Patient participation in and treatment effects of multimodal rehabilitation and the web Behaviour Change Program for Activity

Sammanfattning: The overall aim was to explore experiences of patient participation in pain rehabilitation among patients with persistent musculoskeletal pain, and investigate effects of multimodal rehabilitation (MMR) and a self-guided web-based intervention. Qualitative interviews were conducted with women and men (between 23 to 60 years) with persistent musculoskeletal pain. Their experiences of patient participation prior to MMR, within MMR, and withinMMR in combination with the web Behaviour Change Program for Activity (web-BCPA) were analysed with qualitative content analysis (study I – III). A randomized controlled trial with two intervention arms: 1) MMR in combination with the web-BCPA (MMR+WEB), and 2) MMR, was performed in the primary healthcare to investigate treatment effects of pain intensity (Visual Analogue Scale), self-efficacy to control pain and other symptoms (ArthritisSelf-Efficacy Scale), general self-efficacy (General Self-Efficacy Scale), coping (Two-item Coping Strategies Questionnaire), and patient participation. Adherence, feasibility and satisfaction with treatment were also evaluated. The patients were 85 women and 14 men (mean age 43 years) with persistent musculoskeletal pain for 6.5 years (m) (study IV). The findings showed that patient participation can be understood as complex and individualized (I – III). Patients’ emotional and cognitive resources and restrictions, as well ashealthcare professionals’ attitudes and behaviours were important to patient participation (I, II, III). Experiences of patient participation prior to MMR indicated a search for recognition and an alienation from the healthcare system (I). Patients experienced satisfying patient participation within MMR (II) and within MMR in combination with the web-BCPA (III). Patient participation was to take part in a structured and flexible rehabilitation frameworkcharacterized by co-operation with healthcare professionals (II, III), and solitary work in the web-BCPA (III). Being confirmed in the interaction with healthcare professionals in MMR (II, III), and in interaction with the web-BCPA (III) was fundamental to patient participation. Being confirmed included to be recognized as a patient and as a person (II, III), as well as to perceive trustworthiness and to be able to identify one-self in the rehabilitation (III).Situations of mistrust and disrespect in contacts with the healthcare professionals were experienced as restrained patient participation (I, II, III). Patient participation included various experiences of knowledge and insights: the patients’ knowledge not being acknowledged (I), experiencing a lack of knowledge (II), and experiences of acquiring knowledge and insights (III). Behaviour change was included in patients’ experiences of patient participation (III). Further, the findings showed that MMR in combination with the web-BCPA decreased patients’ catastrophic thinking about their pain (p = .003) over time, compared to MMR (IV). Also, patients in the MMR+WEB group were more satisfied with their multimodal rehabilitation, at 4 (p = .000) and 12 months (p = .003) (IV).There were no differences between the MMR+WEB group and the MMR group regarding the other six subscales of the Two-item Coping Strategies Questionnaire. Nor were there any differences between thegroups for pain intensity, self-efficacy, and patient participation. However, there were significant decrease of average pain (p = .000) over time in the whole study group (MMR+WEB and MMR) (IV). The web-BCPA adherence was 304 minutes (m), with range between 0 to 1142 minutes, and the patients opened in average 5.1 modules out of eight (IV). Patients rated feasibility and satisfaction with the web-BCPA acceptable to excellent (62 to 93/ 100). Due to the large variation of time spent in the web-BCPA a sub-group analysis oflower (LQ) and upper quartile (UQ) of time spent was performed. The study groups were small (fourteen patients in each group) but the results showed a trend that the UQ had higher scores regarding web-BCPA feasibility and satisfaction, and LQ had lower scores. In conclusion, patients’ emotions and cognitions were in focus in patient participation. Experiences of patient participation prior to MMR were understood as a search forrecognition in the healthcare system. In contrast, patients experienced satisfying patientparticipation and being confirmed within MMR and within MMR in combination with the web-BCPA. Patients in MMR in combination with the self-guided web-BCPA decreased their catastrophic thinking about pain. Also, they were more satisfied with their multimodal rehabilitation.