that the investigations are complete, the explanation acceptable, and that the treatment helps to improve daily activities are strong predictors of
treatment satisfaction [98].
In the second rehabilitation project (Study III), the main purpose was to compare
the long-term effects of a multidisciplinary programme for patients with musculoskeletal disorders with those of routine treatment in primary health care; a controlled
study with usual personnel in primary care settings. Both groups demonstrated considerable improvements over the course of three years. However, the experimental group
showed a lower utilization of health care at the 3-year follow-up which may indicate
that the participants were coping in a better way with pain and therefore did not require
any further consultations. Health care utilization data from comprehensive pain
programme trials generally yield favourable results. Earlier research has found a major
reduction of pain related clinic visits in the year following the completion of the
programme with strong cognitive behavioural orientation and several reports have
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54 I anders westman ✍ Musculoskeletal pain in primary health care…
indicated that chronic pain patients do not seek additional therapy for pain within one
year following treatment [22, 134, 154]. The experimental group had a lower risk of
using large amounts of medication at the 3-year follow-up compared with the control
group. A decrease in analgesic consumption is in line with the results of other studies
confirming reduced pain-related drug consumption as an outcome of multidisciplinary
rehabilitation [49].
Economic evaluations of health care technologies and programmes are becoming
more and more important, and from an economic point of view, a reduction in health
care utilization is not to be disregarded. Given the fact that a small group of patients
with musculoskeletal pain problems utilize a great deal of the available resources, it
would have been a valuable contribution to the literature if a more profound economic
evaluation had been carried out. The total number of pain-related visits to physicians in
Sweden, the majority of which are to GPs, is estimated at 4.2 million visits per year.
The cost per visits to a GP is estimated to be approximately 1250 SEK which means
that the total cost for physician visits is about 4.7 billion SEK (SBU, 2006) [131].
A 25% reduction in GP visits would reduce direct costs by more than 1 billion SEK
per year.
Several earlier studies of multidisciplinary pain programmes have supported the
efficacy of these interventions regarding psychosocial variables, quality of life, pain
reduction and return to work [9, 49, 52, 53, 68, 73, 75, 114, 131].
However, the literature is not consistent and there are obviously individuals who do
not benefit from these programmes or who profit similarly well from less costly and
comprehensive interventions. To our surprise, there were no significant differences
between the groups on a number of important variables such as work capacity, function, catastrophizing and pain. It is possible that the intervention had no effect, but
there are also other factors that may have influenced outcome, for example the fact that
the controls received active treatments without our knowledge. Further, the referring
general practitioners were aware of the existence of the programme and its active principles. Routine care may be as successful as the experimental group in offering a multidimensional approach integrating psychosocial aspects. We can neither prove nor
exclude that other therapists treating the control group felt in competition with the multidisciplinary rehabilitation programme and that treatment given in the respective settings therefor improved. Moreover, the Swedish authorities have disseminated information concerning the treatment of musculoskeletal pain recommending a multidimensional approach [131].
A particular problem in the rehabilitation of musculoskeletal pain patients is the
lack of matching between psychological risk factors and the different interventions
available [135]. Furthermore, a general problem noted in the literature is the training of
health care personnel in psychological techniques and their correct application. For
Musculoskeletal pain in primary health care… ✍
55
anders westman I 55
example, Jellema et al. (2005) found that a short training programme did not result in
clinical competency or in the ability of doctors to identify psychosocial risk factors and
to address them in treatment [66]. Similarly, Cherkin et al. found that while doctors
gave high ratings to education in psychosocial factors this had little actual effect on
their management[24]. In the present study, participating clinicians received an educational programme of only a couple of days but their compliance with the programme is
uncertain. Consequently, this could mean, that in reality, the multidimensional aspects
of the programme were followed less extensively than expected. Other researchers
have demonstrated the difficulty of demonstrating significant improvements when implementing new multidimensional approaches [33, 140].
A further explanation may be the composition of the study sample. The study
population is different to many others reported earlier, focusing on patients with
shorter pain and disability duration and less severe symptoms. A consistent finding in
the literature is that the longer pain persists, the poorer is the prognosis for recovery.
As the chronic pain syndrome becomes more firmly and completely a part of a
patient’s life, rehabilitation becomes progressively more difficult [84]. Furthermore, as
has been done in other studies, we did not select patients with psychosocial risk factors
[88, 144]. Taken together, these factors may have reduced the effects of the experimental intervention.
Another circumstance that could have influenced the result is that the treatment
model in the rehabilitation programme consisted of a package of different interventions. This could mean that the screening and the treatment did not sufficiently address
psychological risk factors. Probably we need treatments which, in a better way, provide “real” psychosocial interventions with a more tailored treatment approach for this
group of patients.
Psychological factors have been shown to be good predictors of long-term disability including sick leave and there is a link between these factors and the development
of chronic pain and disability, in that psychosocial risk factors play an important role
in the transition from acute pain to long-lasting pain problems. In many respects,
screening for psychosocial factors could be feasible. The screening questionnaires
could be of importance for the general practitioner and other caregivers in primary
health care and occupational health settings as a complement for patients with musculoskeletal pain and disability. The results in Study II demonstrate that psychosocial
factors as measured by the ÖMPSQ are related to work disability and perceived health
even three years after treatment for patients with non-acute pain problems. Moreover,
the instrument appears to be most helpful in predicting future functional problems as
well as sick leave.
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56 I anders westman ✍ Musculoskeletal pain in primary health care…
Several studies have posited the predictive value of the ÖMPSQ in identifying patients
with musculoskeletal pain at risk of developing long-term problems [17, 59, 61, 62, 85,
91, 169]. The results underscore the recommendations of clinical guidelines which
suggest its use in primary care identifying patients with psychosocial risk factors who
need further assessments and/or early interventions to prevent long-term problems
[59]. The questionnaire is targeted at individuals seeking care with acute, sub-acute or
recurrent musculoskeletal pain and can be used in, for example, primary health-care
settings and physiotherapy clinics. The instrument can also be used on an item basis
where areas of special importance for risk judgment are isolated, as well as topics that
can be taken up in an interview with the patient. In this way, the instrument can function as a tool of communication between the patient and the care giver. The questionnaire can serve as a complement to usual medical examinations and may help the clinicians explore psychosocial aspects in a more optimal manner.
The aim of Study IV was to describe profiles of fear avoidance beliefs, catastrophizing, and emotional distress among musculoskeletal pain patients in primary care.
Five distinct profiles were extracted and meaningfully related to future sick leave and
function. The structures of the profiles were essentially stable and became more accentuated across a 3-year period. Our results suggest that there are distinct subgroups of
patients who seek help in primary care, and these subgroups are strongly related to
future disability. The analysis confirms that the differences become more distinct
across time and it seems that “low score cluster” and “distress only cluster” have the
most favourable scores on the outcome variables pain, function and sick leave. The
clusters “fear avoidance and catastrophizing”, “high score cluster” and “medium
catastrophizing” have less favourable outcomes. The results suggest that catastrophizing and fear avoidance beliefs combined with distress may be contributing factors
in the development of persistent pain problems and disability. The results in this study
underscore earlier research that pain-related fear and distress are important factors in
the development of pain-related disability [15, 16, 78].
Taken together, the results highlight the need to address psychological aspects such
as fear-avoidance beliefs, catastrophizing and emotional distress in the management of
patients with musculoskeletal pain. This may open the way to a better tailored treatment approach for patients with musculoskeletal pain. Identifying homogeneous
subgroups, defined by their variation in psychosocial factors, may improve the secondary prevention of musculoskeletal pain problems because the treatment could be
adjusted according to both pain and psychosocial factors.
Limitations and strengths
Considering the results of the papers in this thesis, a number of general limitations
should be mentioned. Firstly, the studies are based solely on self-report questionnaires
57
Musculoskeletal pain in primary health care… ✍
anders westman I 57
which involve a risk of information bias due to false inaccurate responses or
recollections from the patients. Furthermore, the pain conditions were not categorized
into a diagnosis. Categorization may have rendered useful information regarding
whether an intervention was more or less beneficial than another for a certain specific
diagnosis. Considering Study I, care needs to be taken in drawing conclusions about
utility since no control group was available. However, the focus of the study was on
long-term results rather than comparison with other treatment. The fact that the results
were maintained between the 1-and 5-year follow-ups seems to discount for “placebo”
effects.
In Study II, the long follow-up period (three years) is worth consideration. While
this offers advantages it also opens the door for other events that may influence outcome and reduce the size of the impact of predictor variables. Furthermore, the subjects consisted of an experimental and a control group with different kinds of treatments. However, because an earlier analysis of the effects of treatments did not produce any significant differences at 1-year follow-up, we chose to pool the data to gain
power and clarity in interpreting the results.
In Study III, there are several methodological issues that should be kept in mind
when drawing conclusions from the study. First, because this study compares health
care centres there may be biases in the selection of patients and personnel. For example, those centres volunteering to offer routine treatment may well differ from other
primary health care centres. However, no differences before treatment were found
between the two groups in any of the outcome measures. Therefore, the risk of
selection bias (e.g. for severity of disease) was considered to be small. Moreover, it is
extremely difficult to randomize patients at health care centres. Integrity of the treatments may have been compromised since both were provided at the same centre and
randomization selection bias may have inadvertently occurred. As the centres in our
region are small, difficulties in following the protocol may have arisen due to the small
number of patients in each treatment group. Due to the way in which the participants
were recruited to the study we have very limited information on early dropouts. In
addition, measures relied on self-ratings where recall bias may influence results. We
used entire primary health care centres as either an experimental or a control centre.
That proved it impossible to keep accurate records of the exact content of the treatments in the two groups over the 3-year period. This limited our ability to analyze
actual content and thereby treatment consistency.
In Study IV, it should be kept in mind that the study sample is rather small and the
reliability of the cluster solution would have been strengthened by a somewhat larger
sample.
A strength of our studies are that the interventions were conducted and assessed in
the “real clinical world”, i.e. in authentic and not in artificial clinical settings. This
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58 I anders westman ✍ Musculoskeletal pain in primary health care…
might be of importance since the results could be generalized to authentic settings in
primary health care. Furthermore, Study III is a controlled trail with two experimental
and four control primary health care settings. In the field of pain research there is a
paucity of long-term follow-up studies and it is worth to underscore the long follow-up
periods in the both projects, namely five and three years, respectively, with notably
low dropout rates.
Clinical implications
The results demonstrate that the Örebro Musculoskeletal Pain Screening Questionnaire
(ÖMPSQ) is a clinically valid instrument that may be effective in the early
identification of patients at risk of developing persistent pain problems. The ÖMPSQ
questionnaire could be of importance for the general practitioner and other caregivers
in primary health care and occupational health settings as a supplement for patients
with musculoskeletal pain and disability.
The results of the long-term follow-up after multimodal rehabilitation indicate that
it is possible to maintain clinical improvements five years after a multimodal rehabilitation.
The controlled 3-year follow-up provides new possibilities for managing patients
with musculoskeletal pain in primary health care settings. However, although some
differences were observed in health care utilization and analgesics consumption there
were relatively few differences between the groups at follow up. It seems that multicomponent programmes that consider different important dimensions do not always
have an optimal effect. The multidisciplinary project might have been too general in its
design and more specific subgroup analyses would have been valuable.
Since pain is often a multidimensional problem, profound reflection may be
needed for the successful implementation of pain management interventions in primary
healthcare. Today, thanks to research, it is possible to identify patients who are at risk
of long-term disability. We have, however, no system for matching interventions to
specific risk profiles and there seems to be a need for tailored treatment approaches
related to a patient’s individual profile and needs. As seen in the last study, distinct
profiles of catastrophizing, fear avoidance beliefs, and emotional distress could be
meaningfully extracted and related to future disability. The results give support to the
use of the fear avoidance model in primary care. In this way, psychological aspects in
the management of patients with musculoskeletal pain could be addressed. This may
open the path to a more tailored treatment approach for this patient group. This,
however, requires an interdisciplinary teamwork approach which incorporates psychological competence and profound assessments of MSP patients in primary health care
settings.
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Musculoskeletal pain in primary health care… ✍
anders westman I 59
Future implication
There is a consensus about the importance of incorporating of the BPS model into the
management of pain patients in primary health care. However, a consistent application
of the biopsychosocial explanatory model of pain requires methods that are derived
from medical as well as psychological sciences. This means that the traditional
reductionistic problem-solving model has to be extended and psychological, social and
behavioural factors systematically incorporated into each patient’s consultation. Most
patients with musculoskeletal problems, however, recover without any or with a
moderate degree of intervention. A crucial challenge in PHC is to develop further
understanding of how to treat the “right” person at the right point in time with the
optimal method, where personnel utilization and costs are taken into consideration.
In a real clinical setting, MSP patients are both physically and psychologically heterogeneous, with different needs for treatment and support. This thesis gives support
to development of a better screening procedure with extended investigation of patients
at risk of long-term problems. A future implication might be studies in which
evidence-based treatments are matched to patient homogenous subgroups sharing
similar psychological and psychosocial characteristics.
In figure 9 I have designed a hypothetical model for risk factor screening in primary health care as a plausible method for matching patients to early intervention
strategies that might prevent long-lasting pain problems. In this model, people at low
risk of prolonged disability receive standard guideline based care. However, patients at
high risk are provided with additional interdisciplinary assessments including subgroup
analyses of risk profiles such as avoidance beliefs, catastrophizing and distress. The
multimodal interventions in the last step are characterized by evidence based
treatments based on analyses of the individual’s risk factors, i.e. the intervention is
matched to the patient’s needs.
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60 I anders westman ✍ Musculoskeletal pain in primary health care…
Figure 9. Components of a hypothetical risk factor-based assessment of musculoskeletal pain in primary health care
Highrisk
riskfor
forprolonged
prolonged
High
disability
disability
Early risk
risk factor
factor screening
screening
Early
Lowrisk
riskfor
forprolonged
prolonged
Low
disability
disability
Interdisciplinaryassessment
assessment
Interdisciplinary
Subgroupprofiles
profiles
Subgroup
Emotionaldistress
distress
•• Emotional
Catastrophizing
•• Catastrophizing
Avoidancebeliefs
beliefs
•• Avoidance
Standardguideline
guideline
Standard
basedcare
care
based
Advice
Advice
Gradedactivity
activity
Graded
Multimodalintervention
intervention
Multimodal
Matchingevidence
evidencebased
based
Matching
treatments
treatments
Physiotherapy
Physiotherapy
Pharmacotherapy
Pharmacotherapy
Stressmanagement
management
Stress
Exposure
Exposure
CBT
CBT
distress
• •distress
depression
• •depression
anxiety
• •anxiety
Copingskill
skilltraining
training
Coping
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Musculoskeletal pain in primary health care… ✍
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62
62 I anders westman ✍ Musculoskeletal pain in primary health care…
CONCLUSIONS
•
Improvements in quality of life and work capacity one year after a multimodal rehabilitation of musculoskeletal pain patients in primary health care were basically
maintained after five years.
•
The most salient prognostic factors determining return to work were educational
level and the individual’s perceived health. Individuals working five years after
terminated multimodal rehabilitation differed significantly on almost all variables
(physical and psychological) from those not working, indicating that people in
work enjoy better health.
•
Psychosocial factors as measured by the ÖMSPQ are related to work disability and
perceived health three years after treatment for non-acute pain problems. The
ÖMPSQ questionnaire could be of importance for GPs and other care givers in
primary health care as a complement for patients with musculoskeletal pain and
disability.
•
The experimental group in the controlled multimodal pain rehabilitation programme had lower health care utilization and a reduced risk of using large amounts
of medication after three years indicating that compared with participants in the
control group, they were coping in a better way with pain. However, there were no
significant differences between the groups on a number of important variables such
as work capacity, function, catastrophizing and pain.
•
Distinct profiles of catastrophizing, fear-avoidance beliefs and emotional distress
could be extracted among patients with musculoskeletal pain problems. The profiles were essentially stable across a 3-year period.
•
The profiles were meaningfully related to future sick leave and dysfunction. The
results emphasize the need to address psychological aspects such as fear-avoidance
beliefs, catastrophizing and emotional distress early on in the management of musculoskeletal pain patients.
•
In summary, the results give support to the biopsychosocial model and the
importance of psychosocial factors in long-term outcome. Furthermore, the
results underscore the relevance of the early identifying of patients at risk and their
needs of expanded investigation. In addition, the results indicate a need for more
individually tailored evidence- based treatments for patients with musculoskeletal
pain. Future research to investigate the feasibility and effectiveness of evidence
based interventions being matched to patients´ specific risk profiles would be valuable.
63
Musculoskeletal pain in primary health care… ✍
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64
64 I anders westman ✍ Musculoskeletal pain in primary health care…
ACKNOWLEDGMENTS
I would like to express my sincere gratitude to all those who have helped, supported
and encouraged me during the work with this thesis, in particular:
Steven J Linton, my supervisor, for your outstanding scientific guidance, encouragement and generosity. Your knowledge is so impressive yet you always demonstrate the
greatest humility.
Jerzy Leppert, co-supervisor and head of the Centre for Clinical Research (CKF) for
your great support, encouragement and for giving me the opportunity to work at the
CKF.
Töres Theorell, my co-supervisor, for your generosity and providing many years of
excellent advice and support.
Katja Boersma, co-author of Study IV, for inspiring discussions, guidance and
impressive knowledge of subgroup analyses.
Rolf Nordemar, co-supervisor in the STAR-project, for excellent support and
important guidance.
John Öhrvik, co-author of Studies I-III for impressive guidance with statistics.
Ulf Tidefeldt, Gunilla Ahlsén and Åsa Berglind at the School of Health and Medical
Sciences, Örebro, for support and for providing an eminent research education.
Mats Rothman, head of the Psychosomatic Medicine Clinic (EPM) and all the staff at
EPM, for your continuous support and giving me sense of coherence.
The CHAMP group in Örebro for stimulating discussions, shared enjoyment and not at
least great intellectual fellowship.
Petra Wahlén, for data collection, monitoring and indispensable help with SPSS.
All the PhD and doctoral students at the CKF, for all the inspiring discussions at the
seminars and all the enjoyment we shared together.
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Musculoskeletal pain in primary health care… ✍
anders westman I 65
The team members and the personnel in the “STAR” and “SALUT” projects. I would
especially like to thank Elisabeth Hanning and Ingela Sundqvist for your pioneering
work as group leaders and team supervisors.
Katarina Ringström, for your excellent support over the years with PowerPoint,
EndNote, figures and tables. You are always obliging and willing to help.
Maria Delluva Karlsson, Gun Nyberg, Michaela Eriksson, Tony Wiklund and all the
personnel and researchers at the CKF for your support and for providing an open and
positive research climate.
Ann-Christin Johansson, my room mate at the CKF, for great support, inspiring discussions, constructive advice and many laughs.
Eva Thors Adolfsson, Tuula Wallsten, Arne Eklund and Cecilia Åslund, my postdoctoral forerunners, for good advice, friendship and for giving me hope.
Hans Dahlman, former head of community medicine for the county of Västmanland
for your great support, enthusiasm and sharing of ideas.
Birgitta Ellenius, former head of the county of Västmanland`s Department of Public
Health for your encouraging support.
Christina Hjulström, former head of the primary care, county of Västmanland and
Henry Komulainen, head of the regional social insurance office for encouraging
support in the planning and development of the rehabilitation projects.
The personnel at the primary health care settings in Skinnskatteberg, Norberg,
Fagersta, Åbågen Arbåga, Sevicehälsan Västerås and Munken Enköping for help and
providing patients for the studies.
The staff at the Central Hospital library, Västerås, for all your support and help in
finding references and literature.
David de Boniface, for careful English revisions of the manuscripts and thesis.
My son Johan, my daughter Karin, and their respective families, for love and
reminding me of the greatest values in life.
66
66 I anders westman ✍ Musculoskeletal pain in primary health care…
Christina, my beloved wife, for your generosity and patience over all the years.
Without your love and support I would not have been able to complete this project.
Last, but not at least, I would like to express my very special thanks to all the patients
who participated in the rehabilitation projects. Without you this thesis would not have
been possible.
The studies have been supported by grants from the County Council of Västmanland,
Sweden (Landstinget Västmanland).
67
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anders westman I 67
68
68 I anders westman ✍ Musculoskeletal pain in primary health care…
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