Screening, Targeting, Tailoring, and Implementation in Primary Health Care : An integrated physical therapy and behavioural medicine approach to persons with persistent musculoskeletal pain

Sammanfattning: This thesis deals with a behavioural medicine approach to the management of patients with persistent musculoskeletal pain in primary health care physical therapy. The main aims of the thesis were; to develop, and evaluate the psychometric properties of, a screening instrument for risk of disability and; to evaluate the implementation and effects of a targeted and tailored treatment.The studies comprise four samples of patients with musculoskeletal pain exceeding one month. All subjects were recruited when consulting physical therapists in Swedish primary health care settings. For development and evaluation of the Pain Belief Screening Instrument (PBSI) four samples were used; two samples (n1 = 215 and n2 = 93) in Study I, one sample (n = 168) in Study II, and one sample (n = 45) in Study III. For evaluation of implementation and effects of targeted and tailored treatment the 32 patients who completed treatment in Study III were used. In Study IV treatment documents of 18 patient cases from Study III were studied to evaluate treatment integrity.The concurrent and predictive validity of the PBSI was good, and the instrument was therefore used to define subgroups with either a high or low risk for disability. A low treatment dosage of a tailored treatment for low risk patients was tried and found equally efficient as a longer treatment focusing physical exercise. Subjects who received a treatment tailored to individual patient characteristics perceived a better global outcome of treatment compared to subjects in the control group. However, no between-group differences in the disability measures were found. The evaluation of treatment integrity displayed low therapist adherence to the treatment rationale for the tailored treatment.The studies demonstrate ways to systematically integrate a behavioural medicine approach and physical therapy. The results indicate efficiency in managing patients with persistent musculoskeletal pain in primary health care.