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Objective To describe self-reported symptoms among patients in general practice and to explore the relationships between symptoms experienced by patients and diagnoses given by general practitioners. Design Doctor–patient questionnaires focusing on patients’ self-reported symptoms during the past 7 days and the doctors’ diagnoses. Setting General practices in urban and suburban areas in Southeast Norway. Subjects Forty-seven general practitioners who included 866 patients aged ≥18 years on a random day in practice. Results The most frequently reported symptoms were tiredness (46%), lower back pain (43%), neck pain (41%), headache (39%), shoulder pain (36%), and sleep problems (35%). Women had a significantly higher prevalence than men for 16 of 38 symptoms (p

Introduction Research suggests that current care for shoulder pain is not in line with the best available evidence. This project aims to assess the effectiveness, cost-effectiveness and the implementation of an evidence-based guideline for shoulder pain in general practice in Norway. Methods and analysis A stepped-wedge, cluster-randomised trial with a hybrid design assessing clinical effectiveness, cost-effectiveness and the effect of the implementation strategy of a guideline-based intervention in general practice. We will recruit at least 36 general practitioners (GPs) and randomise the time of cross-over from treatment as usual to the implemented intervention. The intervention includes an educational outreach visit to the GPs, a computerised decision tool for GPs and a self-management application for patients. We will measure outcomes at patient and GP levels using self-report questionnaires, focus group interviews and register based data. The primary outcome measure is the patient-reported Shoulder Pain and Disability Index measured at 12 weeks. Secondary outcomes include the EuroQol Quality of Life Measure (EQ5D-5L), direct and indirect costs, patient’s global perceived effect of treatment outcome, Pain Self-Efficacy and Brief Illness Perception Questionnaire. We will evaluate the implementation process with focus on adherence to guideline treatment. We will do a cost–minimisation analysis based on direct and selected indirect costs and a cost–utility analysis based on EQ5D-5L. We will use mixed effect models to analyse primary and secondary outcomes. Ethics and dissemination Ethics approval was granted by the Regional Committee for Medical and Health Research Ethics-South East Norway (ref. no: 2019/104). Trial results will be submitted for publication in a peer-reviewed medical journal in accordance with Consolidated Standards of Reporting Trials. Trial registration number NCT04806191.

Objectives The Fibromyalgia Survey Diagnostic Criteria-2016 (FSD-2016 criteria) were recently recommended for both clinical and research purposes. The present study aims to examine whether there is concordance between clinician-based and FSD-2016 criteria-based diagnoses of FM, and secondly, to examine how the illness severity and physical function relate to the criteria-based diagnosis among patients referred to a rheumatism hospital. Methods Participants with a clinician-based diagnosis of FM were included consecutively when referred to a patient education programme for patients with FM. Illness severity was assessed with the Fibromyalgia Survey Questionnaire (FSQ). Based on the FSQ, the fulfilment of the FSD-2016 criteria was evaluated. Physical function was assessed using the Fibromyalgia Impact Questionnaire (FIQ) function scale and self-reported employment status. Results The sample included 130 patients (84% women) from 20 to 66 years of age. Eighty-nine per cent met the FSD-2016 criteria, and 44% of the patients were fully or partially employed. Great variability in illness severity was seen irrespective of employment status. There was an association between illness severity and physical function (r=0.4, p Conclusions There was relatively high agreement between clinician- and criteria-based diagnoses. The illness severity overlapped irrespective of different employment status and fulfilment of FSD-2016 criteria.

IntroductionTraumatic injuries constitute a major cause of mortality and morbidity. Still, the public health burden of trauma in Norway has not been characterised using nationwide registry data. More knowledge is warranted on trauma risk factors and the long-term outcomes following trauma. The Injury Prevention and long-term Outcomes following Trauma project will establish a comprehensive research database. The Norwegian National Trauma Registry (NTR) will be merged with several data sources to pursue the following three main research topics: (1) the public health burden of trauma to society (eg, excess mortality and disability-adjusted life-years (DALYs)), (2) trauma aetiology (eg, socioeconomic factors, comorbidity and drug use) and (3) trauma survivorship (eg, survival, drug use, use of welfare benefits, work ability, education and income).Methods and analysisThe NTR (n≈27 000 trauma patients, 2015–2018) will be coupled with the data from Statistics Norway, the Norwegian Patient Registry, the Cause of Death Registry, the Registry of Primary Health Care and the Norwegian Prescription Database. To quantify the public health burden, DALYs will be calculated from the NTR. To address trauma aetiology, we will conduct nested case–control studies with 10 trauma-free controls (drawn from the National Population Register) matched to each trauma case on birth year, sex and index date. Conditional logistic regression models will be used to estimate trauma risk according to relevant exposures. To address trauma survivorship, we will use cohort and matched cohort designs and time-to-event analyses to examine various post-trauma outcomes.Ethics and disseminationThe project is approved by the Regional Committee for Medical Research Ethics. The project’s data protection impact assessment is approved by the data protection officer. Results will be disseminated to patients, in peer-reviewed journals, at conferences and in the media.

BackgroundCo-occurring musculoskeletal pain is common among people with persistent low back pain (LBP) and associated with more negative consequences than LBP alone. The distribution and prevalence of musculoskeletal pain co-occurring with persistent LBP has not been systematically described, which hence was the aim of this review.MethodsLiterature searches were performed in MEDLINE, Embase, CINAHL and Scopus. We considered observational studies from clinical settings or based on cohorts of the general or working populations involving adults 18 years or older with persistent LBP (≥4 wks) and co-occurring musculoskeletal pain for eligibility. Study selection, data extraction and risk of bias assessment were carried out by independent reviewers. Results are presented according to study population, distribution and location(s) of co-occurring pain.ResultsNineteen studies out of 5744 unique records met the inclusion criteria. Studies were from high-income countries in Europe, USA and Japan. A total of 34,492 people with persistent LBP were included in our evidence synthesis. Methods for assessing and categorizing co-occurring pain varied considerably between studies, but based on the available data from observational studies, we identified three main categories of co-occurring pain – these were axial pain (18 to 58%), extremity pain (6 to 50%), and multi-site musculoskeletal pain (10 to 89%). Persistent LBP with co-occurring pain was reported more often by females than males, and co-occurring pain was reported more often in patients with more disability.ConclusionsPeople with persistent LBP often report co-occurring neck pain, extremity pain or multi-site pain. Assessment of co-occurring pain alongside persistent LBP vary considerable between studies and there is a need for harmonisation of measurement methods to advance our understanding of how pain in different body regions occur alongside persistent LBP.Systematic review registrationPROSPEROCRD42017068807.

Background Neck and low back pain represent dynamic conditions that change over time, often with an initial improvement after the onset of a new episode, followed by flare-ups or variations in intensity. Pain trajectories were previously defined based on longitudinal studies of temporal patterns and pain intensity of individuals with low back pain. In this study, we aimed to 1) investigate if the defined patterns and subgroups for low back pain were applicable to neck pain patients in chiropractic practice, 2) explore the robustness of the defined patterns, and 3) investigate if patients within the various patterns differ concerning characteristics and clinical findings. Methods Prospective cohort study including 1208 neck pain patients from chiropractic practice. Patients responded to weekly SMS-questions about pain intensity and frequency over 43 weeks. We categorized individual responses into four main patterns based on number of days with pain and variations in pain intensity, and subdivided each into four subgroups based on pain intensity, resulting in 16 trajectory subgroups. We compared baseline characteristics and clinical findings between patterns and between Persistent fluctuating and Episodic subgroups. Results All but two patients could be classified into one of the 16 subgroups, with 94% in the Persistent fluctuating or Episodic patterns. In the largest subgroup, “Mild Persistent fluctuating” (25%), mean (SD) pain intensity was 3.4 (0.6) and mean days with pain 130. Patients grouped as “Moderate Episodic” (24%) reported a mean pain intensity of 2.7 (0.6) and 39 days with pain. Eight of the 16 subgroups each contained less than 1% of the cohort. Patients in the Persistent fluctuating pattern scored higher than the other patterns in terms of reduced function and psychosocial factors. Conclusions The same subgroups seem to fit neck and low back pain patients, with pain that typically persists and varies in intensity or is episodic. Patients in a Persistent fluctuating pattern are more bothered by their pain than those in other patterns. The low back pain definitions can be used on patients with neck pain, but with the majority of patients classified into 8 subgroups, there seems to be a redundancy in the original model.

Background To address the well-documented gap between hip and knee osteoarthritis (OA) treatment recommendations and current clinical practice, a structured model for integrated OA care was developed and evaluated in a stepped-wedge cluster-randomised controlled trial. The current study used secondary outcomes to evaluate clinically important response to treatment through the Outcome Measures in Rheumatology Clinical Trials clinical responder criteria (OMERACT-OARSI responder criteria) after 3 and 6 months between patients receiving the structured OA care model vs. usual care. Secondly, the study aimed to investigate if the proportion of responders in the intervention group was influenced by adherence to the exercise program inherent in the model. Methods The study was conducted in primary healthcare in six Norwegian municipalities. General practitioners and physiotherapists received training in OA treatment recommendations and use of the structured model. The intervention group attended a physiotherapist-led OA education program and performed individually tailored exercises for 8–12 weeks. The control group received usual care. Patient-reported pain, function and global assessment of disease activity during the last week were evaluated using 11-point numeric rating scales (NRS 0–10). These scores were used to calculate the proportion of OMERACT-OARSI responders. Two-level mixed logistic regression models were fitted to investigate differences in responders between the intervention and control group. Results Two hundred eighty-four intervention and 109 control group participants with hip and knee OA recruited from primary care in six Norwegian municipalities. In total 47% of the intervention and 35% of the control group participants were responders at 3 or 6 months combined; showing an uncertain between-group difference (ORadjusted 1.38 (95% CI 0.41, 4.67). In the intervention group, 184 participants completed the exercise programme (exercised ≥2 times/week for ≥8 weeks) and 55% of these were classified as responders. In contrast, 28% of the 86 non-completers were classified as responders. Conclusions The difference in proportion of OMERACT-OARSI responders at 3 and 6 months between the intervention and control group was uncertain. In the intervention group, a larger proportion of responders were seen among the exercise completers compared to the non-completers. Clinical trial registration Clinicaltrials.gov identifier: NCT02333656. Registered 7. January 2015.

BACKGROUND The Norwegian System of Patient Injury Compensation (NPE) processes compensation claims from patients who believe that they have sustained injuries during treatment in the health services. The number of cases reported to NPE has tended to increase in recent years. The purpose of this study was to obtain an overview of patient-reported injuries within the regular GP scheme. MATERIAL AND METHOD We studied all injuries to patients within the regular GP scheme in NPE in the years 2011-17. The cases of injury contained information on age, sex, diagnosis, location of the injury and compensation paid, as well as texts describing the treatment and injury. RESULTS Out of a total of 33 748 compensation claims submitted to NPE, 3 135 cases originated from the regular GP scheme. Of the group of claimants 53 % were women, and the average age was 44.7 years (standard deviation 17.7 years). Altogether 760 (24 %) of the cases were upheld. Diagnostic error was the reason for 553 (73 %) of the cases being upheld. The groups most frequently represented were 'tumours and cancers' (847 (27 %) of the claims) and 'orthopaedics' (592 (19 %) of the claims). INTERPRETATION The regular GP scheme accounts for many patient contacts, and a review of patient injuries may make it possible to prevent future failures.

IntroductionResearch suggests that current care for shoulder pain is not in line with the best available evidence. This project aims to assess the effectiveness, cost-effectiveness and the implementation of an evidence-based guideline for shoulder pain in general practice in Norway.Methods and analysisA stepped-wedge, cluster-randomised trial with a hybrid design assessing clinical effectiveness, cost-effectiveness and the effect of the implementation strategy of a guideline-based intervention in general practice. We will recruit at least 36 general practitioners (GPs) and randomise the time of cross-over from treatment as usual to the implemented intervention. The intervention includes an educational outreach visit to the GPs, a computerised decision tool for GPs and a self-management application for patients. We will measure outcomes at patient and GP levels using self-report questionnaires, focus group interviews and register based data. The primary outcome measure is the patient-reported Shoulder Pain and Disability Index measured at 12 weeks. Secondary outcomes include the EuroQol Quality of Life Measure (EQ5D-5L), direct and indirect costs, patient’s global perceived effect of treatment outcome, Pain Self-Efficacy and Brief Illness Perception Questionnaire. We will evaluate the implementation process with focus on adherence to guideline treatment. We will do a cost–minimisation analysis based on direct and selected indirect costs and a cost–utility analysis based on EQ5D-5L. We will use mixed effect models to analyse primary and secondary outcomes.Ethics and disseminationEthics approval was granted by the Regional Committee for Medical and Health Research Ethics-South East Norway (ref. no: 2019/104). Trial results will be submitted for publication in a peer-reviewed medical journal in accordance with Consolidated Standards of Reporting Trials.Trial registration numberNCT04806191.

Background:To improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed based on international treatment recommendations. A previous analysis of a cluster RCT (cRCT) showed that compared to usual care, the intervention group reported higher quality of care and greater satisfaction with care. Also, more patients were treated according to international guidelines and fulfilled recommendations for physical activity at the 6-month follow-up.Objectives:To assess the cost-utility of a structured model for hip or knee OA care.Methods:A cRCT with stepped-wedge cohort design was conducted in 6 Norwegian municipalities (clusters) in 2015-17. The OA care model was implemented in one cluster at the time by switching from “usual care” to the structured model. The implementation of the model was facilitated by interactive workshops for general practitioners (GPs) and physiotherapists (PTs) with an update on OA treatment recommendations. The GPs explained the OA diagnosis and treatment alternatives, provided pharmacological treatment when appropriate, and suggested referral to physiotherapy. The PT-led patient OA education programme was group-based and lasted 3 hours followed by an 8–12-week individually tailored resistance exercise programme with twice weekly 1-hour supervised group sessions (5–10 patients per PT). An optional 10-hours Healthy Eating Program was available. Participants were ≥45 years with symptomatic hip or knee OA.Costs were measured from the healthcare perspective and collected from several sources. Patients self-reported visits in primary healthcare at 3, 6, 9 and 12 months. Secondary healthcare visits and joint surgery data were extracted from the Norwegian Patient Register. The health outcome, quality-adjusted life-year (QALY), was estimated based on the EQ-5D-5L scores at baseline, 3, 6, 9 and 12 months. The result of the cost-utility analysis was reported using the incremental cost-effectiveness ratio (ICER), defined as the incremental costs relative to incremental QALYs (QALYs gained). Based on Norwegian guidelines, the threshold is €27500. Sensitivity analyses were performed using bootstrapping to assess the robustness of reported results and presented in a cost-effectiveness plane (Figure 1).Results:The 393 patients’ mean age was 63 years (SD 9.6) and 74% were women. 109 patients were recruited during control periods (control group), and 284 patients were recruited during interventions periods (intervention group). Only the intervention group had a significant increase in EQ-5D-5L utility scores from baseline to 12 months follow-up (mean change 0.03; 95% CI 0.01, 0.05) with QALYs gained: 0.02 (95% CI -0.08, 0.12). The structured OA model cost approx. €301 p.p. with an additional €50 for the Healthy Eating Program. Total 12 months healthcare cost p.p. was €1281 in the intervention and €3147 in the control group, resulting in an incremental cost of -€1866 (95% CI -3147, -584) p.p. Costs related to surgical procedures had the largest impact on total healthcare costs in both groups. During the 12-months follow-up period, 5% (n=14) in the intervention compared to 12% (n=13) in the control group underwent joint surgery; resulting in a mean surgical procedure cost of €553 p.p. in the intervention as compared to €1624 p.p. in the control group. The ICER was -€93300, indicating that the OA care model resulted in QALYs gained and cost-savings. At a threshold of €27500, it is 99% likely that the OA care model is a cost-effective alternative.Conclusion:The results of the cost-utility analysis show that implementing a structured model for OA care in primary healthcare based on international guidelines is highly likely a cost-effective alternative compared to usual care for people with hip and knee OA. More studies are needed to confirm this finding, but this study results indicate that implementing structured OA care models in primary healthcare may be beneficial for the individual as well as for the society.Disclosure of Interests:None declared

Background:To ensure delivery of high-quality osteoarthritis (OA) care, structured care models incorporating patient education and exercise are increasingly implemented in primary care 1. A goal is to improve patients’ physical function and coping with daily life demands and activities. Yet, there is limited knowledge regarding the type and severity of activity limitations experienced by people with hip and knee OA.Objectives:1) To map activity limitations reported by patients with hip and knee OA participating in a research study implementing an OA care model in primary care. 2) To investigate potential changes in self-reported difficulty performing these activities from baseline to 12-weeks follow-up.Methods:A structured OA care model was implemented in six Norwegian municipalities between January 2015 and October 2017, using a stepped-wedge cluster-randomized controlled design. Implementation was facilitated by interactive workshops for general practitioners and physiotherapists (PTs). The PTs provided a 3-hour, group-based patient education program followed by individually tailored 8-12 weeks exercise with twice weekly 1-hour supervised group sessions. Patients with clinically or radiologically verified symptomatic hip or knee OA ≥45 years were eligible. Patients who received the new model of care completed the Patient-Specific Functional Scale (PSFS) at baseline by identifying between one and three “important activities that you are unable to do or are having difficulty with because of your hip or knee OA”. The patients rated their performance of the reported activities on an 11-point numeric rating scale (NRS) ranging from 0 (unable to perform activity) to 10 (perform activity with no problems). After 12 weeks the patients re-rated their previously identified activities. The reported activities were linked to the International Classification of Functioning, Disability and Health (ICF) at Chapter and Domain (second and third) level. Absolute change in scores from baseline to follow-up was calculated as the mean score of the reported activities. Change from baseline to follow-up was investigated using paired samples t-test. P-value was set to Results:A total of 284 patients received the new model of care. The mean age was 63 (SD 10) years, and 211 (74%) were female. The main affected OA joint was the knee for 174 (61%), the hip for 100 (35%) and other joints (e.g. hand) for 9 (3%). The PSFS was completed by 152 (53%) patients, of which 13 reported one, 42 reported two and 97 reported three activities. A total of 382 activities were linked with ICF. Of these, 362 (95%) were linked to the Activities and Participation chapter (D). On second-level, 318 (83%) activities were linked to the Mobility domain (D4). On the third-level, the majority of activities were linked to the domains Changing body positions (d410) (26%), Walking (d450) (23%) and Moving around (d455) (25%). The patients reported significantly less difficulty performing their self-reported activities at 12 week follow-up (4.1 (SD 1.7) versus 6.3 (SD 1.8), mean change 2.1 (95% CI 1.8, 2.5), pConclusion:The majority of activity limitations reported by patients receiving a structured OA care model in primary care were within the ICF Mobility domain. The most common third-level ICF domains were Changing body positions, Walking and Moving around. After participating in OA patient education and structured 8-12 weeks of exercise, the patients reported a statistically significant and clinically important improvement in the difficulty of performing their individual activities.References:[1]Allen KD, Choong PF, Davis AM, et al. Osteoarthritis: Models for appropriate care across the disease continuum. Best practice & research. Clinical rheumatology. 2016;30(3):503-535.Disclosure of Interests:None declared

Background Medical certificates influence the distribution of economic benefits in welfare states; however, the qualitative aspects of these texts remain largely unexplored. The present study is the first systematic investigation done of these texts. Our aim was to investigate how GPs select and mediate information about their patients’ health and how they support their conclusions about illness, functioning and fitness for work in medical certificates. Methods We performed a textual analysis of thirty-three medical certificates produced by general practitioners (GP) in Norway at the request of the Norwegian Labour and Welfare Administration (NAV).The certificates were subjected to critical reading using the combined analytic methods of narratology and linguistics. Results Some of the medical information was unclear, ambiguous, and possibly misleading. Evaluations of functioning related to illness were scarce or absent, regardless of diagnosis, and, hence, the basis of working incapacity was unclear. Voices in the text frequently conflated, obscuring the source of speaker. In some documents, the expert’s subtle use of language implied doubts about the claimant’s credibility, but explicit advocacy also occurred. GPs show little insight into their patients’ working lives, but rather than express uncertainty and incompetence, they may resort to making too absolute and too general statements about patients’ working capacity, and fail to report thorough assessments. Conclusions A number of the texts in our material may not function as sufficient or reliable sources for making decisions regarding social benefits. Certificates as these may be deficient for several reasons, and textual incompetence may be one of them. Physicians in Norway receive no systematic training in professional writing. High-quality medical certificates, we believe, might be economical in the long term: it might increase the efficiency with which NAV processes cases and save costs by eliminating the need for unnecessary and expensive specialist reports. Moreover, correct and coherent medical certificates can strengthen legal protection for claimants. Eventually, reducing advocacy in these documents may contribute to a fairer evaluation of whether claimants are eligible for disability benefits or not. Therefore, we believe that professional writing skills should be validated as an important part of medical practice and should be integrated in medical schools and in further education as a discipline in its own right, preferably involving humanities professors.

To explore whether smoking and alcohol use are associated with hand osteoarthritis (OA) features in two different OA cohorts.We studied 530 people with radiographic hand OA from the Musculoskeletal pain in Ullensaker STudy (MUST) and 187 people from the Oslo hand OA cohort [mean (sd) age 65 (8.0) and 62 (5.7) years, 71% and 91% women, respectively]. Smoking, alcohol use and hand pain were self-reported. Participants underwent conventional hand radiographs and ultrasound examination of 30 hand joints. The Kellgren-Lawrence sum score for radiographic OA severity (0-120 scale) and the proportion of participants having at least one joint with grey-scale synovitis (grade ≥1) were calculated. We studied whether smoking and alcohol use were cross-sectionally associated with radiographic OA, synovitis, and pain using adjusted linear and logistic regression analyses.Smoking was associated with less radiographic OA in both cohorts [β = -4.71, 95% confidence interval (CI) -8.36 to -1.06 for current smoking in MUST and β = -0.15, 95% CI -0.29 to -0.02 for smoking pack-years in the Oslo hand OA cohort]. Stratified analyses indicated that the association was present in men only. Being a monthly drinker (examined in MUST only) was significantly associated with present synovitis compared to never drinkers (odds ratio = 2.35, 95% CI 1.27 to 4.34) (no gender differences). Neither smoking nor alcohol was associated with hand pain.Smoking was associated with less radiographic hand OA whereas alcohol consumption was associated with present joint inflammation in hand OA. Future longitudinal studies are needed to explore the causal associations and explanatory mechanisms behind gender differences.

Background: To address the well-documented gap between hip and knee osteoarthritis (OA) treatment recommendations and current clinical practice, a structured model for integrated OA care was developed and evaluated in a stepped-wedge cluster-randomised controlled trial. The current study used secondary outcomes to evaluate clinically important response to treatment through the Outcome Measures in Rheumatology Clinical Trials clinical responder criteria (OMERACT-OARSI responder criteria) after 3 and 6 months between patients receiving the structured OA care model vs. usual care. Secondly, the study aimed to investigate if the proportion of responders in the intervention group was influenced by adherence to the exercise program inherent in the model. Methods: The study was conducted in primary healthcare in six Norwegian municipalities. General practitioners and physiotherapists received training in OA treatment recommendations and use of the structured model. The intervention group attended a physiotherapist-led OA education program and performed individually tailored exercises for 8-12 weeks. The control group received usual care. Patient-reported pain, function and global assessment of disease activity during the last week were evaluated using 11-point numeric rating scales (NRS 0-10). These scores were used to calculate the proportion of OMERACT-OARSI responders. Two-level mixed logistic regression models were fitted to investigate differences in responders between the intervention and control group. Results: 284 intervention and 109 control group participants with hip and knee OA recruited from primary care in six Norwegian municipalities. In total 47% of the intervention and 35% of the control group participants were responders at 3 or 6 months combined; showing an uncertain between-group difference (OR adjusted 1.38 (95% CI 0.41, 4.67). In the intervention group, 184 participants completed the exercise programme (exercised ≥2 times/week for ≥8 weeks) and 55% of these were classified as responders. In contrast, 28% of the 86 non-completers were classified as responders. Conclusions: The difference in proportion of OMERACT-OARSI responders at 3 and 6 months between the intervention and control group was uncertain. In the intervention group, a larger proportion of responders were seen among the exercise completers compared to the non-completers.

Background To improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed based on international recommendations. The objective of this study was to assess the effectiveness of this model in primary care. Methods and findings We conducted a cluster-randomised controlled trial with stepped-wedge cohort design in 6 Norwegian municipalities (clusters) between January 2015 and October 2017. The randomised order was concealed to the clusters until the time of crossover from the control to the intervention phase. The intervention was implementation of the SAMBA model, facilitated by interactive workshops for general practitioners and physiotherapists with an update on OA treatment recommendations. Patients in the intervention group attended a physiotherapist-led OA education and individually tailored exercise programme for 8–12 weeks. The primary outcome was patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire; 0–100, 100 = optimal quality) at 6 months. Secondary outcomes included patient-reported referrals to physiotherapy, magnetic resonance imaging (MRI), and orthopaedic surgeon consultation; patients’ satisfaction with care; physical activity level; and proportion of patients who were overweight or obese (body mass index ≥ 25 kg/m2). In all, 40 of 80 general practitioners (mean age [SD] 50 [12] years, 42% females) and 37 of 64 physiotherapists (mean age [SD] 42 [8] years, 65% females) participated. They identified 531 patients, of which 393 patients (mean age [SD] 64 [10] years, 71% females) with symptomatic hip or knee OA were included. Among these, 109 patients were recruited during the control periods (control group), and 284 patients were recruited during interventions periods (intervention group). The patients in the intervention group reported significantly higher quality of care (score of 60 versus 41, mean difference 18.9; 95% CI 12.7, 25.1; p < 0.001) and higher satisfaction with OA care (odds ratio [OR] 12.1; 95% CI 6.44, 22.72; p < 0.001) compared to patients in the control group. The increase in quality of care was close to, but below, the pre-specified minimal important change. In the intervention group, a higher proportion was referred to physiotherapy (OR 2.5; 95% CI 1.08, 5.73; p = 0.03), a higher proportion fulfilled physical activity recommendations (OR 9.3; 95% CI 2.87, 30.37; p < 0.001), and a lower proportion was referred to an orthopaedic surgeon (OR 0.3; 95% CI 0.08, 0.80; p = 0.02), as compared to the control group. There were no significant group differences regarding referral to MRI (OR 0.6; 95% CI 0.13, 2.38; p = 0.42) and proportion of patients who were overweight or obese (OR 1.3; 95% CI 0.70, 2.51; p = 0.34). Study limitations include the imbalance in patient group size, which may have been due to an increased attention to OA patients among the health professionals during the intervention phase, and a potential recruitment bias as the patient participants were identified by their health professionals. Conclusions In this study, a structured model in primary care resulted in higher quality of OA care as compared to usual care. Future studies should explore ways to implement the structured model for integrated OA care on a larger scale. Trial registration ClinicalTrials.gov NCT02333656., Author summary Why was this study done? Hip and knee osteoarthritis is a common chronic joint disease in the adult population causing significant pain and disability. Non-surgical treatment modalities including patient osteoarthritis education, exercise therapy, and weight management represent core treatments recommended in professional guidelines. However, they are currently underutilised in people with hip and knee osteoarthritis. It is not established to what extent a structured osteoarthritis care model can change this and improve the quality of care. What did the researchers do and find? A cluster-randomised trial was conducted to compare a structured osteoarthritis care model with usual care with respect to appropriate care delivery in people with hip and knee osteoarthritis. Forty general practitioners and 37 physiotherapists working in primary care attended workshops to get an update on recommendations for osteoarthritis care and were trained in the core elements of the structured care model: osteoarthritis education in groups, an individually tailored 8- to 12-week exercise programme, and a dietary intervention, if needed. Of the 393 patient participants, 284 were allocated to the intervention group and 109 to the usual care group. At 6 months, patient-reported quality of care and satisfaction with care were greater, more patients were referred to physiotherapy and fewer to orthopaedic surgeons, and more patients fulfilled physical activity criteria in the intervention group as compared to the usual care group. What do these findings mean? A structured osteoarthritis care model provided by trained primary care general practitioners and physiotherapists resulted in the provision of osteoarthritis care that was more in line with current care recommendations and in higher patient-reported quality of care and satisfaction as compared to usual care. A structured and well-planned approach, in line with evidence-based treatment recommendations for hip and knee osteoarthritis and executed in primary care, has the potential to improve patients’ health and reduce disability. In doing so, it may also reduce the risk of sick leave and may thereby reduce the direct and indirect costs of osteoarthritis for the individual and the society. Although a stepped-wedge cluster-randomised controlled trial design is appropriate to conduct an effectiveness study in a clinical practice setting, strategies to prevent selection bias and differences in recruitment rates in the control and intervention periods are needed.

Objective - It is currently unknown whether osteoarthritis (OA) is inherited mainly from the mother, father, or both. This study was undertaken to explore the effect of maternal and paternal factors on hip, knee, and hand OA in offspring. Methods - Participants from the Musculoskeletal Pain in Ullensaker Study (MUST) (69% female; mean ± SD age 64 ± 9 years) and a Norwegian OA twin study (Nor‐Twin) (56% female; 49 ± 11 years) reported whether their mother and/or father had OA. Using a recurrence risk estimation approach, we calculated whether maternal and paternal OA increased the risk of 1) surgically defined hip and knee OA (i.e., total joint replacement) and 2) clinically defined hip, knee, and hand OA (i.e., the American College of Rheumatology criteria) using logistic regression. Relative risks (RRs) with 95% confidence intervals (95% CIs) were calculated. Results - Maternal OA consistently increased the risk of offspring OA across different OA locations and severities. Having a mother with OA increased the risk of any OA in daughters (RR 1.13 [95% CI 1.02–1.25] in the MUST cohort; RR 1.44 [95% CI 1.05–1.97] in the Nor‐Twin cohort) but not (or with less certainty) in sons (RR 1.16 [95% CI 0.95–1.43] in the MUST cohort; RR 1.31 [95% CI 0.71–2.41] in the Nor‐Twin cohort). Having a father with OA was less likely to increase the risk of any OA in daughters (RR 1.00 [95% CI 0.85–1.16] in the MUST cohort; RR 1.52 [95% CI 0.94–2.46] in the Nor‐Twin cohort) and sons (RR 1.08 [95% CI 0.83–1.41] in the MUST cohort; RR 0.93 [95% CI 0.35–2.48] in the Nor‐Twin cohort). Conclusion - OA in the mother increased the risk of surgically and clinically defined hip, knee, and hand OA in offspring, particularly in daughters. Our findings imply that heredity of OA may be linked to maternal genes and/or maternal‐specific factors such as the fetal environment.

Low back pain (LBP) varies over time. Consumers, clinicians, and researchers use various terms to describe LBP fluctuations, such as episodes, recurrences and flares. Although “flare” is use commonly, there is no consensus on how it is defined. This study aimed to obtain consensus for a LBP flare definition using a mixed-method approach. Step 1 involved the derivation of a preliminary candidate flare definition based on thematic analysis of views of 130 consumers in consultation with an expert consumer writer. In step 2, a workshop was conducted to incorporate perspectives of 19 LBP experts into the preliminary flare definition, which resulted in 2 alternative LBP flare definitions. Step 3 refined the definition using a 2-round Delphi consensus with 50 experts in musculoskeletal conditions. The definition favored by experts was further tested with 16 individuals with LBP in step 4, using the definition in three scenarios. This multiphase study produced a definition of LBP flare that distinguishes it from other LBP fluctuations, represents consumers’ views, involves expert consensus, and is understandable by consumers in clinical and research contexts: “A flare-up is a worsening of your condition that lasts from hours to weeks that is difficult to tolerate and generally impacts your usual activities and/or emotions.” Perspective: A multiphase process, incorporating consumers’ views and expert consensus, produced a definition of LBP flare that distinguishes it from other LBP fluctuations.

AJ Haugen,1 L Grøvle,1 JI Brox,2 B Natvig,3 M Grotle4 1Department of Rheumatology, Østfold Hospital Trust, Grålum, 2Department of Physical Medicine and Rehabilitation, Division for Neuroscience, Oslo University Hospital, 3Department of General Practice, Institute of Health and Society, University of Oslo, 4FORMI (Communication Unit for Musculoskeletal Disorders), Division of Neuroscience, Oslo University Hospital, Oslo, Norway Objectives: The purpose of this study was to explore the associations between pain-related fear, pain disability, and self-perceived recovery among patients with sciatica and disk herniation followed up for 2years.Patients and methods: Pain-related fear was measured by the Tampa Scale for Kinesiophobia (TSK) and the Fear-Avoidance Beliefs Questionnaire-Physical Activity (FABQ-PA) subscale. Disability was measured by the Maine–Seattle Back Questionnaire. At 2years, patients reported their sciatica/back problem on a global change scale ranging from completely gone to much worse. No specific interventions regarding pain-related fear were provided.Results: Complete data were obtained for 372 patients. During follow-up, most patients improved. In those who at 2years were fully recovered (n=66), pain-related fear decreased substantially. In those who did not improve (n=50), pain-related fear remained high. Baseline levels of pain-related fear did not differ significantly between those who were fully recovered and the rest of the cohort. In the total cohort, the correlation coefficients between the 0–2-year change in disability and the changes in the TSK and the FABQ-PA were 0.33 and 0.38, respectively. In the adjusted regression models, the 0–2-year change in pain-related disability explained 15% of the variance in the change in both questionnaires.Conclusion: Pain-related fear decreased substantially in patients who recovered from sciatica and remained high in those who did not improve. Generally, the TSK and the FABQ-PA yielded similar results. To our knowledge, this is the first study that has assessed pain-related fear in patients who recover from sciatica. Keywords: kinesiophobia, fear-avoidance, recovery

Background:To improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed and implemented among general practitioners (GPs) and physiotherapists (PTs) in primary care. The model was developed based on international treatment recommendations. After 6 months, patient-reported quality of care and satisfaction with care were greater, more patients were referred to physiotherapy and fewer to orthopaedic surgeon, and more patients fulfilled physical activity criteria among OA patients receiving the new model of care compared to the usual care control group1.Objectives:To assess the long-term effects 12 months after implementing the model in primary care.Methods:A cluster-randomised controlled trial with a stepped-wedge design was conducted in six Norwegian municipalities (clusters). The intervention included implementation of the model, facilitated by interactive workshops for GPs and PTs. The main components of the model were a PT led, 3 hour patient education programme followed by 8-12 weeks of individually tailored, supervised exercise. Patient participants were ≥45 years with symptomatic hip or knee OA. Primary outcome was patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire; 0–100, 100 = optimal quality). Secondary outcomes included satisfaction with care, referrals to physiotherapy, orthopaedic surgeon and magnetic resonance imaging (MRI), joint replacement surgery, fulfilment of physical activity recommendations, and proportion with overweight (body mass index ≥25 kg/m2). Data was analysed using multilevel mixed models adjusted for age, sex and secular time.Results:In all, 40 of 80 GPs and 37 of 64 PTs attended the workshops. A total of 393 patients with hip and knee OA were included, with 284 in the intervention and 109 in the usual care control group. In the intervention group, 92% attended the OA education programme and 64% completed ≥8 weeks of exercise. At 12 months the intervention group reported significantly higher quality of care (score 58 vs. 41, mean difference: 17.6; 95% CI 11.1, 24.0) compared to the control group. The intervention group reported significantly higher satisfaction with care (Odds ratio (OR) 7.8; 95% CI 3.55, 17.27) and a significantly larger proportion (OR: 4.0; 95% CI 1.27, 12.63) met the recommendations for physical activity compared to the control group. A smaller proportion was referred to orthopaedic surgeon (OR 0.5; 95% CI 0.29, 1.00) and a smaller proportion received joint replacement surgery in the intervention (4%) compared to the control group (11%) (OR 0.3; 95% CI 0.14, 0.74). The proportion of patients referred to physiotherapy or MRI and the proportion with overweight were similar between the groups.Conclusion:Implementation of a structured model for OA care led to improved quality of care, higher satisfaction with care and higher physical activity levels after 12 months. These results are comparable to the 6 months results, which indicate a long-term persistence in the beneficial effects of the intervention. The lower surgical rate in the intervention compared to the control group suggests that higher uptake of OA recommendations in primary care may reduce or postpone the need for surgery in people with hip or knee OA.References:[1]Østerås N, Moseng T, Bodegom-Vos LV, et al. Implementing a structured model for osteoarthritis care in primary healthcare: A stepped-wedge cluster-randomised trial.PLOS Medicine.2019;16(10):e1002949.Disclosure of Interests:None declared

When the patient applies for disability benefit in Norway, the general practitioner (GP) is required by the National Insurance Administration (NAV) to confirm that the patient is unfit for work due to disease. Considering the important social role of medical certificates, they have been given surprisingly little attention by the medical critique. They may make essential differences to peoples’ lives, legitimise large social costs and, in addition, the GPs report that issuing certificates can be problematic. This article explores values, attitudes and persuasive language in a selection of medical certificates written by GPs. We direct attention to such texts as significant social actors using a mixed rhetoric including certain values and attitudes. When arguing for granting the patient disability benefit, some GPs emphasised the ‘worthiness’ of the patient by pointing to positive attitudes approved by the national insurance: a will to work and participate, to cooperate and be motivated. Others pointed out the patient’s positive character in terms of universally accepted values, called for the reader’s (the NAV official) sympathy , understanding and helpfulness or appealed to his/her willingness to be realistic and pragmatic and grant disability benefit (DB). The dialogic style varied: some certifiers—although they argued for disability benefit—showed openness to possible opposing or alternative voices by displaying their own uncertainty. Others addressed the reader to share responsibility, demanding or urging for DB. This shifting rhetoric, we believe, mirrors that the GPs see themselves as the patient’s advocate, and that they may find themselves conflicted. We propose further studies within qualitative research to investigate the effect of this rhetoric on the reader, the decision-makers. In addition, to improve the quality and accuracy of these important documents, we suggest that medical schools introduce students to the making of text as a specific skill of medical practice.

Summary Objectives To assess validity, reliability, responsiveness and interpretability of the revised OsteoArthritis Quality Indicator (OA-QI) questionnaire version 2 (v2) assessing patient-reported quality of osteoarthritis care. Methods The OA-QI v2 (16 items, score range 0–100 (100 = best score)) was included in a longitudinal cohort study. Attendees of a 4.5 h osteoarthritis patient education programme at Diakonhjemmet Hospital, Norway, completed the OA-QI at four time points: 2 weeks before, immediately before, immediately after, and 3 months after the programme. Test-retest reliability and measurement error over a 2-week time period were assessed in those that had not seen health professionals in the interim. Construct validity and responsiveness were assessed with predefined hypotheses. Floor and ceiling effects, smallest detectable change (SDC95%) and minimal important change (MIC) were assessed to evaluate interpretability. Results The intraclass correlation coefficient for all 16 items was 0.89. For single items the test-retest kappa estimates ranged 0.38–0.85 and percent agreement 69–92%. Construct validity was acceptable with all six predefined hypotheses confirmed. Responsiveness was acceptable with 33 of 48 and three of four predefined hypotheses confirmed for single items and all items, respectively. There were no floor or ceiling effects. The SDC95% was 29.1 and 3.0 at the individual and group levels, respectively. MIC was 20.4. Conclusions The OA-QI v2 had higher reliability estimates compared to v1, showed acceptable validity, and is the recommended version for future use. The results of responsiveness testing further support the use of the OA-QI v2 as an outcome measure in studies aiming to improve osteoarthritis care.

OBJECTIVE: To explore factors related to hand pain in persons with radiographic hand osteoarthritis (OA).METHODS: Persons in the Musculoskeletal Pain in Ullensaker Study with radiographic hand OA (≥1 joint with Kellgren/Lawrence grade ≥2) were included (n = 530). We examined the cross-sectional association between possible explanatory variables and hand pain in the entire sample and in 2 hand OA phenotypes (erosive versus nonerosive) using structural equation analyses. Outcome variables were the Australian/Canadian Hand Osteoarthritis Index (AUSCAN; range 0-20) and number of tender finger joints upon palpation (NTJ; range 0-30).RESULTS: The mean age was 65 years (40-79 years) and 375 participants were women (71%). Diabetes mellitus, female sex, lower education status, familial OA, infrequent alcohol drinking, widespread pain, poor mental health, and higher number of finger joints with ultrasound-detected synovitis and radiographic OA were related to more hand pain in the entire sample. Stratified analyses showed that diabetes mellitus was strongly associated with AUSCAN pain (B-unstandardized coefficient = 3.81 [95% confidence interval (95% CI) 2.27, 5.35]) and NTJ (B-unstandardized coefficient = 4.16 [95% CI 2.01, 6.31]) in erosive hand OA only. In nonerosive OA, lower education status, having familial OA, and poor mental health were associated with hand OA pain. Widespread pain was associated with both outcomes in both phenotypes.CONCLUSION: Structural and inflammatory OA changes as well as demographic factors, psychosocial factors, and diabetes mellitus were associated with pain in hand OA. The strong association between diabetes mellitus and pain in erosive hand OA should be further explored. (Less)

Background Individuals with persistent low back pain commonly have a broad range of other health concerns including co-occurring musculoskeletal pain, which significantly affect their quality of life, symptom severity, and treatment outcomes. The purpose of this review is to get a better understanding of prevalence and patterns of co-occurring musculoskeletal pain complaints in those with persistent low back pain and its potential association with age, sex, and back-related disability as it might affect prognosis and management. Methods This systematic review protocol has been designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. We will perform a comprehensive search, with no date limit, in the following bibliographic databases: MEDLINE and Embase (via Ovid), CINAHL, and Scopus for citation tracking, based on the following domains: back pain, co-occurring musculoskeletal pain, combined with a focus group that emphasizes study design. Appropriate papers will be screened against the eligibility criteria by three reviewers independently, data extracted by two independent author pairs and disagreement resolved by consensus meetings or other reviewers if required. Assessment of methodological quality and risk of bias will be conducted using a modified version of the Risk of Bias Tool for Prevalence Studies developed by Hoy and colleagues. The overall risk of bias will be determined for each included study based on the raters’ consensus of the responses to the items in this tool. In case of sufficiently homogenous studies, meta-analysis will be performed. Discussion Given the lack of standard terms used to define co-occurring musculoskeletal pain, the search strategy will include the broader term “back pain,” different terms for the “other co-occurring pain,” and specific study designs combined with several exclusion terms. The results of this proposed review will identify the prevalence and patterns of co-occurring musculoskeletal pain among those with persistent low back pain, which is likely to inform clinical management, research, and policy in management of musculoskeletal disorders. Systematic review registration PROSPERO CRD42017068807

Objectives To investigate the longitudinal validity of patients' ratings of global perceived change (GPC) and to assess the implications of using the GPC as the anchor to determine the minimal important change (MIC). Study Design and Setting Secondary analysis of data from a multicenter study including 380 patients with disc-related sciatica with follow-ups at 3, 6, 12, and 24 months. The GPC scale ranged from much worse to completely gone. Five patient-reported outcome measures were used. An MIC was defined as the mean change score in the actual outcome measure for patients reporting being better. The influence of patients' current state and baseline scores on the GPC was analyzed by multivariate linear regression. Differences in the magnitude of the MIC between the 3- and 24-month recall periods were analyzed by hierarchical linear models. Results Across all recall periods and outcome measures, the GPC was strongly influenced by the patient's state at the time of asking. In four of five outcome measures, the magnitude of the MIC increased when recall increased from 3 to 24 months. Conclusion Caution is needed when using the GPC to determine the MIC of patient-reported outcome measures in patients with chronic conditions.

Background. Patients frequently present with multiple and ‘unexplained’ symptoms, often resulting in complex consultations. To better understand these patients is a challenge to health care professionals, in general, and GPs, in particular. Objectives. In our research on symptom reporting, we wanted to explore whether patients consider that they may suffer from conditions commonly regarded as unexplained, and we explored associations between these concerns and symptom load, life stressors and socio-demographic factors. Methods. Consecutive, unselected patients in general practice completed questionnaires addressing eight conditions commonly regarded as unexplained (amalgam poisoning, Candida syndrome, fibromyalgia, food intolerance, electromagnetic hypersensitivity, burnout syndrome, chronic fatigue syndrome and irritable bowel syndrome). With logistic regression, we analysed associations with symptom load, burden of life stressors with negative impact on present health and socio-demographic variables. Results. Out of the 909 respondents (response rate = 88.8%), 863 had complete data. In total, 39.6% of patients had considered that they may suffer from one or more unexplained conditions (UCs). These concerns were strongly and positively associated with recent symptom load and number of life stressors. If we excluded burnout and food intolerance, corresponding associations were found. Conclusion. Patients frequently considered that they may suffer from UCs. The likelihood of such concerns strongly increased with an increasing symptom load and with the number of life stressors with negative impact on present health. Hence, the number of symptoms may be a strong indicator of whether patients consider their symptoms part of such often controversial multisymptom conditions.

Objective To develop and test a new instrument for patient self-reported quality of osteoarthritis (OA) care, and to provide quality indicator (QI) pass rates in a Norwegian OA cohort. Methods The OsteoArthritis Quality Indicator (OA-QI) questionnaire was developed using published QIs, expert panels, and patient interviews. Self-reported data were collected from 359 persons in a Norwegian OA cohort, and test–retest reliability and validity were assessed. Separate QI pass rates and summary QI pass rates were calculated. Results The 17-item questionnaire includes QIs related to patient education and information, regular provider assessments, referrals, and pharmacologic treatment. The patient self-reported questionnaire was completed with minimal respondent burden. Support for content validity was confirmed by 2 patient research partners and 2 expert panels. All 10 predefined hypotheses relating to construct validity were confirmed. Test–retest kappa coefficients ranged from 0.20–0.80 and the percentage of exact agreement ranged from 62–90%. The mean pass rate for individual QIs was 31% (range 5–49%). The median summary QI pass rate was 27% (interquartile range 12–50%), with lower summary pass rates for nonpharmacologic compared to pharmacologic treatments. Conclusion To our knowledge, this is the first instrument developed to measure patient-reported QI pass rates for OA care. This study indicates that the OA-QI questionnaire is acceptable to persons with OA, and its short format makes it suitable for population surveys. The low patient self-reported QI pass rates in this study suggest a potential for quality improvement in OA care.

To explore how patients with sciatica rate the 'bothersomeness' of paresthesia (tingling and numbness) and weakness as compared with leg pain during 2 years of follow-up.Observational cohort study including 380 patients with sciatica and lumbar disc herniation referred to secondary care. Using the Sciatica Bothersomeness Index paresthesia, weakness and leg pain were rated on a scale from 0 to 6. A symptom score of 4-6 was defined as bothersome.Along with leg pain, the bothersomeness of paresthesia and weakness both improved during follow-up. Those who received surgery (n = 121) reported larger improvements in both symptoms than did those who were treated without surgery. At 2 years, 18.2% of the patients reported bothersome paresthesia, 16.6% reported bothersome leg pain, and 11.5% reported bothersome weakness. Among patients with no or little leg pain, 6.7% reported bothersome paresthesia and 5.1% bothersome weakness.During 2 years of follow-up, patients considered paresthesia more bothersome than weakness. At 2 years, the percentage of patients who reported bothersome paresthesia was similar to the percentage who reported bothersome leg pain. Based on patients' self-report, paresthesia and weakness are relevant aspects of disc-related sciatica.

BACKGROUND: Multisite pain and obesity are cross-sectionally related and are common conditions that may influence each other through socio-demographic, lifestyle and/or health-related factors. The aim of the present study was to examine the cross-sectional and prospective associations between overweight/obesity and multisite pain in a general population.METHODS: In a 20-year population-based prospective cohort study, persons aged 20-62 years in 1990 participated in postal surveys in 1990, 1994, 2004 and 2010 (n = 855). Multisite pain was defined as reporting ≥ 2 number of pain sites (NPS) on the Standardized Nordic Questionnaire. Overweight was defined as body mass index (BMI) 25-30 kg/m(2) and obesity as BMI ≥ 30 kg/m(2). To exploit all measurement times, generalized estimating equation analyses adjusting for age, sex, educational and occupational status, smoking, sleep quality, mental distress and physical activity were employed.RESULTS: The mean age was 41 years at baseline and 57% were women. Overweight/obesity and NPS were significantly associated cross-sectionally. Being overweight/obese was associated with reporting future NPS ≥ 2 [overweight: odds ratio (OR), 1.40, 95% confidence interval (CI), 1.12-1.75, obese: OR, 1.54, 95% CI, 1.04-2.28]. Having NPS ≥ 2 was not associated with becoming overweight, but increased the OR for future obesity (OR 1.27, 95% CI, 1.02, 1.59). Smoking was a confounder in this relationship.CONCLUSIONS: Being overweight or obese was associated with future multisite pain, although the magnitude of the association was small and the dose-response relationship observed in cross-sectional analyses disappeared in prospective analyses. There was less evidence that having multisite pain was a predictor of future overweight/obesity. (Less)

We analysed a set of medical certificates to investigate how GPs portray patients who seek disability benefits in Norway, focusing on patient centredness, agency and involvement. We performed a qualitative linguistic analysis of 33 medical certificates collected throughout Norway that were strategically selected based on the patients' sex, age and diagnosis. We found that patients were represented as passive carriers of symptoms, in whom agency was low, failed, conditional or non-existing, or as passive objects of the actions of impersonalised others. Conversely, symptoms were foregrounded as independent and powerful actors. The patient's experience of illness was sometimes reported, but the perspective of the GP tended to be doctor oriented, rather than patient centred. The policy of the social services, which emphasises patient involvement, patient centredness and work, rather than social benefits, was almost completely absent from these medical certificates. If medical certificates are to be a valid basis for decisions within the social services, we suggest that doctor paternalism in these documents must give way to considering the patient as an involved and co-responsible individual in the processes of disability assessment.

Objective To investigate the agreement between self-report and a public registry regarding the occurrence and duration of sickness absence (SA) in patients with sciatica. Study Design and Setting Observational 2-year longitudinal study including 227 patients. Self-report SA data were obtained by postal questionnaires covering recall periods of 3, 6, and 12 months and compared with data from the Norwegian National Sickness Benefit Register. Results The percent agreement on the occurrence of SA between self-report and registry was above 85% for all three recall periods. The patients overestimated the duration of their SA by 2.4 (95% confidence interval, 1.1–3.7) weeks for the 3-month recall period. The 95% limits of agreement were generally wide, varying from −12.5 to 17.3 weeks for the 3-month recall period to −38.8 to 37.2 weeks for the 12-month period. For the 3-, 6-, and 12-month recall periods, 48.1%, 29.8%, and 27.3% of the patients reported an SA duration that differed by ≤1 week from that recorded in the registry. Conclusion Mainly because of low precision, the agreement on the duration of SA was poor for all three recall periods. The agreement between self-report and registry regarding the occurrence of SA was good.