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Objectives: To investigate the outcomes one year after multimodal rehabilitation programmes in primary care for patients with chronic pain, both as a whole and for men and women separately. A second aim was to identify predictive factors for not being on sickness absence at follow-up after one year.

Methods: A prospective longitudinal cohort study of 234 patients, 34 men and 200 women, age range 18–65 years, who participated in multimodal rehabilitation programmes in primary care in 2 Swedish county councils. Pain, physical and emotional functioning, coping, health-related quality of life, work-related factors, sickness absence (sick leave, sickness compensation/disability pension) were evaluated prior to and one year after multimodal rehabilitation programmes.

Results: Patients showed significant improvements at 1-year follow-up for all measures (all p ≤ 0.004) except satisfaction with vocation (p = 0.060). The proportion of patients on sick leave decreased significantly at follow-up (p = 0.027), while there was no significant difference regarding the proportion of patients on sickness compensation/disability pension (p = 0.087). Higher self-rated work ability was associated with not being on sickness absence at 1-year follow-up (odds ratio (OR) 1.19, 95% confidence interval (CI) 1.21–1.06, p = 0.005).

Conclusion: This study indicates that multimodal rehabilitation programmes in primary care could be beneficial for patients with chronic pain, since the outcomes at 1-year follow-up for pain, physical and emotional functioning, coping, and health-related quality of life were positive. However, the effect sizes were small and thus further development of multimodal rehabilitation programmes is warranted in order to improve the outcomes.

Background: Chronic pain is a complex condition that has consequences both for individual people and for society. The individual often experiences impact on function, activity and participation. Society is affected by high healthcare and sick leave costs and a loss of workforce. Multimodal rehabilitation programmes (MMRP) have mainly been provided through specialist care but it is now also available through primary care. The overall aim of this thesis was to evaluate the effects of MMRP in patients with chronic musculoskeletal pain and to explore patients’ and healthcare professionals’ experiences of MMRP.

Study I: Aim: To evaluate the effects of an interdisciplinary team assessment and MMRP for patients with chronic pain in a specialist care setting. Design: Longitudinal cohort study. Method: Pain intensity, pain dimensions, anxiety and depression were measured at assessment and at the start and end of MMRP.  A total of 93 women were evaluated. Result: Pain and pain-related measures were significantly improved both after the interdisciplinary assessment and after MMRP.

Study II: Aim: To explore healthcare professionals’ experiences of MMRP in primary care. Design: Individual interviews, analysed with qualitative content analysis. Method: Fourteen healthcare professionals (11 women, 3 men) were interviewed about their work with MMRP. Result: Healthcare professionals considered that MMRP was useful but also challenging. It was difficult to select appropriate patients, and health care professionals felt they were torn between following healthcare legislation and the goals of MMRP. They had to deal with ethical dilemmas as well as decide what constitutes good results.

Study III: Aim: To explore patients’ experiences of participating in MMRP in primary care. Design: Individual interviews, analysed with qualitative content analysis. Method: Twelve former patients (7 women and 5 men) were interviewed about their experiences of MMRP in primary care. Result: Patients in primary care experienced a complex, ongoing process of accepting chronic pain. Obtaining redress, learning about chronic pain, and experiencing fellowship with others with the same condition contributed to the acceptance process.

Study IV: Aim: To evaluate the effects of MMRP in primary care at one-year follow-up for all patients together and for men and women separately and to identify predictive factors for being employable at follow-up. Design: Prospective longitudinal cohort study. Method: Pain, physical and emotional functioning, coping, health-related quality of life, work-related factors, sick leave extent and sickness compensation were evaluated prior to and one year after MMRP in 234 patients, 34 men and 200 women. Result: All patients improved significantly in most measures at one-year follow-up, and the effect was larger in women. Sick leave decreased while no significant difference was found for total sickness compensation. Patients’ self-reported rating of current work ability before MMRP was significantly associated with being employable at follow-up.

General conclusions and implications: 

MMRP seems to be effective for patients with chronic musculoskeletal pain, both in specialist care and in primary care. MMRP was more effective for women than for men, and the reasons for this need to be investigated further. An interdisciplinary team assessment could also be beneficial for decreasing pain and pain-related measures. Patients in primary care experience a complex, ongoing process of accepting chronic pain. Healthcare professionals have to deal with conflicting emotions with regard to different commitments from healthcare legislation and the goals of MMRP.                         

OBJECTIVE: To explore patient experiences of participating in multimodal pain rehabilitation in primary care.

SUBJECTS: Twelve former patients (7 women and 5 men) in multimodal rehabilitation in primary care were interviewed about their experiences of multimodal rehabilitation.

METHODS: The interviews were analysed using qualitative content analysis.

RESULTS: Analysis resulted in 4 categories: (i) from discredited towards obtaining redress; (ii) from uncertainty towards knowledge; (iii) from loneliness towards togetherness; and (iv) "acceptance of pain": an ongoing process. The results show that having obtained redress, to obtain knowledge about chronic pain, and to experience fellowship with others with the same condition were helpful in the acceptance process. However, there were patients who found it difficult to reconcile themselves with a life with chronic pain after multimodal rehabilitation. To find what was "wrong" and to have a medical diagnosis and cure were important.

CONCLUSION: Patients in primary care multimodal rehabilitation experience a complex, ongoing process of accepting chronic pain. Four important categories were described. These findings will help others to understand the experience and perspective of patients with chronic pain who engage in multimodal rehabilitation.

Purpose: Exploring healthcare professional experiences of Multimodal rehabilitation (MMR) in primary care.

Methods: Fourteen healthcare professionals (11 women, 3 men) were individually interviewed about their work with MMR in primary care. Interviews covered experiences of assessing patients and work with patients in the programme. Transcribed interviews were analysed by qualitative content analysis.

Results: The analysis resulted in four categories: select patients for success; a multilevel challenge; ethical dilemmas and considering what is a good result. MMR work was experienced as useful and efficient, but also challenging because of patient complexity. Preconceptions about who is a suitable patient for MMR influenced the selection of patients (e.g. gender, different culture). Interviewees were conflicted about not to being able to offer MMR to patients who were not going to return to work. They thought that there were more factors to evaluate MMR than by the proportion that return to work.

Conclusions: Healthcare professionals perceive MMR as a helpful method for treating chronic pain patients. At the same time, they thought that only including patients who would return to work conflicted with their ethical views on equal healthcare for all patients. Preconceptions can influence selection for, and work with, MMR.

Objective: The aim of this study was to evaluate the effects of interdisciplinary team assessment and a 4-wk rehabilitation program in chronic pain patients.

Design: This was a longitudinal cohort study evaluating interdisciplinary pain rehabilitation measures in a specialist care setting. A total of 93 women (42.2 +/- 9.5 yrs) with chronic musculoskeletal pain (median pain duration, 8 yrs) were evaluated at assessment and at the start and end of the rehabilitation program. Pain intensity measured with a visual analog scale, pain dimensions measured with the Multidimensional Pain Inventory, and anxiety and depression measured with the Hospital Anxiety and Depression Scale were registered.

Results: The participants exhibited significantly improved results of pain and pain-related measures. The results were seen both after the short-term intervention in the form of the interdisciplinary assessment and after the 4-wk rehabilitation program. The improvements seen after the assessment were not related to specific interventions, such as change of medication, and therefore seem to be a result of the interdisciplinary assessment concept as such.

Conclusions: Both interdisciplinary assessment and rehabilitation program seem to be effective in chronic pain rehabilitation, at least for women. Further studies are needed to investigate potential sex differences, as well as content and duration for optimal pain rehabilitation programs.