Multimodal rehabilitation for patients with chronic pain in northern Sweden, focusing on gender and age

The overall aim of this thesis was to study outcomes and experiences of multimodal rehabilitation programmes (MMRP) for patients with chronic pain in northern Sweden, focusing on gender and age. This thesis is based on four studies that used both quantitative and qualitative methods. The quantitative studies (I-III) investigated patient-reported outcome measures (PROM) from the Swedish Quality Registry for Pain Rehabilitation (SQRP) collected during 2011-2016 at two specialist clinics in northern Sweden. Adults aged 18-65 years were included, n=436 (356 women and 83 men), divided into three age groups (18-30, 31-45 and 46-65 years of age). Data from the two programmes at three measurement occasions were used, at the start of MMRP, immediately after MMRP and at one-year follow-up. Descriptive and multivariate statistics were used in Studies I-III. The analyses were performed separately for women, men and three different age groups. In Study I, the analysis was performed in two steps: in the first step the two patient populations in the two MMRPs were analysed separately and in the next step, the patients in the two programmes were analysed together. In Studies (II-III), the patient in the programmes were analysed together. In Study IV, a qualitative design was used to explore how patients with chronic pain experienced staying at a residency during participation in MMRP. In Study IV, a grounded theory method with emergent design was used for data collection and analysis. Individual semi-structured interviews with 12 patients (8 women and 4 men) with experiences of MMRP were conducted. In Study I, patients improved regardless of the design of the MMRP in terms of pain intensity, emotional functioning, activity and physical functioning at the one-year follow-up. For both programmes, the women were found to improve in more variables than the men did. In Study II, all subgroups (men, women and age groups) improved in terms of pain intensity and emotional functioning immediately after MMRP. The results revealed that the men showed greater short-term improvements than the women did. The women improved in more variables at one-year follow-up than the men did. The youngest age group was found to have greater positive effects of MMRP in terms of pain intensity and emotional functioning, immediately after MMRP and at one-year follow-up, than the other two age groups. In Study III, a number of interacting factors influenced whether patients participating in MMRP ended up on full-time sick leave at one-year follow-up, or not. Sick leave at start was an important factor for all subgroups. For women at start, low physical functioning, low health-related quality of life, low work importance and low affective distress were related to full-time sick leave at one-year follow-up. The results showed that unemployed men who reported widespread pain were related to full-time sick leave at one-year follow-up. The 31-45 years age group, which reported high pain intensity, low emotional functioning and low activity and physical functioning, was related to full-time sick leave at one-year follow-up. Those in the 46-65 years age group with low education, low work importance, low belief in recovery and long duration of pain were found to be related to full-time sick leave at one-year follow-up. In Study IV, the analysis resulted in a core category “Finding my self-worth”, consisting of the four categories: “Space for myself”, “Mirroring myself”, “I am of value” and “Dealing with returning to everyday life”. The results showed that the patients who stayed at a residency during MMRP were more likely to be released from the obligations of chores in their everyday life at home. This created space and time for reflection and interaction with others. The patients’ participation in MMRP while staying at a residency contributed to experiences of awareness of their own value and the significance of taking care of themselves and changing their behaviour after returning home. In conclusion, the results showed that MMRP seems to be an effective method of treating patients with chronic pain, in terms of reduced pain, improved emotional functioning, activity and physical functioning and health. The results also revealed that men seemed to need more support after MMRP to sustain the effects of MMRP while woman were more likely to sustain the positive effects at one-year follow-up. Full-time sick leave for patients with chronic pain at one-year follow-up can be affected by a number of interacting factors and these factors differ for women, men and different age groups. The opportunity to be released from everyday obligations, enjoy time for reflection and interaction with others can contribute to personal awareness which facilitates the implementation of changes at home following MMRP.