OBJECTIVE: Kinesiophobia has been proposed to influence recovery in patients with Achilles tendinopathy. However, whether there are differences in outcomes in patients with different levels of kinesiophobia is unknown. The purpose of this study was to compare the characteristics of patients at baseline and recovery over time in patients with Achilles tendinopathy and various levels of kinesiophobia.

METHODS: This study was a secondary analysis of a prospective observational cohort study of 59 patients with Achilles tendinopathy. The patients were divided into 3 groups on the basis of scores on the Tampa Scale for Kinesiophobia (TSK) (those with low TSK scores [≤33] [low TSK group], those with medium TSK scores [34-41] [medium TSK group], and those with high TSK scores [≥42] [high TSK group]). All patients were evaluated with self-reported outcomes, clinical evaluation, tendon morphology, viscoelastic property measurements, and a calf muscle endurance test at baseline, 6 months, and 12 months. No treatment was provided throughout the study period.

RESULTS: There were 16 patients (8 women) in the low TSK group (age = 51.9 [SD = 15.3] years, body mass index [BMI] = 24.3 [22.3-25.4]), 28 patients (13 women) in the medium TSK group (age = 52.7 [SD = 15.2] years, BMI = 26.4 [22.5-30.8]), and 15 patients (8 women) in the high TSK group (age = 61.1 [SD = 11.1] years, BMI = 28.1 [25.2-33.6]). Among the groups at baseline, the high TSK group had significantly greater BMI and symptom severity and lower quality of life. All groups showed significant improvement over time for all outcomes except tendon viscoelastic properties and tendon thickening when there was an adjustment for baseline BMI. The high and medium TSK groups saw decreases in kinesiophobia at 6 months, but there was no change for the low TSK group.

CONCLUSION: Despite the high TSK group having the highest BMI and the worse symptom severity and quality of life at baseline, members of this group showed improvements in all of the outcome domains similar to those of the other groups over 12 months.

IMPACT: Evaluating the degree of kinesiophobia in patients with Achilles tendinopathy might be of benefit for understanding how they are affected by the injury. However, the degree of kinesiophobia at baseline does not seem to affect recovery; this finding could be due to the patients receiving education about the injury and expectations of recovery.

OBJECTIVE: The purpose of this study was to explore thoughts and ideas about the body and pain in patients with nonspecific low back pain (LBP) who have a high degree of fear of movement.

METHODS: Patients with nonspecific LBP and a high degree of fear of movement, as measured using the Tampa Scale of Kinesiophobia, were asked to participate in the study. Individual semistructured in-depth interviews were conducted with 11 participants. The material was analyzed using content analysis with an inductive approach.

RESULTS: From these patients' stories, an overarching theme-decreased confidence in the body becomes a barrier to living life to the fullest-emerged. This theme was further divided into 4 subthemes: (1) "What is wrong with my body?"-the constant search for an explanation; (2) searching for the right way to move; (3) loss of mobility means a lack of meaning in life; and (4) the message from health care professionals guides feelings, thoughts, and movement behavior.

CONCLUSION: This study indicates that the message of keeping physically active when experiencing LBP has succeeded, but patients with fear require support to feel secure and have enough confidence in their body to move and exercise. Clinicians need to better incorporate evidence-based practice for patients with fear and support them so that they can apply an understanding of pain to their bodies and their every day life.

IMPACT: These results offer guidance for health care professionals to enhance their practice by providing more updated information to their patients who have recurrent LBP and fear. With better support, patients may be able to regain confidence in their bodies and live their lives to the fullest.

LAY SUMMARY: If you have recurrent LBP and fear of moving your body, ask your health care professional to provide you with updated knowledge on pain and to help you regain confidence in your body so that you can live your life to the fullest.

BACKGROUND: There is an increasing trend towards person-centred care (PCC) worldwide, suggesting that PCC should be mastered by future health care professionals. This study aims to explore programme directors' views on facilitators and barriers to implementing PCC in four of the largest national study programmes in Sweden training future health care professionals.

METHODS: A qualitative design was applied and interviews were conducted with 19 programme directors of Swedish national study programmes in medicine, nursing, occupational therapy and physiotherapy. The interviews were analysed using qualitative content analysis. Themes were sorted according to the Consolidated Framework for Implementation Research (CFIR) in an abductive approach. COREQ guidelines were applied.

RESULTS: The overarching theme, as interpreted from the programme directors' experiences, was 'Person-centred care is on the move at different paces.' The theme relates to the domains identified by the CFIR as outer setting, innovation, inner setting and process. PCC was understood as something familiar but yet new, and the higher education institutions were in a state of understanding and adapting PCC to their own contexts. The movement in the outer setting consists of numerous stakeholders advocating for increased patient influence, which has stirred a movement in the inner setting where the higher educational institutions are trying to accommodate these new demands. Different meanings and values are ascribed to PCC, and the concept is thus also 'on the move', being adapted to traditions at each educational setting.

CONCLUSION: Implementation of PCC in Swedish higher education is ongoing but fragmented and driven by individuals with a specific interest. There is uncertainty and ambiguity around the meaning and value of PCC and how to implement it. More knowledge is needed about the core of PCC as a subject for teaching and learning and also didactic strategies suitable to support students in becoming person-centred practitioners.

PURPOSE: The purpose of this qualitative study was to describe women's experiences with anterior cruciate ligament reconstruction (ACLR) and a subsequent ACL rupture, and to identify potential facilitators and barriers for coping with rehabilitation after the second injury.

METHODS: Eight women between 17 and 36 years (mean 26, SD 6.5) who had experienced ACLR, followed by another ACL rupture, participated in the study. Semi-structured interviews were conducted, and data were analyzed using qualitative content analysis.

RESULTS: One overarching theme, "Rehabilitation after a second ACL injury-A lifelong adaptive coping process", emerged from analyses. Undergoing a second rehabilitation is described as a process of adaptation, beginning with the first injury and still ongoing, more than 5 years later. Participants applied different coping strategies to adapt to these life-altering injuries, but the common denominator was of major life adjustments with no return to previous activity levels. Initially, after the reinjury, it was about coping with the catastrophe of the dreaded second injury. Over time, they accepted their "new" life and reset their recovery/rehabilitation goal not just as "return to sport" but rather as a "personal life goal".

CONCLUSION: Undergoing a second ACL injury is a long process that challenges the patient's coping skills. Given these results, rehabilitation programs need to be more person centred according to the patients-adjusted life goals.

LEVEL OF EVIDENCE: 3.

BACKGROUND: Movement behaviours, such as sedentary behaviour (SB) and moderate to vigorous physical activity (MVPA), are linked with multiple aspects of health and can be influenced by various pain-related psychological factors, such as fear of movement, pain catastrophising and self-efficacy for exercise. However, the relationships between these factors and postoperative SB and MVPA remain unclear in patients undergoing surgery for lumbar degenerative conditions. This study aimed to investigate the association between preoperative pain-related psychological factors and postoperative SB and MVPA in patients with low back pain (LBP) and degenerative disc disorder at 6 and 12 months after lumbar fusion surgery.

METHODS: Secondary data were collected from 118 patients (63 women and 55 men; mean age 46 years) who underwent lumbar fusion surgery in a randomised controlled trial. SB and MVPA were measured using the triaxial accelerometer ActiGraph GT3X+. Fear of movement, pain catastrophising and self-efficacy for exercise served as predictors. The association between these factors and the relative time spent in SB and MVPA 6 and 12 months after surgery was analysed via linear regression models, adjusting for potential confounders.

RESULTS: Preoperative fear of movement was significantly associated with relative time spent in SB at 6 and 12 months after surgery (β = 0.013, 95% confidence interval = 0.004 to 0.022, p = 0.007). Neither pain catastrophising nor self-efficacy for exercise showed significant associations with relative time spent in SB and MVPA at these time points.

CONCLUSIONS: Our study demonstrated that preoperative fear of movement was significantly associated with postoperative SB in patients with LBP and degenerative disc disorder. This finding underscores the potential benefits of preoperative screening for pain-related psychological factors, including fear of movement, preoperatively. Such screenings could aid in identifying patients who might benefit from targeted interventions to promote healthier postoperative movement behaviour and improved health outcomes.

BACKGROUND: As person centred care (PCC) is being implemented globally, higher educational institutions (HEI) have begun to play a crucial part in enabling this transition. In Sweden, however, the delivery of PCC is inconsistently implemented in medicine, nursing, occupational therapy, and physiotherapy study programmes. This inconsistency is partly the result of a lack of a national strategy across HEI. Program directors are responsible for the PCC content of their programs, so their views influence how PCC is taught. Using interviews with programme directors in higher education, we aim to deepen the understanding of the preconditions needed to implement PCC by exploring discourses and identifying subject positions of how PCC is taught and learned.

METHODS: We performed a discourse analysis based on interviews with program directors in the above-mentioned national study programmes. A discourse can be seen as a struggle over identity. The subject position - i.e., discourses designate positions for persons to occupy as subjects - guided our analysis and identification of the subject positions of the teacher and the student in teaching and learning PCC.

RESULTS: This study unfolded in two main antagonistic aspects with respect to teaching and learning PCC, resulting in four subject positions for the teacher and four corresponding subject positions for the students. First, the teacher and student were given a subject position as change agents towards a more egalitarian healthcare and were assigned a subject position to cope with a practical reality they could not change. Second, the teacher and student were assigned a subject position that embodied profession-specific identities, navigating and valuing these boundaries. Simultaneously, both teachers and students assumed a subject position that required interprofessional interaction and co-creation for teaching and learning PCC.

CONCLUSION: This study demonstrates the discursive tension surrounding the implementation of PCC in HEI, and the findings can serve as a basis for creating future relevant and high-quality learning activities. The process of negotiating diverse and co-existing perspectives as well as building interprofessional trust when incorporating PCC into higher education is essential and requires further exploration.

BACKGROUND: Spinal stenosis is the most common reason for elective spine surgery, and the cardinal symptom is leg pain and discomfort when walking. Patients with spinal stenosis have a decreased level of physical activity and thereby an increased risk of poor health. Get Back is a person-centred digital programme that strives to support patients being physically active after surgery. The aim is to explore if Get Back, in its present format (referred to as Get Back_feasibility), is feasible and contributes to detectable change in variables related to intervention content.

METHODS: Thirty patients planned for decompression surgery due to central lumbar spinal stenosis who present with low physical activity, pain catastrophizing or fear of movement, will be included in a randomized feasibility study. All patients will be randomly allocated to either Get Back_feasibility or usual physical therapy. Get Back_feasibility aims to increase the patient's physical activity level by combining a person-centred and cognitive behavioural approach. It comprises 10 video and telephone sessions led by a physical therapist over 12 weeks (pre/postoperatively). Outcomes are treatment fidelity (treatment dose, adherence, and content), process feasibility (recruitment, intervention use, and acceptability of measurements and intervention), and variables related to the intervention content (steps per day, physical activity level, pain catastrophizing, fear of movement, and general self-efficacy). Treatment fidelity and feasibility data will be assessed during the full study period (12 weeks). Physical activity, physical capacity, and patient-reported outcomes will be assessed digitally at baseline (2 weeks preoperatively) and 11-12 weeks postoperatively. Variables related to the intervention content will be monitored weekly through a digital application. Feasibility data will be analysed descriptively and inferentially using a nonparametric approach, data from repeated measures will be displayed graphically and data from telephone interviews will be analysed using content analysis with a descriptive manifest approach.

DISCUSSION: The results will provide information on whether Get Back in its present format is feasible and can be evaluated for effectiveness in a larger randomized controlled trial, for patients with a low physical activity level and a high fear of movement who are undergoing decompression surgery.

TRIAL REGISTRATION: Registered at ClinicalTrails.gov 04/08/2023, registration no. NCT05806593.

OBJECTIVE: Long-term follow-ups of prehabilitation programs for lumbar spine surgery are lacking, and more comprehensive evaluations are needed. In the current study, we evaluated the long-term effects of a prehabilitation program compared with conventional care in relation to lumbar fusion surgery in patients with degenerative disc disease.

METHODS: Patients (n = 118) receiving lumbar fusion surgery were included in a multicenter randomized controlled trial, involving 1 university hospital and 2 spine clinics. The intervention was a person-centered prehabilitation program based on cognitive-behavioral physical therapy that targeted psychological presurgical risk factors, physical activity, and overall health. The control group received conventional preoperative care. Patient-reported outcome measures (PROMs) included assessments at 8 time-points: Low back disability (primary outcome), back pain intensity, leg pain intensity, pain catastrophizing, fear of movement, anxiety and depressive mood, health-related quality of life, and patient-specific functioning. Physical activity and physical capacity were assessed at 5 time points. Linear mixed models were used to analyze the effects of the intervention.

RESULTS: There were no significant differences between groups at the 12- and 24-month follow-ups for any outcome, except for the One Leg Stand test 1 year following surgery, in favor of the control group. There were significant improvements for both groups, from baseline to the 12- and 24-month follow-ups for all physical capacity test and PROMs, except for leg pain and self-efficacy for exercise.

CONCLUSIONS: No long-term effects were found for the prehabilitation program compared to conventional care. Physical activity did not improve over time, despite significantly improved self-reported functioning and physical capacity measurements.

IMPACT: These findings have implications for the current understanding of the long-term effects of prehabilitation and suggest that future research should focus on programs promoting physical activity both before and after lumbar spine surgery to decrease the risk of long-term adverse health outcomes.

OBJECTIVE: This study aimed to elucidate the meaning of lived experiences of support from social networks and the healthcare sector in persons with chronic pain.

DESIGN: A qualitative, phenomenological hermeneutic method was used to analyse interview data.

SETTING: Participants were recruited from patient organisations in Sweden.

PARTICIPANTS: Ten (seven women, two men and one non-binary) individuals with chronic musculoskeletal pain were included.

FINDINGS: The meaning of lived experiences of support in persons with chronic pain involves balancing between being the most valuable player (MVP) and passing the ball, meaning balancing between being a capable person and accepting support to be that capable person.

CONCLUSION: For participants who lived with chronic pain, support means balancing between being capable (the MVP) and willing to accept support (passing the ball), which aligns with the concept of person-centred care. Our findings may be useful for policy-makers, managers and clinical professionals when planning and performing care for persons with chronic pain. Future research should focus on how the healthcare sector can create support to enable persons with chronic pain to be the MVP while being able to pass the ball to their social networks and the healthcare sector.

BACKGROUND: Chronic pain (pain > 3 months) is a disabling condition affecting around one fifth of the population. Chronic pain significantly affects a person's psychological and physical health and often interferes with the ability to work. It is one of the most common reasons for extended sick leave and persons with chronic pain often have difficulties returning to work. Interpreting the experiences of currently available is necessary in order to facilitate a return to working life. Therefore, this study aimed to describe and interpret the meaning of support during the return-to-work process for persons on sick leave due to chronic pain.

METHOD: A qualitative interview study was conducted with 14 participants (12 women and 2 men) who experienced sick leave due to chronic pain. The participants were recruited through patient organizations focusing on pain or pain-related conditions. Collected data was analyzed using a phenomenological hermeneutical approach.

RESULTS: Have my back as I get back to work was the theme of the analysis, along with six subthemes. Being able to work was important for the participants. However, they often experienced returning to work was a battle for support, dealing with fragmentized backing from the involved stakeholders. Participants with access to collaborative support involving competent care, recognition and the possibility to influence their work felt valuable and capable as persons and workers. Thus, they were provided conditions allowing a successful re-entry into the workplace.

CONCLUSIONS: Our findings contribute to an enhanced understanding of the importance of stakeholder support in persons with chronic pain re-entering the workplace after an extended break due to sick leave. Through an inclusive, collaborative and flexible approach involving all stakeholders working towards the same goal, a person with chronic pain can feel supported in developing and cultivating the capabilities necessary to manage life and work.

OBJECTIVE: Chronic pain is a complex health problem affecting about one-fifth of the European population. It is a leading cause of years lived with disability worldwide, with serious personal, relational and socioeconomic consequences. Chronic pain and sick leave adversely affect health and quality of life. Thus, understanding this phenomenon is essential for reducing suffering, understanding the need for support and promoting a rapid return to work and an active lifestyle. This study aimed to describe and interpret persons' experiences of being on sick leave due to chronic pain.

DESIGN: A qualitative study with semistructured interviews analysed using a phenomenological hermeneutic approach.

SETTING: Participants were recruited from a community setting in Sweden.

PARTICIPANTS: Fourteen participants (12 women) with experiences of part-time or full-time sick leave from work due to chronic pain were included in the study.

RESULTS: Suffering out of sight but not out of mind was the main theme of the qualitative analysis. This theme implies that the participants' constant suffering was invisible to others, causing them to feel they were not being justly treated in society. Feeling overlooked led to a continuous struggle for recognition. Moreover, the participants' identities and their trust in themselves and their bodies were challenged. However, our study also revealed a nuanced understanding of the experiences of sick leave as a consequence of chronic pain, where the participants learnt important lessons, including coping strategies and re-evaluated priorities.

CONCLUSIONS: Being on sick leave due to chronic pain threatens a person's integrity and leads to substantial suffering. An enhanced understanding of the meaning of sick leave due to chronic pain provides important considerations for their care and support. This study highlights the importance of feeling acknowledged and being met with justice in encounters with others.

OBJECTIVE: To investigate whether early changes in fear of movement (kinesiophobia), self-efficacy and catastrophizing were mediators of the relationship between allocation to the pre-habilitation intervention and later changes in health outcomes.

METHODS: The original pre-habilitation trial (PREPARE, ISRCTN17115599) recruited 118 participants awaiting lumbar fusion surgery, half of whom received a prehabilitation intervention designed based on the modified fear-avoidance model and half of whom received usual care. Mediation analysis was performed to test each mediator separately. Analysis was performed on each outcome of interest separately (Oswestry disability index, patient-specific function, EQ general health and moderate/vigorous physical activity). Mediation analysis was carried out using PROCESS. Beta coefficients and bootstrapped 95% CIs were used to interpret the results.

RESULTS: None of the potential mediators was found to mediate the relationship between allocation to the intervention and 3-month scores on any of the health outcomes tested.

CONCLUSIONS: Screening patients for higher levels of catastrophizing and fear avoidance and lower levels of self-efficacy could help ensure only the patients who are most likely to benefit from the intervention are included.

SIGNIFICANCE: Prehabilitation interventions for spinal fusion surgery have been found to improve health outcomes for patients. Theory-based interventions that target key mechanisms are more effective at improving outcomes than non-theory-based interventions. While no mediating effects were found for this particular intervention, the analysis suggests that the underlying theoretical model and treatment targets are appropriate and could drive improvement if more strongly targeted.

BACKGROUND AND AIMS: Fear of movement is among the main concerns of patients following knee replacement surgery and a determining factor in the success of surgery. The strategies adopted by patients to overcome this fear have not yet been identified, but once pin pointed, these strategies can be strengthened and modified through intervention. The aim of the present study was to explore the personal strategies adopted by patients following knee replacement to overcome fear of movement.

MATERIALS AND METHODS: Interviews were conducted with 15 patients who had undergone knee replacement, selected by purposive sampling. Data were collected through in-depth semi-structured interviews and analyzed using inductive content analysis.

RESULTS: The patients' strategies as depicted in their narratives were classified into three categories: 1) Movement based on awareness; 2) Movement based on support; and 3) Movement based on hope. These three categories are described in eight subcategories and show what strategies the patients used to overcome their fear of movement.

CONCLUSION: These findings can help to increase awareness about strategies to overcome fear of movement in patients following knee replacement and to develop and support tailored treatment strategies with the aim of reducing such fear of movement and increasing physical activity among the patients.

The potential to classify low back pain as being characterised by dominant nociceptive, neuropathic, or nociplastic mechanisms is a clinically relevant issue. Preliminary evidence suggests that these low back pain phenotypes might respond differently to treatments; however, more research must be done before making specific recommendations. Accordingly, the low back pain phenotyping (BACPAP) consortium was established as a group of 36 clinicians and researchers from 13 countries (five continents) and 29 institutions, to apply a modified Nominal Group Technique methodology to develop international and multidisciplinary consensus recommendations to provide guidance for identifying the dominant pain phenotype in patients with low back pain, and potentially adapt pain management strategies. The BACPAP consortium's recommendations are also intended to provide direction for future clinical research by building on the established clinical criteria for neuropathic and nociplastic pain. The BACPAP consortium's consensus recommendations are a necessary early step in the process to determine if personalised pain medicine based on pain phenotypes is feasible for low back pain management. Therefore, these recommendations are not ready to be implemented in clinical practice until additional evidence is generated that is specific to these low back pain phenotypes.

PURPOSE: Most patients treated in a hospital setting are fully or partially immobilised. The Activity Board (Träningstavlan^® Phystec) is a useful tool to enhance mobilisation after major abdominal cancer surgery. Knowledge of patient experiences of the mobilisation tool is crucial in implementing the Activity Board in health care. This study aimed to describe patient experiences of using the Activity Board after surgery for abdominal cancer.

MATERIALS AND METHODS: Semi-structured face-to-face interviews were conducted in 15 patients who underwent abdominal surgery due to colorectal, ovarian or urinary bladder cancer. All 15 patients (mean age 67.7 years, range 40-86) used the Activity Board postoperatively. The interviews were transcribed verbatim and analysed according to inductive content analysis.

RESULTS: The overarching theme that emerged from the interviews was that "enabling participation facilitates empowerment over rehabilitation". Three categories supported the theme: prerequisites for using the Activity Board, the value of using supportive behavioural techniques, and the possibility to influence the patients' care.

CONCLUSIONS: These findings suggest that the Activity Board could be a viable tool that activates the person-centred postoperative rehabilitation process by cooperating with the medical team at the hospital ward.Implications for rehabilitationPatients who are in hospital due to cancer surgery are often immobilised, which increases the risk of complications.The Activity Board can stimulate the patients to participate in the rehabilitation process in a more active way.The Activity Board can be used to improve and clarify the person-centred approach in hospital settings.

BACKGROUND: Pain is a major symptom in adolescents with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome. Although the underlying mechanism causing generalized pain in children with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome is unclear, central sensitization has been suggested as a possible explanation. The aim of this study was to explore the feasibility of a study protocol for a future case-control study, investigating features of central sensitization in adolescents with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome.

METHODS: Central sensitization features were measured in ten patients and nine healthy controls aged 13-17 years via experimental pain measurement quantifying primary and secondary hyperalgesia, endogenous pain modulation, and exercise-induced hyperalgesia. Descriptive statistics were used. Frequency, median, and range values were calculated.

RESULTS: Eleven out of 57 patients chose to participate. No control could be recruited through public schools. Therefore, a convenience sampling strategy was used for the recruitment of the control group. The process of assessing primary and secondary hyperalgesia, endogenous pain modulation, and exercise-induced hyperalgesia was well tolerated by all participants (patients and controls). When assessing endogenous pain modulation via conditioned pain modulation, two participants in the patient group and three in the control group did not achieve a pain experience ≥ 3 on the numerical rating scale when immersing their hands in cold water.

CONCLUSION: This study investigated the feasibility, safety, and toleration of experimental pain measurements in adolescents with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome. Although the test protocol proved to be sufficiently feasible for use with the participant group, it will need to be adapted in the main study in order to obtain more reliable data. Recruitment, especially of participants for the control group, can be a major obstacle for future studies and requires careful planning.

TRIAL REGISTRATION: Researchweb.org, 270,501. Registered on 9 May 2019.

BACKGROUND: Hypermobility Spectrum Disorder (HSD) and Hypermobile Ehlers-Danlos Syndrome (hEDS) are two overlapping heritable connective tissue disorders characterized by joint hypermobility, chronic pain, impaired body perception, and musculoskeletal symptoms. Central sensitization has been proposed as a plausible explanation for symptoms like widespread pain, fatigue, mood disorders, and sleep disturbances in patients with HSD/hEDS.

OBJECTIVE: The aim of this study was to investigate signs of central sensitization, including exercise-induced hypoalgesia (EIH), and fatigue severity in adolescents with HSD/hEDS.

METHODS: In this prospective, experimental, case-control study, thirty-seven adolescents with HSD/hEDS and 47 healthy adolescents (all aged 13-17 years) were included. Pressure pain thresholds (PPTs) were measured at four muscle groups using a pressure algometer. EIH was evaluated by measuring PPTs on two muscle groups immediately after an exercise test on a bicycle ergometer. Participants also completed questionnaires on fatigue and cognitive/emotional factors.

RESULTS: The study demonstrated significantly lower PPTs in four different muscle groups in adolescents with HSD/hEDS compared to the healthy control group. Both groups achieved a significantly higher PPTs after exercise in the muscle involved in the activity. Adolescents with HSD/hEDS reported higher fatigue levels and more cognitive/emotional difficulties than the control group.

CONCLUSION: Adolescents with HSD/hEDS showed generalized hyperalgesia measured through PPTs at different body sites. EIH was partly affected in adolescents with HSD/hEDS, presenting as unchanged pain sensitivity in the remote muscle. Pain should be considered as a phenomenon that is influenced by different biopsychosocial factors, including possible central sensitization, which increase its complexity.

SIGNIFICANCE STATEMENT: This study breaks new ground by showing signs of central sensitization, including diminished EIH, in adolescents with HSD or hEDS. Given that exercise is a key element in pain management, these findings offer valuable insights when developing treatment plans for adolescents with HSD or hEDS.

OBJECTIVE: To assess short term recovery between individuals with Achilles tendinopathy with varying degrees of kinesiophobia when treated with the Silbernagel protocol. Secondarily to investigate short term change in degree of kinesiophobia.

DESIGN: Prospective single cohort analysis.

SETTING: University/Clinical.

PARTICIPANTS: 116 participants with midportion Achilles tendinopathy were grouped from their baseline Tampa Scale of Kinesiophobia (TSK) score: Low (≤33), Medium (34-41), and High (≥42).

MAIN OUTCOME MEASURES: Symptom severity, Achilles tendon structure, and function were assessed at baseline and 8-weeks following initiation of the Silbernagel protocol. Differences in recovery between TSK groups were analyzed.

RESULTS: No group by time interactions were observed for symptoms, structure, or function. A significant interaction of group by time was observed for TSK score. The Medium (n = 66) and High (n = 28) TSK groups significantly decreased TSK score after 8 weeks by 2.4 and 4.4 points respectively while the Low TSK group (n = 22) did not change.

CONCLUSION: There were no differences in short term recovery of symptoms, Achilles tendon structure, and function in individuals with midportion Achilles tendinopathy treated with the Silbernagel protocol regardless of baseline degree of kinesiophobia. Those with moderate and high levels of kinesiophobia at baseline decreased TSK score in the short term.

BACKGROUND: Fear-avoidance variables are present in patients with musculoskeletal pain conditions, such as chronic low back pain (CLBP) and Achilles tendinopathy (AT) and can lead to reduced function and recovery. It is unknown how these variables relate in populations with different etiologies but similar pain provocation mechanisms.

OBJECTIVE: To compare kinesiophobia, pain catastrophizing, and disability between these two groups.

METHODS: Patients with CLBP and those with AT were included. Tampa Scale of Kinesiophobia (TSK-17) and Pain Catastrophizing Scale (PCS-13) were evaluated in both groups. The CLBP group completed the Oswestry Disability Index (ODI) and the AT group completed the PROMIS-29 questionnaire. Gait speed was calculated for each group. Disability outcomes were normalized between groups.

RESULTS: 119 patients in the CLBP group (64 female, 46 ± 8 years) and 83 patients in the AT group (42 female, 48 ± 12 years) were included. Both groups (CLBP, AT) presented with high prevalence of kinesiophobia (67%, 55%) but the CLBP group presented with higher prevalence of pain catastrophizing (22%, 2%). The CLBP group demonstrated higher levels of disability via normalized ODI (MD= 12.4, 95% CI: 9.2, 15.5) but the AT group demonstrated slower gait speed (MD= 0.1 m/s, 95% CI: 0.0, 0.2).

CONCLUSION: Similarly high prevalence of kinesiophobia was found in patients with CLBP and patients with AT. While the CLBP group reported greater prevalence of catastrophizing thoughts and greater disability, the AT group had slower gait speed. Overall, these findings demonstrate that CLBP and AT have similarities that may allow clinicians to learn from one to inform treatment of the other.

CLINICAL TRIAL REGISTRATION NUMBERS: NCT03523325, ISRCTN17115599.

OBJECTIVES: To examine the effect of an early postsurgical intervention consisting of graded activity and pain education (GAPE) in patients with chronic low back pain (CLBP) undergoing lumbar spinal fusion (LSF) on sedentary behavior, disability, pain, fear of movement, self-efficacy for exercise and health-related quality of life (HRQoL) at 3-, 6-, and 12 months follow-up.

DESIGN: A parallel-group, observer-blinded randomized controlled trial.

SETTING: Department of Occupational- and Physiotherapy and the Centre for Rheumatology and Spine Diseases, Rigshospitalet, Denmark.

PARTICIPANTS: In total, 144 participants undergoing an LSF for CLBP were randomly assigned to an intervention or a control group.

INTERVENTIONS: The intervention group received 9 sessions of GAPE, based on principles of operant conditioning.

MAIN OUTCOME MEASURES: The primary outcome was reduction in time spent in sedentary behavior, measured by an accelerometer at 3 months. The secondary outcomes were reduction in time spent in sedentary behavior at 12 months and changes from baseline to 3-, 6-, and 12 months on disability, pain, fear of movement, self-efficacy for exercise, and HRQoL.

RESULTS: No difference in changes in sedentary behavior between groups was found 3 months after surgery. At 12 months after surgery, there was a significant difference between groups (mean difference: -25.4 min/d (95% confidence interval -49.1 to -1.7)) in favor of the intervention group.

CONCLUSIONS: Compared with usual care, GAPE had no effect on short-term changes in sedentary behavior but GAPE had a statistical, but possibly not clinical significant effect on sedentary behavior 12 months after LSF. Further, the behavioral intervention was safe to perform.

BACKGROUND: Currently, evidence regarding fear avoidance beliefs as potential predictors for lumbar surgery outcomes seems insufficient and strong conclusions are not yet available.

OBJECTIVE: This systematic review aimed to evaluate the predictive value of preoperative fear avoidance beliefs for postoperative pain intensity, functional status, and health-related quality of life following surgery for lumbar degenerative disease.

STUDY DESIGN: Systematic review and best evidence synthesis.

METHODS: An extensive search was performed in PubMed/Medline, EMBASE, PsycINFO, CINAHL and the Cochrane library for articles published up until October 2021. Two independent reviewers performed the screening, data extraction, and quality assessment, with a third independent reviewer consulting to resolve any disagreement. Observational studies that included patients undergoing surgery for lumbar degenerative disease, as well as evaluated fear avoidance beliefs (i.e., pain-related fear, pain catastrophizing, pain anxiety) in relation to a surgical outcome measure (i.e., pain intensity, functional status and health-related quality of life) were included in the review. The CHARMS- and QUIPS-tools were used for data extraction and quality assessment, respectively. A best evidence synthesis was performed resulting in conclusions regarding strong, moderate, conflicting, and limited levels of evidence.

RESULTS: A total of 24 studies (n = 17,881) were included in this review. Following best evidence synthesis, 3 included studies reported no significant predictive value of preoperative pain-related fear for postoperative pain intensity resulting in moderate evidence for this relationship. Moderate evidence was also found indicating no significant predictive value of preoperative pain-related fear for postoperative functional status, as 6 out of 8 relevant studies reported this result. Only one study reported on the predictive value of preoperative pain catastrophizing for postoperative health-related quality of life, resulting in limited evidence for the absence of this predictive relationship. All other relationships were found to have conflicting evidence.

LIMITATIONS: To evaluate surgical outcome, only patient-reported outcome measures as used by spine registries were included. Thus, our findings cannot be extrapolated to all surgery outcomes following lumbar degenerative disease and should only be interpreted in relation to postoperative pain intensity, functional status, or health-related quality of life.

CONCLUSION: Best evidence synthesis showed moderate evidence indicating that preoperative pain-related fear is not a significant predictor for postoperative pain and function following surgery for lumbar degenerative disease. Additionally, limited evidence was found for a lack of predictive value of preoperative pain catastrophizing for postoperative health-related quality of life. As current evidence regarding the predictive value of preoperative fear avoidance beliefs following such a surgery is mixed, further research is required before more definitive conclusions can be made.

To illuminate adolescents' experiences of Help Overcoming Pain Early (HOPE), a person-centred intervention delivered in a school setting by school nurses. Twenty-one adolescents with chronic pain recruited from secondary school, who had completed the HOPE intervention, were included in the interview study. The HOPE intervention was built on person-centred ethics and consisted of four meetings between school nurses and adolescents on the subject of stress and pain management. A qualitative method using content analysis with an inductive approach was employed. In the interviews, the adolescents describe how they reclaim their lives with the help of HOPE. They use different strategies and parts of the intervention to move on with their lives. A trustful relationship, as that with the school nurse, was essential to dare to change. The overarching theme summarizes in Becoming myself again and is built up by three sub-themes: Trust a pillar for growth, Making sense of my life with pain, and Putting myself into the world again. A person-centred intervention such as HOPE applied in a school context is promising for promoting confidence in adolescents with chronic pain. A trust-building process emerged, in terms of both the adolescents' trust in the healthcare staff they meet and their confidence in their own ability to handle and influence their situation, which in the long term can promote trust in themselves as a person.

INTRODUCTION AND AIMS: Chronic pain and symptoms of insomnia affect large numbers of adolescents and early interventions are prioritized. The aim of the current study was to evaluate potential secondary effects of the intervention, Help Overcoming Pain Early (HOPE), on symptoms of insomnia and self-rated health.

METHODS: The study included non-randomized aggregated data from the active and control conditions in a previously conducted randomized controlled trial evaluating the efficacy of HOPE, after the participants in the control condition also had received the intervention. Symptoms of insomnia were assessed with the Minimal Insomnia Symptom Scale and self-rated health was assessed with one item, at the start of the intervention, post intervention, and at a six-month follow-up. Baseline variables included age, gender, pain localization, pain impact, school absence and symptoms of depression (assessed with the Center for Epidemiological Studies Depression Scale for Children). Inferential analyzes were performed using Linear Mixed Models (LMM). Effect sizes were evaluated by calculating Cohen's d.

RESULTS: There were statistically significant improvements in symptoms of insomnia at the six-month follow-up, and statistically significant improvements in self-rated health at the end of the intervention and at the six-month follow-up. Effect sizes were small across outcomes and assessments.

DISCUSSION AND CONCLUSION: Results illustrated significant but small improvements in symptoms of insomnia and self-rated health in adolescents with chronic pain following the HOPE intervention. Although caution is needed when assessing the findings, results illustrate the potential utility of an accessible brief early intervention in a school context.

BACKGROUND: Although person-centered care (PCC) ensures high-quality care for patients, studies have shown that it is unevenly applied in clinical practice. The extent to which future health care providers are currently offered education in PCC at their universities is unclear. We aimed to clarify the PCC content offered to students as a basis for their understanding by exploring the PCC content of Swedish national study programs in medicine, nursing, occupational therapy, and physiotherapy.

METHODS: Using a qualitative document analysis design, we sampled the steering documents from all higher education institutions (n = 48) with accreditation in medicine (n = 7), nursing (n = 25), occupational therapy (n = 8), or physiotherapy (n = 8) at a single time point. All national study programs (n = 4), local program syllabuses (n = 48), and local course syllabuses (n = 799) were reviewed using a 10-item protocol.

RESULTS: We found no content related to PCC in the steering documents at the national level. At the local level, however, signs of PCC were identified in local program syllabuses and local course syllabuses. Seven of the 48 local program syllabuses (15%) included PCC in their intended learning outcomes. Eight of the 799 local course syllabuses (1%) contained course titles that included the phrase 'person-centered care,' and another 101 listed 142 intended learning outcomes referring to PCC. A total of 21 terms connected to PCC were found, and the term 'person-centered care' was most commonly used in the nursing programs and least commonly in the medical programs.

CONCLUSIONS: There is a broad range in how the national study programs in Sweden have incorporated PCC. The implementation has been driven by a bottom-up strategy. A deliberate and standardized strategy is needed to ensure full implementation of PCC into clinical curricula in higher education.

Person-centred care (PCC) is being implemented within many health care systems and educational institutions are important enablers of learning PCC. Teachers in higher education are responsible for helping students develop the ability to reflect. One approach is with serious games, which allow students to reflect on realistic situations and shape their skills with virtual patients. This paper describes the development of a serious game, the person-centred care game - (PCC game), which was designed to promote learning of PCC by reflection. We demonstrated how this PCC game could be used to induce PCC knowledge and skills by student reflection in an academic course on PCC.