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  • 1.
    Axén, Iben
    et al.
    Institute of Environmental Medicine, Unit of Intervention and Implementation Research, The Karolinska Institutet, Stockholm, Sweden.
    Bodin, Lennart
    Institute of Environmental Medicine, Unit of Intervention and Implementation Research, The Karolinska Institutet, Stockholm, Sweden.
    Bergström, Gunnar
    Institute of Environmental Medicine, Unit of Intervention and Implementation Research, The Karolinska Institutet, Stockholm, Sweden.
    Halasz, Laszlo
    Private practise, Lund, Sweden.
    Lange, Fredrik
    Private practise, Stockholm, Sweden.
    Lövgren, Peter W.
    Private practise, Stockholm, Sweden.
    Rosenbaum, Annika
    Private practise, Linköping, Sweden.
    Leboeuf-Yde, Charlotte
    Institute of Regional Health Research, Spine Centre of Southern Denmark, Hospital Lillebælt, University of Southern Denmark, Kolding, Denmark.
    Jensen, Irene
    Institute of Environmental Medicine, Unit of Intervention and Implementation Research, The Karolinska Institutet, Stockholm, Sweden.
    Clustering patients on the basis of their individual course of low back pain over a six month period2011In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 12, article id 99Article in journal (Refereed)
    Abstract [en]

    Background: Several researchers have searched for subgroups in the heterogeneous population of patients with non-specific low back pain (LBP). To date, subgroups have been identified based on psychological profiles and the variation of pain.

    Methods: This multicentre prospective observational study explored the 6- month clinical course with measurements of bothersomeness that were collected from weekly text messages that were sent by 176 patients with LBP. A hierarchical cluster analysis, Ward's method, was used to cluster patients according to the development of their pain.

    Results: Four clusters with distinctly different clinical courses were described and further validated against clinical baseline variables and outcomes. Cluster 1, a "stable" cluster, where the course was relatively unchanged over time, contained young patients with good self- rated health. Cluster 2, a group of "fast improvers" who were very bothered initially but rapidly improved, consisted of patients who rated their health as relatively poor but experienced the fewest number of days with bothersome pain of all the clusters. Cluster 3 was the "typical patient" group, with medium bothersomeness at baseline and an average improvement over the first 4-5 weeks. Finally, cluster 4 contained the "slow improvers", a group of patients who improved over 12 weeks. This group contained older individuals who had more LBP the previous year and who also experienced most days with bothersome pain of all the clusters.

    Conclusions: It is possible to define clinically meaningful clusters of patients based on their individual course of LBP over time. Future research should aim to reproduce these clusters in different populations, add further clinical variables to distinguish the clusters and test different treatment strategies for them.

  • 2.
    Bergström, Cecilia
    et al.
    Division of Intervention and Implementation Research, Department of Public Health, Karolinska Institutet, Stockholm, Sweden.
    Hagberg, Jan
    Division of Intervention and Implementation Research, Department of Public Health, Karolinska Institutet, Stockholm, Sweden.
    Bodin, Lennart
    Division of Intervention and Implementation Research, Department of Public Health, Karolinska Institutet, Stockholm, Sweden.
    Jensen, Irene
    Division of Intervention and Implementation Research, Department of Public Health, Karolinska Institutet, Stockholm, Sweden.
    Bergström, Gunnar
    Division of Intervention and Implementation Research, Department of Public Health, Karolinska Institutet, Stockholm, Sweden.
    Using a psychosocial subgroup assignment to predict sickness absence in a working population with neck and back pain2011In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 12, article id 81Article in journal (Refereed)
    Abstract [en]

    Background: The overall objective was to evaluate the predictive validity of a subgroup classification based on the Swedish version of the MPI, the MPI-S, among gainfully employed workers with neck pain (NP) and/or low back pain (LBP) during a follow-up period of 18 and 36 months.

    Methods: This is a prospective cohort study that is part of a larger longitudinal multi-centre study entitled Work and Health in the Process and Engineering Industries (AHA). The attempt was to classify individuals at risk for developing chronic disabling NP and LBP. This is the first study using the MPI-questionnaire in a working population with NP and LBP.

    Results: Dysfunctional individuals (DYS) demonstrated more statistically significant sickness absence compared to adaptive copers (AC) after 36 months. DYS also had a threefold increase in the risk ratio of long-term sickness absence at 18 months. Interpersonally distressed (ID) subgroup showed overall more sickness absence compared to the AC subgroup at the 36-month follow-up and had a twofold increase in the risk ratio of long-term sickness absence at 18 months. There was a significant difference in bodily pain, mental and physical health for ID and DYS subgroups compared to the AC group at both follow-ups.

    Conclusions: The present study shows that this multidimensional approach to the classification of individuals based on psychological and psychosocial characteristics can distinguish different groups in gainfully employed working population with NP/LBP. The results in this study confirm the predictive validity of the MPI-S subgroup classification system.

  • 3.
    Eklund, Andreas
    et al.
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Bergström, Gunnar
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Bodin, Lennart
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Axén, Iben
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Research Department, Spine Center of Southern Denmark, Hospital Lillebaelt, Institute of Regional Health Research, Middelfart, Denmark.
    Do psychological and behavioral factors classified by the West Haven-Yale Multidimensional Pain Inventory (Swedish version) predict the early clinical course of low back pain in patients receiving chiropractic care?2016In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 17, no 1, article id 75Article in journal (Refereed)
    Abstract [en]

    Background: To investigate if psychological and behavioral factors (as determined by the Swedish version of the West Haven-Yale Multidimensional Pain Inventory, MPI-S) can predict the early clinical course of Low Back Pain (LBP).

    Methods: MPI-S data from patients (18–65 years of age) seeking chiropractic care for recurrent and persistent LBP were collected at the 1st visit. A follow-up questionnaire was administered at the 4th visit. The predictive value of the MPI-S subgroups Adaptive Copers (AC), Interpersonally Distressed (ID) and Dysfunctional (DYS) was calculated against the subjective improvement at the 4th visit and clinically relevant difference in pain intensity between the 1st and 4th visit.

    Results: Of the 666 subjects who were included at the 1st visit, 329 completed the questionnaire at the 4th visit. A total of 64.7 % (AC), 68.0 % (ID) and 71.3 % (DYS) reported a definite improvement. The chance of “definite improvement”, expressed as relative risk (95 % CI) with the AC group as reference, was 1.05 (.87–1.27) for the ID and 1.10 (.93–1.31) for the DYS groups, respectively. The DYS and ID groups reported higher values in pain intensity both at the 1st and the 4th visit. The proportion of subjects who reported an improvement in pain intensity of 30 % or more (clinically relevant) were 63.5 % AC, 72.0 % ID and 63.2 % DYS. Expressed as relative risk (95 % CI) with the AC group as reference, this corresponded to 1.26 (.91–1.76) for the ID and 1.09 (.78–1.51) for the DYS groups, respectively.

    Conclusions: The MPI-S instrument could not predict the early clinical course of recurrent and persistent LBP in this sample of chiropractic patients.

  • 4.
    Eklund, Andreas
    et al.
    Institute of Environmental Medicine, Unit of Intervention and Implementation Research, Karolinska Institutet, Stockholm, Sweden.
    Bergström, Gunnar
    Institute of Environmental Medicine, Unit of Intervention and Implementation Research, Karolinska Institutet, Stockholm, Sweden.
    Bodin, Lennart
    Institute of Environmental Medicine, Unit of Intervention and Implementation Research, Karolinska Institutet, Stockholm, Sweden.
    Axén, Iben
    Institute of Environmental Medicine, Unit of Intervention and Implementation Research, Karolinska Institutet, Stockholm, Sweden; Research Department, Spine Center of Southern Denmark, Institute of Regional Health Research, Hospital Lillebælt, Middelfart, Denmark.
    Psychological and behavioral differences between low back pain populations: a comparative analysis of chiropractic, primary and secondary care patients2015In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 16, article id 306Article in journal (Refereed)
    Abstract [en]

    Background: Psychological, behavioral and social factors have long been considered important in the development of persistent pain. Little is known about how chiropractic low back pain (LBP) patients compare to other LBP patients in terms of psychological/behavioral characteristics.

    Methods: In this cross-sectional study, the aim was to investigate patients with LBP as regards to psychosocial/behavioral characteristics by describing a chiropractic primary care population and comparing this sample to three other populations using the MPI-S instrument. Thus, four different samples were compared. A: Four hundred eighty subjects from chiropractic primary care clinics. B: One hundred twenty-eight subjects from a gainfully employed population (sick listed with high risk of developing chronicity). C: Two hundred seventy-three subjects from a secondary care rehabilitation clinic. D: Two hundred thirty-five subjects from secondary care clinics. The Swedish version of the Multidimensional Pain Inventory (MPI-S) was used to collect data. Subjects were classified using a cluster analytic strategy into three pre-defined subgroups (named adaptive copers, dysfunctional and interpersonally distressed).

    Results: The data show statistically significant overall differences across samples for the subgroups based on psychological and behavioral characteristics. The cluster classifications placed (in terms of the proportions of the adaptive copers and dysfunctional subgroups) sample A between B and the two secondary care samples C and D.

    Conclusions: The chiropractic primary care sample was more affected by pain and worse off with regards to psychological and behavioral characteristics compared to the other primary care sample. Based on our findings from the MPI-S instrument the 4 samples may be considered statistically and clinically different.

  • 5.
    Glans, Martin
    et al.
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Humble, Mats B.
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Elwin, Marie
    Örebro University, School of Medical Sciences. Örebro University Hospital. University Health Care Research Centre.
    Bejerot, Susanne
    Örebro University, School of Medical Sciences. University Health Care Research Centre.
    Self-rated joint hypermobility: the five-part questionnaire evaluated in a Swedish non-clinical adult population2020In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 21, no 1, article id 174Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The conventional way to identify generalised joint hypermobility is by a physical examination according to the Beighton Score. However, a physical examination is time-consuming in clinical practise and may be unfeasible in population-based studies. The self-assessment five-part questionnaire on hypermobility (5PQ) offers a more practicable way to identify GJH. The aim of this study was to test validity and reliability of the five-part questionnaire on hypermobility (5PQ) translated into Swedish on a non-clinical adult population.

    METHODS: A structured procedure was used for the translation of the 5PQ into Swedish. The Beighton Score was used as reference standard for generalised joint hypermobility. Test-retest reliability was tested in a separate group who filled in the questionnaire twice with a ten-week interval. Participants consisted of a convenience sample recruited in Stockholm, Sweden (2017).

    RESULTS: A total of 328 participants were included in the study, 297 participants in the validity group and 31 participants in the reliability group. When evaluated against a present Beighton Score with an age-dependent cut-off, the Swedish 5PQ attained a sensitivity of 91%, a specificity of 75% and an area under the curve of 0.87. The Swedish 5PQ showed substantial to almost perfect test-retest reliability.

    CONCLUSIONS: The Swedish 5PQ is a valid and reliable instrument to screen for or to identify generalised joint hypermobility.

  • 6.
    Mahdi, Aamir
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro County, Sweden.
    Hälleberg Nyman, Maria
    Örebro University, School of Health Sciences.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics, Örebro County, Sweden.
    How do orthopaedic surgeons inform their patients before knee arthroplasty surgery?: A cross-sectional study2018In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 19, article id 414Article in journal (Refereed)
    Abstract [en]

    Background: Total knee arthroplasty (TKA) is a successful and common procedure. However, 6–28% of patients are dissatisfied postoperatively. The provision of preoperative patient information, inquiring about patients’ expectations, and taking a psychiatric history are essential parts of both preoperative evaluation and postoperative outcome. The aim of this study was to investigate how orthopaedic knee surgeons in Sweden inform their patients before surgery.

    Methods: A questionnaire was distributed to all knee surgeons performing TKA in Sweden. Responses were received from 60 of the 65 orthopaedic departments performing TKA in Sweden (92%), covering 219 of the approximately 311 knee surgeons at the 65 departments (70%). The answers were analysed with descriptive statistics. A content analysis of the surgeons’ opinions was also performed using a thematic method.

    Results: In terms of information provision, 58% of the surgeons always gave written information while 92% informed orally. Only 44% always asked about the patient’s expectations, and only 42% always informed patients about the 20% dissatisfaction rate after TKA. Additionally, 24% never operated on mild indication of arthrosis, 20% always took a psychiatric history, and half never or seldom consulted a psychiatrist. However, all the knee surgeons believed in a psychiatric impact on TKA outcome. Qualitative analysis revealed five common causes of patient dissatisfaction, which in descending frequency were: patients’ expectations, choice of patients to operate on, surgical factors, combinations of factors, and insufficient information provision to patients.

    Conclusions: Knee surgeons in Sweden have considerable awareness of the importance of preoperative patient information, the impact of patient expectations, and psychiatric illness. However, they need to improve their preoperative routines when it comes to providing written information, asking about the patient’s expectations, and psychiatric assessment.

  • 7.
    Mahdi, Aamir
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopaedics.
    Svantesson, Mia
    Örebro University Hospital. Örebro University, School of Health Sciences. University Health Care Research Center.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopaedics.
    Hälleberg Nyman, Maria
    Örebro University, School of Health Sciences.
    Patients’ experiences of discontentment one year after total knee arthroplasty: a qualitative study2020In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 21, no 1, article id 29Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Total knee arthroplasty is a common procedure with generally good results. However, there are still patients who are dissatisfied without known explanation. Satisfaction and dissatisfaction have previously been captured by quantitative designs, but there is a lack of qualitative studies regarding these patients' experiences. Qualitative knowledge might be useful in creating strategies to decrease the dissatisfaction rate.

    METHODS: Of the 348 patients who responded to a letter asking if they were satisfied or dissatisfied with their surgery, 61 (18%) reported discontent. After excluding patients with documented complications and those who declined to participate, semi-structured interviews were conducted with 44 patients. The interviews were analyzed according to qualitative content analysis. The purpose was to describe patients' experiences of discontentment 1 year after total knee arthroplasty.

    RESULTS: The patients experienced unfulfilled expectations and needs regarding unresolved and new problems, limited independence, and lacking of relational supports. They were bothered by pain and stiffness, and worried that changes were complications as a result of surgery. They described inability to perform daily activities and valued activities. They also felt a lack of relational supports, and a lack of respect and continuity, support from health care, and information adapted to their needs.

    CONCLUSION: Patient expectation seems to be the major contributing factor in patient discontentment after knee replacement surgery. This qualitative study sheds light on the on the meaning of unfulfilled expectations, in contrast to previous quantitative studies. The elements of unfulfilled expectations need to be dealt with both on the individual staff level and on the organizational level. For instance, increased continuity of healthcare staff and facilities may help to improve patient satisfaction after surgery.

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    Patients' experiences of discontentment one year after total knee arthroplasty: a qualitative study
  • 8.
    Muder, Daniel
    et al.
    Department of Surgical Sciences/Orthopedics & Hand Surgery, Uppsala University Hospital, Uppsala, Sweden; Department of Orthopedics, Falu Lasarett, Falun, Sweden.
    Nilsson, Ola
    Örebro University, School of Medical Sciences. University Hospital, Örebro, Sweden; Division of Pediatric Endocrinology and Center of Molecular Medicine, Department of Women's and Children's Health, Karolinska Institutet and University Hospital, Stockholm, Sweden.
    Vedung, Torbjörn
    Department of Surgical Sciences/Orthopedics & Hand Surgery, Uppsala University Hospital, Entrence 70 1 floor, 751 85, Uppsala, Sweden; Elisabeth Hospital Aleris, Uppsala, Sweden.
    Reconstruction of finger joints using autologous rib perichondrium: an observational study at a single Centre with a median follow-up of 37 years2020In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 21, no 1, article id 278Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Gratifying long-term results are difficult to achieve when reconstructing osteoarthritic finger joints. Implant surgery is the most commonly used method to restore function and dexterity. However, all types of implant have disadvantages and may be a less favorable option in some cases, especially in young patients with a long expected lifetime and high demands on manual load. Implant related complications as loosening, instability, subsidence and stiffness are the main concerns. In this context, joint reconstruction using rib perichondrium might be a reasonable alternative in selected cases. The aim of the study was to evaluate the long-term results of finger joint reconstruction using rib perichondrial transplantation.

    METHODS: The study group (n = 11) consisted of eight individuals reconstructed in the proximal interphalangeal (PIP) joints and three reconstructed in the metacarpophalangeal (MCP) joints during 1974-1981. All patients were evaluated at clinical visits (median: 37 years after perichondrial transplantation, range: 34-41 years) using radiographs, disability in arm-shoulder-hand (DASH) score, Visual Analog Scale (VAS), range-of-motion (ROM) and manual strength (JAMAR).

    RESULTS: None of the 11 patients had undergone additional surgery. All of the PIP-joints (n = 8) were almost pain-free at activity (VAS 0,6) (range 0-4), had an average range-of-motion of 41 degrees (range 5-80) and a mean DASH-score of 8,3 (range 1-51). The mean strength was 41 kg compared to 44 kg in the contralateral hand (93%). The three MCP joints were almost pain-free at activity (VAS 0,7), (range 0-1). The ROM was on average 80 degrees (range 70-90) and the mean DASH-score was 2 (range 1-3). The mean strength was 43 kg compared to 53 kg in the contralateral hand (81%).

    CONCLUSIONS: Perichondrium transplants restored injured PIP and MCP joints that remained essentially pain-free and mostly well-functioning without need for additional surgeries up to 41 years after the procedure. Additional studies are needed to evaluate long-term results in comparison to modern implants and to better describe the factors that determine the outcome of these procedures.

    LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

  • 9.
    Naili, Josefine E.
    et al.
    Department of Women’s and Children’s Health, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedics, School of Medical Sciences, Örebro University, Örebro University Hospital, Örebro, Sweden.
    Lindgren, Viktor
    Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
    Iversen, Maura D.
    Department of Women’s and Children’s Health, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Physical Therapy, Movement & Rehabilitation Sciences, Bouve College of Health Sciences, Northeastern University, Boston MA, United States; Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Harvard Medical School, Boston MA, United States.
    Hedström, Margareta
    Department of Clinical Science, Intervention and Technology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
    Broström, Eva W.
    Department of Women’s and Children’s Health, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
    Improved knee biomechanics among patients reporting a good outcome in knee-related quality of life one year after total knee arthroplasty2017In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 18, article id 122Article in journal (Refereed)
    Abstract [en]

    Background: It is not well understood why one in five patients report poor outcomes following knee arthroplasty. This study evaluated changes in knee biomechanics, and perceived pain among patients reporting either a good or a poor outcome in knee-related quality of life after total knee arthroplasty.

    Methods: Twenty-eight patients (mean age 66 (SD 7) years) were included in this prospective study. Within one month of knee arthroplasty and one year after surgery, patients underwent three-dimensional (3D) gait analysis, completed the Knee Injury and Osteoarthritis Outcome Score (KOOS), and rated perceived pain using a visual analogue scale. A "good outcome" was defined as a change greater than the minimally detectable change in the KOOS knee-related quality of life, and a "poor outcome" was defined as change below the minimally detectable change. Nineteen patients (68%) were classified as having a good outcome. Groups were analyzed separately and knee biomechanics were compared using a two-way repeated measures ANOVA. Differences in pain between groups were evaluated using Mann Whitney U test.

    Results: Patients classified as having a good outcome improved significantly in most knee gait biomechanical outcomes including increased knee flexion-extension range, reduced peak varus angle, increased peak flexion moment, and reduced peak valgus moment. The good outcome group also displayed a significant increase in walking speed, a reduction (normalization) of stance phase duration (% of gait cycle) and increased passive knee extension. Whereas, the only change in knee biomechanics, one year after surgery, for patients classified as having a poor outcome was a significant reduction in peak varus angle. No differences in pain postoperatively were found between groups.

    Conclusion: Patients reporting a good outcome in knee-related quality of life improved in knee biomechanics during gait, while patients reporting a poor outcome, despite similar reduction in pain, remained unchanged in knee biomechanics one year after total knee arthroplasty. With regards to surgeon-controlled biomechanical factors, surgery may most successfully address frontal plane knee alignment. However, achieving a good outcome in patient-reported knee-related quality of life may be related to dynamic improvements in the sagittal plane.

  • 10.
    Wiklund, Tobias
    et al.
    Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden; Department of Medical and Health Sciences, University of Linköping, Linköping, Sweden.
    Linton, Steven J.
    Örebro University, School of Law, Psychology and Social Work.
    Alföldi, Peter
    Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Gerdle, Björn
    Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
    Is sleep disturbance in patients with chronic pain affected by physical exercise or ACT-based stress management?: A randomized controlled study2018In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 19, no 1, article id 111Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Most people suffering chronic pain are plagued by sleeping difficulties. Cognitive behaviour therapy has produced promising results for insomnia comorbid with chronic pain, but the access to such treatment is often limited. Over the last ten years, interventions aiming to increase cognitive flexibility and physical activity have been assumed to be effective treatments for a variety of conditions, including insomnia and chronic pain. If proven effective, these treatments could constitute the first steps in a stepped care model for chronic pain and insomnia.

    METHODS: Two hundred ninety-nine chronic pain subjects were randomized to Exercise, ACT-based stress management (ACT-bsm), or an active control group. Two hundred thirty-two participants (78%) received their allocated intervention at least to some extent. These participants were evaluated using mixed model analyses for changes in sleep (Insomnia Severity Index, ISI), pain intensity, depression, and anxiety immediately after treatment, six months and twelve months after treatment.

    RESULTS: The mixed model analyses revealed that Exercise had a positive effect on insomnia compared with the control group and the effect remained after 12 months. No clear effect (i.e., both for completers and for completers together with treatment non-completers) upon ISI was found for the ACT-bsm. Pain intensity decreased significantly both in the exercise group and in the control group. For the two psychological variables (i.e., symptoms of anxiety and depression) were found significant improvements over time but no group differences. The treatment effects for ISI and pain intensity did not reach clinical significance per definitions presented in other relevant studies.

    CONCLUSIONS: Beneficial significant effects on insomnia was confirmed in the exercise condition. However, these changes were probably not clinically important. For pain intensity a general decrease was found in the Exercise condition and in the control condition, while no change occurred in ACT-bsm. No group differences were found for the two psychological variables.

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