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A significant number of individuals experience post-COVID-19 symptoms, but knowledge of perceived consequences and life satisfaction is lacking. Here, we investigate perceived consequences regarding everyday life, health, physical activity and work post-COVID-19 and factors associated with low life satisfaction. A total of 766 people (mean age 48; 672 women) experiencing post-COVID-19 symptoms at least two months after infection (mean 13 months) responded to an online survey. A majority (≥77%) perceived physical fatigue, mental fatigue, dizziness, reduced work ability, low life satisfaction and a reduced level of aerobic capacity. In the final logistic regression model (Nagelkerke R Square 0.296, p < 0.001), poor work ability was the most important factor for perceiving low satisfaction with life (Odds ratio 3.369, 95% CI 2.040–5.565, p < 0.001, Nagelkerke R Square 0.177). Reduced aerobic capacity, fatigue and living in a city also increased the odds of low life satisfaction. As people with post-COVID-19 report several long-term consequences, this suggests that there is a need for targeted care for this group. The results of this study can serve as guidance for healthcare authorities regarding important long-term consequences that should be considered in rehabilitation programs directed toward post-COVID-19.

A significant number of individuals experience post-COVID-19 symptoms, but knowledge of perceived consequences and life satisfaction is lacking. Here, we investigate perceived consequences regarding everyday life, health, physical activity and work post-COVID-19 and factors associated with low life satisfaction. A total of 766 people (mean age 48; 672 women) experiencing post-COVID-19 symptoms at least two months after infection (mean 13 months) responded to an online survey. A majority (≥77%) perceived physical fatigue, mental fatigue, dizziness, reduced work ability, low life satisfaction and a reduced level of aerobic capacity. In the final logistic regression model (Nagelkerke R Square 0.296

Background Mobile health and wearable activity trackers (WATs) could support physical activity (PA) in individuals with hip and knee osteoarthritis (OA), but little is described regarding experiences and perceptions of digital support and the use of WAT to self-monitor PA. Thus, the aim of this study was to explore the experiences of using a WAT to monitor PA and the general perceptions of digital support in OA care among individuals of working age with hip and knee OA. Methods We did a focus group study where individuals with hip and knee OA (n=18) were recruited from the intervention group in a cluster-randomized controlled trial (C-RCT). The intervention in the C-RCT comprised of 12-weeks use of a WAT with a mobile application to monitor PA in addition to participating in a supported osteoarthritis self-management program. In this study, three focus group discussions were conducted. The discussions were transcribed and qualitive content analysis with an inductive approach was applied.Results The analysis resulted in two main categories: A WAT may aid in optimization of PA, but is not a panacea with subcategories WATs facilitate PA; Increased awareness of one’s limitations and WATs are not always encouraging, and the second main category was Digital support is an appreciated part of OA care with subcategories Individualized, early and continuous support; Physiotherapy is essential but needs to be modernized and Easy, comprehensive, and reliable digital support. Conclusion WATs may facilitate PA but also aid individuals with OA to find the optimal level of activity to avoid increased pain. Digital support in OA care was appreciated, particularly as a part of traditional care with physical visits. The participants expressed that the digital support should be easy, comprehensive, early, and continuous.

Background: Osteoarthritis is a leading cause of disability worldwide. Current treatment supports coping strategies to improve health-related quality of life (HRQoL). The need to predict response to treatment has been raised to personalise care. This study aims to examine change in HRQoL from baseline to three and nine months follow-up after participating in a Supported OsteoArthritis Self-Management Programme (SOASP) and to examine if empowerment and/or enablement could predict change in HRQoL among patients participating in a SOASP. Methods: Patients participating in a SOASP were recruited consecutively between April 2016 and June 2018. The EQ-5D was used to measure HRQoL, the SWE-RES-23 23 (score range 1–5) to measure empowerment and the PEI (score range 0–12) to measure enablement. The instruments were answered before (EQ-5D, SWE-RES-23) and after (EQ-5D, SWE-RES-23, PEI) the SOASP. A patient partner was engaged to enhance the patient perspective. Changes in outcome were examined with paired sample t-test and standardized effect sizes (Cohen´s d). Potential predictive variables were tested with multiple linear regression analysis. Results: In total, 143 patients participated in baseline measurement. The mean EQ-5D-5L index score increased significantly from baseline to three months corresponding to a standardised effect size (Cohen´s d) of d=.43, 95 % CI [.24, .63] (n=109), and from baseline to nine months d=.19, 95 % CI [.01, .37] (n=119). The average EQ VAS score increased significantly from baseline to three months corresponding to a standardised effect size of d=.26, 95 % CI [.07, .45] (n=109), and from baseline to nine months d=.18, 95 % CI [.00, .36] (n=119). Neither the SWE-RES-23 nor the PEI at three months follow-up or the change in the SWE-RES-23 score from baseline to three months follow-up predicted change in either EQ-5D-5L index (p>.05) or the EQ VAS (p>.05). Conclusions: Health-related quality of life increased after participating in a SOASP. Empowerment and enablement as measured with the SWE-RES-23 and the PEI respectively could not predict change in HRQoL among patients participating in a SOASP. Trial registration: ClinicalTrials.gov. Identification number: NCT 02974036. First registration 28/11/2016, retrospectively registered.

Previous research has suggested an association between physical activity (PA), joint function, and molecular biomarkers, but more studies are needed. The aim of this study was to explore the associations between PA or self-reported joint function and molecular biomarkers of cartilage and inflammation in individuals with hip and/or knee osteoarthritis (OA). Specific objectives were to explore the correlations between (1) the change over 3 months in self-reported PA/joint function and the change in molecular biomarkers (2) objectively measured PA and molecular biomarkers measured at 3-month follow-up.Working age participants (n = 91) were recruited from a cluster randomized controlled trial. Self-reported PA, joint function, and serum samples were collected at baseline and after 3 months. Serum concentrations of the inflammatory marker C-reactive protein (CRP) and the cartilage markers Alanine-Arginine-Glycine-Serine (ARGS)-aggrecan, cartilage oligomeric matrix protein (COMP), and type II collagen C2C were analyzed by immunoassays. Objectively measured PA (steps/day) was collected during 12 weeks from activity trackers used by 53 participants. Associations were analyzed with Spearman's rank correlation.There was a weak negative correlation between the change in self-reported PA and the change in COMP (In general, no or only weak associations were found between PA/joint function and molecular biomarkers. Future research recommends including participants with lower PA, extend the follow-up, and use a design that allows comparisons.

Background In Sweden, core treatment for osteoarthritis is offered through a Supported Osteoarthritis Self-Management Programme (SOASP), combining education and exercise to provide patients with coping strategies in self-managing the disease. The aim was to study enablement and empowerment among patients with osteoarthritis in the hip and/or knee participating in a SOASP. An additional aim was to study the relation between the Swedish version of the Patient Enablement Instrument (PEI) and the Swedish Rheumatic Disease Empowerment Scale (SWE-RES-23). Methods Patients with osteoarthritis participating in a SOASP in primary health care were recruited consecutively from 2016 to 2018. The PEI (score range 0–12) was used to measure enablement and the SWE-RES-23 (score range 1–5) to measure empowerment. The instruments were answered before (SWE-RES-23) and after the SOASP (PEI, SWE-RES-23). A patient partner was incorporated in the study. Descriptive statistics, the Wilcoxon’s signed rank test, effect size (r), and the Spearman’s rho (rs) were used in the analysis. Results In total, 143 patients were included in the study, 111 (78%) were women (mean age 66, SD 9.3 years). At baseline the reported median value for the SWE-RES-23 (n = 142) was 3.6 (IQR 3.3–4.0). After the educational part of the SOASP, the reported median value was 6 (IQR 3–6.5) for the PEI (n = 109) and 3.8 (IQR 3.6–4.1) for the SWE-RES-23 (n = 108). At three months follow-up (n = 116), the reported median value was 6 (IQR 4–7) for the PEI and 3.9 (IQR 3.6–4.2) for the SWE-RES-23. The SWE-RES-23 score increased between baseline and three months (p ≤ 0.000). The analysis showed a positive correlation between PEI and SWE-RES-23 after the educational part of the SOASP (rs = 0.493, p n = 108) and at follow-up at three months (rs = 0.507, p n = 116). Conclusions Patients reported moderate to high enablement and empowerment and an increase in empowerment after participating in a SOASP, which might indicate that the SOASP is useful to enable and empower patients at least in the short term. Since our results showed that the PEI and the SWE-RES-23 are only partly related both instruments can be of use in evaluating interventions such as the SOASP. Trial registration ClinicalTrials.gov. NCT02974036. First registration 28/11/2016, retrospectively registered.

(1) Background: Inpatient falls are a serious threat to patients’ safety and their extrinsic factors are, at present, insufficiently described. Additionally, hospital overcrowdedness is known for its malicious effects but its relation to the inpatient falls is currently underexplored. The aim of this study was to explore the distribution of falls and their extrinsic characteristics amongst a range of different clinics, and to explore the correlation and predictive ability of hospital overcrowding in relation to inpatient falls. (2) Methods: An observational, cross-sectional, registry-based study was conducted using retrospective data from an incidence registry of a hospital organization in Sweden during 2018. The registry provided data regarding the extrinsic factors of inpatient falls, including the clinics’ overcrowdedness. Simple descriptive statistics, correlation analysis and simple linear regression analysis were used. (3) Results: Twelve clinics were included. A total of 870 inpatient falls were registered during 2018. Overcrowdedness and total amount of falls were positively and very strongly correlated (r = 0.875, p &lt, 0.001). Overcrowdedness was a significant predictor of the total amount of inpatient falls (p &lt, 0.001, α = 0.05). (4) Conclusions: The characteristics regarding inpatient falls vary among the clinics. Inpatient overcrowding might have a significant role in the prevalence of inpatient falls, but further high-evidence-level studies are required.

Background Given today’s high prevalence of common mental disorders and related sick leave among teachers, an urgent need exists for a more systematic approach to the management of social and organizational risk factors within schools. In 2015, we launched the first Swedish occupational health guideline to support a structured prevention of these risks at the workplace. The existence of guidelines does however not guarantee their usage, as studies show that guidelines are often underused. Knowledge is therefore needed on effective implementation strategies that can facilitate the translation of guidelines into practice. The primary aim of the randomized waiting list-controlled trial described in this study protocol is to compare the effectiveness of a multifaceted implementation strategy versus a single implementation strategy for implementing the Guideline for the prevention of mental ill-health at the workplace within schools. The effectiveness will be compared regarding the extent to which the recommendations are implemented (implementation effectiveness) and with regard to social and organisational risk factors for mental ill-health, absenteeism and presenteeism (intervention effectiveness). Methods The trial is conducted among primary schools of two municipalities in Sweden. The single implementation strategy is an educational strategy (an educational meeting). The multifaceted strategy consists of the educational meeting, an implementation team and a series of workshops. The outcome measure of implementation effectiveness is guideline adherence. The primary outcome of intervention effectiveness is exhaustion. Secondary outcomes include demands at work, work organization and job contents, interpersonal relations and leadership, presenteeism, work performance, recovery, work-life balance, work-engagement, self-reported stress, self-perceived health, sickness absence and psychosocial safety climate. Process outcomes as well as barriers and facilitators influencing the implementation process are assessed. Data will be collected at baseline, 6, 12, 18 and 24 months by mixed methods (i.e. survey, focus-group interviews, observation). Discussion The study described in this protocol will provide valuable knowledge on the effectiveness of implementation strategies for implementing a guideline for the prevention of common mental disorders within schools. We hypothesize that successful implementation will result in reductions in school personnel’s perceived social and organizational risk factors, mental ill-health and sick-leave. Trial registration ClinicalTrials.gov ID: NCT03322839 (trial registration: 09/19/2017).

Purpose: To describe how patients with acute/subacute back pain and/or neck pain experienced a workplace intervention, conducted as a structured workplace dialogue (convergence dialogue meeting, CDM) within physiotherapy practice in primary care. Materials and methods: Semi-structured interviews were performed with 10 patients who took part in the CDM. Qualitative content analysis was applied to the data. Results: Three categories emerged from the analysis: physiotherapist (PT) as a facilitator, the employer as a key stakeholder and lack of transparency and concrete changes. Conclusion: This study describes patients’ experiences of a workplace dialogue in physiotherapy practice. Even though few patients experienced concrete changes at the workplace, they were supportive for the intervention as well as how the PTs conducted the CDM. The patients expressed trust in the PTs who were seen as someone who could facilitate changes at the workplace, being proficient and supportive. The CDM could be a method to facilitate communication between stakeholders and support work ability. (Less)

Background There is limited research on prevention of mental ill-health of school personnel and the systematic management of school work environments. The aim of this study was to assess the effectiveness of implementing the guideline recommendations for the prevention of mental ill-health in schools, in particular, whether there was a difference in adherence to guideline recommendations between a multifaceted (group 1) and single implementation strategy (group 2) from baseline to 6 and to 12 months. Method We conducted a cluster-randomized controlled trial with a 6- and 12-month follow-up. Data was collected from nearly 700 participants in 19 Swedish schools. Participants were school personnel working under the management of a school principal. The single implementation strategy consisted of one educational meeting, while the multifaceted implementation strategy comprised an educational meeting, an ongoing training in the form of workshops, implementation teams and Plan-Do-Study-Act cycles. Adherence was measured with a self-reported questionnaire. Generalized Linear Mixed Models were used to assess the difference between groups in adherence to the guideline between baseline, 6-, and 12-months follow-up. Results There were no statistically significant differences between the groups in improvements in adherence to the guideline between baseline, 6-, and 12-months follow-up. However, among those schools that did not undergo any organizational changes during the 12 months of the study significant differences between groups were observed at 12 months for one of the indicators. Conclusions The multifaceted strategy was no more effective than the single strategy in improving guideline adherence. There are some limitations to the study, such as the measurement of the implementation outcome measure of adherence. The outcome measure was developed in a systematic manner by the research team, assessing specific target behaviors relevant to the guideline recommendations, however not psychometrically tested, which warrants a careful interpretation of the results. Trial registration ClinicalTrials.gov, 150571. Registered 12 September 2017.

Background A majority of individuals with osteoarthritis (OA) are insufficiently physically active. Self-monitoring with wearable activity trackers (WAT) could promote physical activity (PA), and increased knowledge of PA patterns and adherence to using a WAT is needed. The aim of this study was to describe PA patterns and adherence to WAT-use during an intervention among participants of working age with hip and/or knee OA. The study further explores the correlation between self-reported joint function and PA. Methods Individuals of working age with hip and/or knee OA who used a WAT, Fitbit Flex 2, for 12 weeks were included. Participants monitored their PA in the Fitbit-app. An activity goal of 7,000 steps/day was set. Steps and minutes in light (L), moderate and vigorous (MV) PA were collected from the Fitbit. Self-reported joint function (HOOS/KOOS) was completed. Data was analyzed with linear mixed models and Spearman’s rank correlation. Results Seventy-five participants (45–66 years) walked on average 10 593 (SD 3431) steps/day, spent 248.5 (SD 42.2) minutes in LPA/day, 48.1 (SD 35.5) minutes in MVPA/day, 336.0 (SD 249.9) minutes in MVPA/week and used the Fitbit for an average of 88.4 % (SD 11.6) of the 12-week period. 86.7 % took > 7,000 steps/day and 77.3 % spent > 150 min in MVPA/week. Mean daily steps/week decreased significantly over the 12 weeks (β-coefficient − 117, 95 % CI -166 to -68, p = p = p = 0.008) and mean adherence to Fitbit-use per week (β-coefficient − 1.3, 95 % CI -1.8 to -0.8, p = Conclusions The majority of participants reached 7,000 steps/day and the recommended 150 min in MVPA per week. However, PA decreased slightly but gradually over time. Adherence to using the Fitbit was high but also decreased during the intervention. Understanding PA patterns and the use of a Fitbit to promote PA could be beneficial in tailoring interventions for individuals with hip and/or knee OA.

Purpose: To study differences between men and women in physical activity (PA) and health-related quality of life (HRQoL) before and after participating in a supported osteoarthritis (OA) self-management programme. Materials and methods: A prospective observational study using data from a Swedish National Quality Register. Patients recorded between 2008 and 2013 with hip and/or knee OA with data at baseline, at 3 and 12 months follow-up (n = 7628) were included. Outcome measures were patient-reported PA and HRQoL (EQ-5D-3L). Results: A greater proportion of men (p = 0.002) changed to being physically active ≥150 min/week at 3 months follow-up. The proportion of women being physically active ≥150 min/week was larger than for men at baseline (p = 0.003) and at follow-up at 12 months (p = 0.035). Women reported lower HRQoL than men at baseline (p < 0.001), at follow-up at 3 (p < 0.001) and 12 months (p = 0.010). There were no differences between men and women in change in HRQoL at 3 (p = 0.629) and 12 months (p = 0.577) follow-up. Conclusions: This study showed differences between men and women in PA and HRQoL before and after participating in a supported OA self-management programme. These differences should be considered when supporting PA and HRQoL.Implications for rehabilitation Men with hip and/or knee osteoarthritis (OA) might need more support during rehabilitation in order to maintain or even increase physical activity (PA) in the long run. Women with hip and/or knee OA might need more support during rehabilitation in order to maintain or even increase health-related quality of life (HRQoL) in the long run. Booster sessions might be suggested in order to enable both men and women with hip and/or knee OA to sustain improvements in PA and HRQoL after participating in a supported OA self-management programme.

Purpuse The aim of this systematic review was to describe interventions which promote safe patient handling and movement (PHM) among workers in healthcare by reviewing the literature of their effectiveness for work and health-related outcomes. Methods Data bases were searched for studies published 1997‒2018. Measures was operationalised broadly, capturing outcomes of work and health. Only Randomized controlled trials (RCTs) and cohort studies with control group were included. Quality was assessed using evidence-based checklists by Swedish Agency for Health Technology Assessment and Assessment of Social Services. Results The systematic review included 10 RCTs and 19 cohort. Providing work equipment and training workers is effective: it can increase usage. Training workers to be peer coaches is associated with fewer injuries. Other effective strategies are participatory ergonomics and management engagement in collaboration with workers, facilitating safe PHM. Conclusions This systematic review suggests interventions for safe PHM with an impact of health-related outcomes should include access to work equipment, training as well as employer and employee engagement. The additional impact of multifaceted interventions is inconclusive. Practitioner summary In clinical practice, there is a need for employers in healthcare to; 1) provide healthcare workers access to suitable work equipment. 2) provide training on how to use work equipment to prevent work-related injuries. Furthermore, the study also indicates that 3) training and appointing peer coaches can facilitate safe manual handling and movement (PHM) and, 4) It can be beneficial to involve workers in a participatory approach.

Purpose: To translate and culturally adapt the Swedish version of the 'Blue flags' questionnaire into Dutch and to examine the validity and reliability aspects of the Dutch version. Methods: The 'Blue flags' questionnaire was translated and culturally adapted to the Dutch situation. A total of 58 participants filled in the first questionnaire at baseline and 51 participants filled in the second questionnaire sent two weeks later. The data of the participants who filled in the first questionnaire was used to determine internal consistency, structural validity and concurrent validity. The data of the participants who filled in both questionnaires was used to determine test-retest reliability. Results: The internal consistency was good with a Cronbach's alpha of 0.83. The structural validity was satisfactory with a Kaiser-Meyer-Olkin (KMO) test of 0.75 and a significance of p < .001 for the Bartlett's test. Four factors were extracted using principal component analysis (PCA) with varimax rotation with an explained total variance of 70.8%. Spearman's rho for concurrent validity was 0.68 (p < .001). The intraclass correlation coefficient (ICC) for test-retest was 0.80 (p < .001) for the total score. Conclusions: The Dutch version of the 'Blue flags' questionnaire showed good internal consistency, satisfactory structural validity, strong concurrent validity (with mixed item representation results) and strong reliability.

BackgroundOsteoarthritis is a common joint disorder causing pain, functional limitations and an increased risk of comorbidities. Physical activity (PA) is the standard treatment but the majority of individuals with OA do not meet the recommended levels of PA (150 min/week). Monitoring PA with a wearable activity tracker (WAT) could promote PA but increased knowledge on PA patterns and usage of a WAT is needed. The aim of this study was to describe PA patterns and adherence to using a WAT among participants of working age with hip and/or knee OA, during a 12-week intervention. In addition, this study explores the correlation between baseline joint function and subsequent PA.MethodsIndividuals of working age with hip and/or knee OA (n = 75) who used a WAT, Fitbit Flex 2, for 12 weeks as part of an intervention in a cluster-randomized controlled trial were included. Participants were encouraged to monitor their PA in the Fitbit-app. An activity goal of 7,000 steps per day was set. Activity data was collected from the Fitbit. HOOS/KOOS were completed at baseline.ResultsParticipants walked on average 10 593 (SD 3431) steps per day, spent 336.0 (SD 249.9) minutes in moderate/vigorous (MV) PA and used the Fitbit for 88.4% of the 12-week intervention period. Steps per day decreased significantly over the 12 weeks (β-coefficient − 117, 95% CI -166 to -68, p =

A cluster-randomized controlled trial, WorkUp, was conducted for working-aged patients at risk of sick leave or on short-term sick leave due to acute/subacute neck and/or back pain in Sweden. The purpose of WorkUp was to facilitate participants to stay at work or in case of sick leave, return-to-work. The aim of this study was to study whether the WorkUp trial was cost-effective. Patients in the intervention and reference group received structured evidence-based physiotherapy, while patients in the intervention group also received a work place dialogue with the employer as an add-on. The participants, 352 in total, were recruited from 20 physiotherapeutic units in primary healthcare in southern Sweden. The economic evaluation was performed both from a healthcare and a societal perspective with a 12-month time frame with extensive univariate sensitivity analyses. Results were presented as incremental cost–effectiveness ratios (ICER) with outcomes measured as quality-adjusted life-years (QALY) and proportion working for at least 4 weeks in a row without reported sick leave at 12-month follow-up. From the healthcare perspective, the ICER was €23,606 (2013 price year) per QALY gain. From the societal perspective the intervention was dominating, i.e.. less costly and more effective than reference care. Bootstrap analysis showed that the probability of the intervention to be cost-effective at €50,000 willingness-to-pay per QALY was 85% from the societal perspective. Structured evidence-based physiotherapeutic care together with workplace dialogue is a cost-effective alternative from both a societal and a healthcare perspective for acute/subacute neck and/or back pain patients. Trial registration ClinicalTrials.gov: NCT02609750. Electronic supplementary material The online version of this article (10.1007/s10198-018-1003-1) contains supplementary material, which is available to authorized users.

Musculoskeletal disorders (MSDs) are characterized by pain and reduced physical functioning that often results in decreased quality of life. Work-related musculoskeletal disorders (WRMDs) are health problems in which working conditions (ie, physically demanding or repetitive activities or a poor work environment) significantly contribute to the onset or progression of the disorder, but are not necessarily the sole cause. Even if work-related environmental factors do not directly cause MSDs, the symptoms can be work relevant (ie, the work can influence the symptoms, or the symptoms can affect the ability to work). WRMDs are burdensome to patients, employers and society as they are associated with high rates of disability, absenteeism, presenteeism, loss of productivity, longer recovery timeframes and workers’ compensation costs. In this Point of View, we argue that physical therapists treating patients with MSDs should adopt a work-focused approach. There is ample evidence showing that being employed is associated with better health.1 Physical therapists can improve the health-related quality of life for patients with MSDs through adopting a work-focused approach and promoting participation in work. Refereed/Peer-reviewed

Aim: Investigate the feasibility of identifying a well-defined treatment group and a comparable reference group in clinical register data. Background: There is insufficient knowledge on how to avert neck/back pain from turning chronic or to impair work ability. The Swedish Government implemented a national multimodal rehabilitation (MMR) programme in primary care intending to promote work ability, reduce sick leave and increase return to work. Since randomised control trial data for effect is lacking, it is important to evaluate existing observational data from clinical settings. Methods: We identified all unique patients with musculoskeletal pain (MSP) diagnoses undergoing the MMR programme in primary care in the Skåne Health care Register (n = 2140) during 2010–2011. A reference cohort in primary care (n = 56 300) with similar MSP diagnoses, same ages and the same level of sick leave before baseline was identified for the same period. The reference cohort received ordinary care and treatment in primary care. The final study group consisted of 603 eligible MMR patients and 2874 eligible reference patients. Socio-economic and health-related baseline data including sick leave one year before up to two years after baseline were compared between groups. Findings: There were significant socio-economic and health differences at baseline between the MMR and the reference patients, with the MMR group having lower income, higher morbidity and more sick leave days. Sick leave days per year decreased significantly in the MMR group (118–102 days, P < 0.001) and in the reference group (50–42 days, P < 0.001) from one year before baseline to two years after. Conclusions: It was not feasible to identify a comparable reference group based on clinical register data. Despite an ambitious attempt to limit selection bias, significant baseline differences in socio-economic and health were present. In absence of randomised trials, effects of MMR cannot be sufficiently evaluated in primary care.

Objective: To determine whether nature-based rehabilitation, as an add-on to standard care, has a long-term influence on post-stroke fatigue, perceived value of everyday occupations, disability, health-related quality of life, anxiety, and depression at follow-up 8 and 14 months after randomization. Design: Single-blinded, 2-armed, randomized controlled trial. Methods: Stroke survivors, identified through routine 3-month follow-up visit (sub-acute) or medical records (chronic stroke > 1 year previously), were randomized to standard care + nature-based rehabilitation (intervention group) or standard care alone (control group). Blinded evaluations were conducted at follow-up 8 and 14 months after randomization, for the following outcomes: post-stroke fatigue (Mental Fatigue Scale; MFS), perceived value of everyday occupations (Occupational value instrument with pre-defined items), disability (modified Rankin Scale; mRS), health-related quality of life (Euro-QoL-5 Demension Questionnaire), anxiety (Hospital Anxiety and Depression Scale; HAD) and depression (HAD). Results: Approximately one-quarter of the screened patients were eligible for inclusion in the study; of these, half agreed to participate; a final total of 101 patients were randomized (mean age 67 years, 60% female). The patients with sub-acute stroke were highly compliant with the intervention. The participants in both the intervention and control groups improved, However, no statistically significant differences in improvement were found between the intervention and control groups for any of the outcome measures. Fatigue decreased to a value below the suggested cut-off for mental fatigue (

Fatigue is common after stroke and contributes to disability and impaired quality of life. Currently, there is insufficient evidence on the efficacy of any intervention for post-stroke fatigue. The aim of the study was to examine whether 10 weeks Nature-based rehabilitation (NRB) as add-on to standard care may improve post-stroke fatigue, perceived value of everyday occupations, function, activity and participation compared to standard care only (Clinical Trial.gov Identifier: NCT02435043, 2012/352, 05-06-2015). The study was carried out as a single blinded two-armed randomised controlled trial. Stroke survivors identified through routine 3-month follow-up visit (sub-acute) or medical records (chronic stroke > 1 year earlier) were randomised to Standard care + NBR or Standard care only. Blinded evaluations were conducted at follow-up 8 and 14 months after randomisation. The primary outcomes were post-stroke fatigue (Mental Fatigue Scale, total score) and perceived value of everyday occupations (Oval-pd) 8 months after randomisation. About a quarter of the screened patients were eligible; half accepted to participate and 101 were randomised, mean age 67 years, 60% female. The patients with sub-acute stroke were highly compliant with the intervention. Fatigue decreased to a value below the suggested cut-off for mental fatigue (

Background and purpose - Assessment of potential disparities in access to care is a vital part of achieving equity in health and healthcare. We have therefore studied the effect of socioeconomic status (SES) on the rates of knee and hip replacement due to osteoarthritis. Methods - This was a cohort study in Skane, Sweden. We included all residents aged ≥ 35 years with consultations between 2004 and 2013 for hip or knee osteoarthritis. We retrieved individual information on income, education, and occupation and evaluated the rates of knee and hip replacement according to SES, with adjustment for age and sex. Professionals, legislators, senior officials, and managers, and individuals with the longest education, served as the reference group. Results - We followed 50,498 knee osteoarthritis patients (59% women) and 20,882 hip osteoarthritis patients (58% women). The mutually adjusted rate of knee replacement was lower in those with an elementary occupation (hazard ratio (HR) = 0.81, 95% CI: 0.72-0.92), in craft workers and those with related trades (HR = 0.88, CI: 0.79-0.98), and in skilled agricultural/fishery workers (HR = 0.83, CI: 0.72-0.96), but higher in the 2 least educated groups (HR = 1.2 in both). The rate of hip replacement was lower in those with an elementary occupation (HR = 0.77, 95% CI: 0.68-0.87), in plant and machine operators/assemblers (HR = 0.83, CI: 0.75-0.93), and service workers/shop assistants (HR = 0.88, CI: 0.80-0.96). The rate of hip replacement was higher in the highest income group (HR = 1.1, 95% CI: 1.0-1.2). Interpretation - There was a lower rate of joint replacement in osteoarthritis patients working in professions often associated with lower socioeconomic status, suggesting inequity in access to care. However, the results are not unanimous, as the rate of knee replacement was higher in the least educated groups.

ObjectivesThe predictive ability of the STarT Back Tool (SBT) has not yet been examined among acute/subacute back and/or neck pain in a primary care setting in respect to health-related quality of life (HRQoL) and work ability outcomes. The aim of this study was to evaluate the SBT’s predictive validity for HRQoL and work ability outcomes at long-term follow-up in a population with acute/subacute back and/or neck pain.SettingProspective data from 35 primary care centres in south Sweden during 2013.ParticipantsPatients (n=329) with acute/subacute back and/or neck pain, aged 18–67 years, not on sick leave or OutcomesThe predictive ability of the SBT for HRQoL and work ability outcomes was examined using Kruskal-Wallis test, logistic regression and area under the curve (AUC).ResultsBased on SBT risk group stratification, 103 (43%), 107 (45%) and 28 (12%) patients were considered as low, medium and at high risk, respectively. There were statistically significant differences in HRQoL (pConclusionsThe SBT is an appropriate tool for identifying patients with a poor long-term HRQoL and/or work ability outcome in a population with acute/subacute back and/or neck pain, and maybe a useful adjunct to primary care physiotherapy assessment and practice.Trial registration numberNCT02609750; Results.

Workplace involvement in rehabilitation for patients with musculoskeletal pain may improve work ability. Convergence Dialogue Meeting (CDM) is a model aimed at helping the patient, the care giver, and the employer to support work ability and return-to-work. Our aim was to study the effect on work ability when adding a workplace dialogue according to CDM in physiotherapy practice for patients with pain in ordinary primary care. We conducted a prospective pairwise cluster randomised controlled trial (ClinicalTrials.gov ID: NCT02609750) in primary care involving 20 primary care rehabilitation units with 1-year follow-up. Adult patients with acute/subacute neck and back pain, worked ≥4 weeks past year and not currently on sick leave or no more than 60 days of sick leave and considered at-risk of sick leave were included (n = 352). All patients received structured physiotherapy and the intervention was the addition of CDM, delivered by the treating physiotherapist. The main confirmatory outcome, work ability (defined as working at least 4 consecutive weeks at follow-up), was assessed by a weekly short text message question on number of sick leave days past week. Work ability was reached by significantly more patients in the intervention group (108/127, 85%) compared with the reference group (127/171, 74%) (P = 0.02). The intervention increased the odds of having work ability at 1-year follow-up, also after adjustment for baseline health-related quality of life (odds ratio 1.85, confidence interval 1.01-3.38). We conclude that an early workplace dialogue in addition to structured physiotherapy improved work ability significantly.

Background: Pain from various locations in the body and mental illness are common and the comorbidity between the two is well-known although the temporal relationship remains to be determined. Our aim was to follow patients over time to study if pain (here dorsalgia/abdominal pain) or fibromyalgia lead to an increased risk of developing mental illness (here depression/anxiety) and/or the reverse, that is whether patients with mental illness have an increased risk to develop pain or fibromyalgia, compared to the rest of the population. Methods: This prospective cohort study used the Skane Healthcare Register, covering all care in the region of Skane, southern Sweden (population ~1.3 million). The cohort included healthcare consultations in primary care, outpatient specialized care and inpatient care between 2007 and 2016 for all patients without prior registered diagnosis of mental illness or pain, aged 18 or older (n = 504,365). Results: The incidence rate ratio (IRR) for developing mental illness after pain was 2.18 (95% CI = 2.14-2.22) compared to without pain. IRR for developing pain after mental illness was 2.02 (95% CI = 1.98-2.06) compared to without mental illness. Corresponding IRR for developing mental illness after fibromyalgia was 4.05 (95% CI = 3.58-4.59) and for developing fibromyalgia after mental illness 5.54 (95% CI = 4.99-6.16). Conclusions: This study shows a bidirectional influence of similar magnitude of pain and mental illness, respectively. In monitoring patients with pain or mental illness, a focus on both conditions is thus important to develop appropriate, targeted interventions and may increase the likelihood of improved outcomes. Significance: We followed a population-based cohort over a period of 10 years, including incident cases of both exposure and outcome and found a bidirectional relationship between pain and mental illness. Clinicians need to pay attention on both conditions, in patients seeking care due to mental illness or pain. (Less)

Background In 2008, the Swedish government introduced a National Rehabilitation Program, in which the government financially reimburses the county councils for evidence-based multimodal rehabilitation (MMR) interventions. The target group is patients of working age with musculoskeletal disorders (MSD), expected to return to work or remain at work after rehabilitation. Much attention in the evaluations has been on patient outcomes and on processes. We lack knowledge about how factors related to health care providers and community can have an impact on how patients have access to MMR. The aim of this study was therefore to study the impact of health care provider and community related factors on referrals to MMR in patients with MSD applying for health care in primary health care. Methods This was a primary health care-based cohort study based on prospectively ascertained register data. All primary health care centres (PHCC) contracted in Region Skåne in 2010-2012, referring to MMR were included (n = 153). The health care provider factors studied were: community size, PHCC size, public or private PHCC, whether or not the PHCCs provided their own MMR, burden of illness and the community socioeconomic status among the registered population at the PHCCs. The results are presented with descriptive statistics and for the analysis, non-parametric and multiple linear regression analyses were applied. Results PHCCs located in larger communities sent more referrals/1000 registered population (p = 0.020). Private PHCCs sent more referrals/1000 registered population compared to public units (p = 0.035). Factors related to more MMR referrals/1000 registered population in the multiple regression analyses were PHCCs located in medium and large communities and with above average socioeconomic status among the registered population at the PHCCs, private PHCC and PHCCs providing their own MMR. The explanation degree for the final model was 24.5%. Conclusions We found that referral rates to MMR were positively associated with PHCCs located in medium and large sized communities with higher socioeconomic status among the registered population, private PHCCs and PHCCs providing their own MMR. Patients with MSD are thus facing significant inequities and were thus not offered the same opportunities for referrals to rehabilitation regardless of which PHCC they visited.

Background: One way to facilitate the translation of research into the occupational health service practice is through clinical practice guidelines. To increase the implementability of guidelines it is important to include the end-users in the development, for example by a community of practice approach. This paper describes the development of an occupational health practice guideline aimed at the management of non-specific low back pain (LBP) by using a community of practice approach. The paper also includes a process evaluation of the development providing insight into the feasibility of the process. Methods: A multidisciplinary community of practice group (n = 16) consisting of occupational nurses, occupational physicians, ergonomists/physical therapists, health and safety engineers, health educators, psychologists and researchers from different types of occupational health services and geographical regions within Sweden met eleven times (June 2012-December 2013) to develop the practice guideline following recommendations of guideline development handbooks. Process-outcomes recruitment, reach, context, satisfaction, feasibility and fidelity were assessed by questionnaire, observations and administrative data. Results: Group members attended on average 7.5 out of 11 meetings. Half experienced support from their workplace for their involvement. Feasibility was rated as good, except for time-scheduling. Most group members were satisfied with the structure of the process (e.g. presentations, multidisciplinary group). Fidelity was rated as fairly high. Conclusions: The described development process is a feasible process for guideline development. For future guideline development expectations of the work involved should be more clearly communicated, as well as the purpose and tasks of the CoP-group. Moreover, possibilities to improve support from managers and colleagues should be explored. This paper has important implications for future guideline development; it provides valuable information on how practitioners can be included in the development process, with the aim of increasing the implementability of the developed guidelines. Funding Agencies|Swedish Council for Working Life and Social Research [130153, 2010-1572, 2012-1785]; AFA insurance, Sweden

Aims: This article reviews current practice relating to arts and culture on prescription in Sweden, Norway, Denmark and in the United Kingdom. It considers future possibilities and also each of the Scandinavian countries from a culture and health policy and research perspective. The United Kingdom perhaps leads the field of Arts on Prescription practice, and subsequent research is described in order to help identify what the Scandinavian countries might learn from the UK research. Method: The method adopted for the literature search was a rapid review which included peer-reviewed and grey literature in English and the respective languages of Scandinavia. Results: The discussion considers the evidence to support social prescription and the potential obstacles of the implementation of Arts on Prescription in Scandinavian countries. Conclusion: The article concludes that of the Scandinavian countries, Sweden is ahead in terms of Arts on Prescription and has embraced the use of culture for health benefits on a different scale compared to Norway and Denmark. Denmark, in particular, is behind in recognising ways in which art and culture can benefit patients and for wider public health promotion. All three countries may benefit from the evidence provided by UK researchers.

Purpose. To describe experiences and perceptions of work ability and how it can be assessed among Swedish physicians. Method. We interviewed eight men and six women in the fields of general practice, occupational health, rehabilitation and orthopaedic surgery. Qualitative content analysis was applied to the data. Results. The approach striving to support the patient in mutual confidence was what primarily affected how work ability was understood and how it could be assessed. Two main categories, with sub categories were settled: familiar but vague, with subcategories conflicting expectations and relations and consensus within speciality and the second main category relying on intuition and examinations, with sub categories life as a whole, reasonableness, progression plan, external obstacles and need for knowledge and collaboration. Conclusions. We found that physicians mainly rely on what patients were telling about their work situation when assessing work ability. But it was not clear if they should consider the patient’s whole life situation, motivation and wishes. Protecting the physician‐patient relationship was seen as important as well as the need for teamwork assessments and increased work place knowledge.