Midwives' and Diabetes Nurses' Experience of Screening and Care of Women with Gestational Diabetes Mellitus: A Qualitative Interview Study.

Background: Gestational diabetes mellitus (GDM) is increasing and is associated with adverse outcomes for both mother and child. The metabolic demands of pregnancy can reveal a predisposition for type 2 diabetes mellitus (T2DM), and women with a history of GDM are more likely to develop T2DM than women with normoglycemic pregnancies. Aim: The aim of this study was to explore midwives' and diabetes nurses' experience of their role in screening, care, and follow-up of women with gestational diabetes mellitus and, further, to explore their opinions and thoughts about existing routines and guidelines. Method: Individual interviews were performed with ten diabetes nurses and eight midwives working in primary and special care. Qualitative content analysis was done according to Graneheim and Lundman. Results: The analysis of the interviews resulted in the overall theme "An act of balance between normalcy and illness, working for motivation with dilemmas throughout the chain of health care." Difficulties in carrying out the important task of handling GDM while at the same time keeping the pregnancy in focus were central. Women were described as highly motivated to maintain a healthy lifestyle during pregnancy with the baby in mind, but it seemed difficult to maintain this after delivery, and compliance with long-term follow-up with the aim of reducing the risk of T2DM was low. The women came to the first follow-up but did not continue with later contact. This was at a time when the women felt healthy and were focusing on the baby and not themselves. A lack of cooperation and easy access to a dietician and physiotherapist were pointed out as well as a wish for resources such as group activities and multiprofessional teams.

Cold air exposure at - 15 °C induces more airway symptoms and epithelial stress during heavy exercise than rest without aggravated airway constriction.

PURPOSE: Exposure to cold air may harm the airways. It is unclear to what extent heavy exercise adds to the cold-induced effects on peripheral airways, airway epithelium, and systemic immunity among healthy individuals. We investigated acute effects of heavy exercise in sub-zero temperatures on the healthy airways. METHODS: Twenty-nine healthy individuals underwent whole body exposures to cold air in an environmental chamber at - 15 °C for 50 min on two occasions; a 35-min exercise protocol consisting of a 5-min warm-up followed by 2 × 15 min of running at 85% of VO2max vs. 50 min at rest. Lung function was measured by impulse oscillometry (IOS) and spirometry before and immediately after exposures. CC16 in plasma and urine, and cytokines in plasma were measured before and 60 min after exposures. Symptoms were surveyed pre-, during and post-trials. RESULTS: FEV1 decreased after rest (- 0.10 ± 0.03 L, p < 0.001) and after exercise (- 0.06 ± 0.02 L, p = 0.012), with no difference between trials. Exercise in - 15 °C induced greater increases in lung reactance (X5; p = 0.023), plasma CC16 (p < 0.001) as well as plasma IL-8 (p < 0.001), compared to rest. Exercise induced more intense symptoms from the lower airways, whereas rest gave rise to more general symptoms. CONCLUSION: Heavy exercise during cold air exposure at - 15 °C induced signs of an airway constriction to a similar extent as rest in the same environment. However, biochemical signs of airway epithelial stress, cytokine responses, and symptoms from the lower airways were more pronounced after the exercise trial.

An experimental exposure study revealing composite airway effects of physical exercise in a subzero environment.

Exposure to a cold climate is associated with an increased morbidity and mortality, but the specific mechanisms are largely unknown. People with cardiopulmonary disease and winter endurance athletes are particularly vulnerable. This study aimed to map multiple domains of airway responses to exercise in subzero temperature in healthy individuals.Thirty-one healthy subjects underwent whole-body exposures for 50 minutes on two occasions in an environmental chamber with intermittent moderate-intensity exercise in +10 °C and -10 °C. Lung function, plasma/urine CC16 , and symptoms were investigated before and after exposures.Compared to baseline, exercise in -10 °C decreased FEV1 (p=0.002), FEV1/FVC (p<0.001), and increased R20Hz (p=0.016), with no differences between exposures. Reactance increased after +10 °C (p=0.005), which differed (p=0.042) from a blunted response after exercise in -10 °C. Plasma CC16 increased significantly within exposures, without differences between exposures. Exercise in -10 °C elicited more intense symptoms from the upper airways, compared to +10 °C. Symptoms from the lower airways were few and mild. Short-duration moderate-intensity exercise in -10 °C induces mild symptoms from the lower airways, no lung function decrements or enhanced leakage of biomarkers of airway epithelial injury, and no peripheral bronchodilatation, compared to exercise in +10 °C.

Investigating the Probability of Response Bias in Owner-Perceived Pain Assessment in Dogs With Osteoarthritis.

Owners' ability to recognize signs of chronic pain in dogs undergoing pharmacologic and nonpharmacologic pain interventions during a period of physical rehabilitation is not known. This study aimed to compare dogs with and without chronic pain, and to assess the relationship between explanatory factors, including the probability of owners' response bias induced by pharmacologic and nonpharmacologic pain intervention, and chronic pain in dogs with osteoarthritis (OA). Seventy-one dogs with OA were included in this observational study. Owner-perceived pain interference was measured by Canine Brief Pain Inventory (CBPI) and owner-perceived pain behavior was assessed using Helsinki Chronic Pain Index. A dichotomous variable of Helsinki Chronic Pain Index was used in regression analysis to investigate the association between chronic pain and explanatory factors (body condition, anti-inflammatory medication, animal physiotherapy consultation once or more and owners' perception of pain interfering). Seventy-five percent of the dogs had ongoing anti-inflammatory medication, 51% of were overweight and 45% had a physiotherapy consultation. Higher levels of overt pain behaviors were reported in items addressing activities. Body condition, physiotherapy consultation and medication were not associated with chronic pain. Odds ratio (OR) and 95% confidence intervals of OR for the CBPI were 1.74 (1.23-2.47) and significantly associated with chronic pain. The adjusted OR of the CBPI did not differ from the crude OR. Owner-perceived pain behavior was not confounded by the dogs' medication. Results indicated that CBPI was not mediated by the medication. The CBPI pain interference score was not associated with response bias and may be used as clinical outcome measure of chronic pain and pain-related disability in dogs with OA along a period of physical rehabilitation comprising pharmacologic and nonpharmacologic pain interventions.

Patients' Experiences of a Stress-Management Programme in Primary Care.

INTRODUCTION: Stress and stress-related ill health have a multifactorial impact; both on physical and mental health. To better meet this category of patients a primary care unit started a stress-management programme using cognitive behavioural therapy and basic body awareness therapy. PURPOSE: To describe participant´s experiences of a primary care stress-management programme using cognitive behavioural therapy and basic body awareness therapy. METHODS: In a qualitative study, a semi-structured interview guide was used in individual interviews with 9 people, all women aged 41-57, working or on sick leave, who had enrolled in the stress-management programme. The material was analysed through qualitative content analysis. RESULTS: The analysis resulted in the theme "Process of change for a sustainable everyday living". The participants described having gained awareness of the symptoms of their stress, knowledge and tools to manage their stress, ways to relax, awareness of their body, and the means to develop better habits and to change their behaviour. Fundamental in the material was the importance of participants' identification with the others in the group. CONCLUSION: The participants started a process of change with new knowledge and growth, but they encountered difficulties and obstacles. Behavioural change is a time-consuming process.

Qualitative identification and characterisation of self-reported symptoms arising in humans during experimental exposure to cold air.

BACKGROUND: Exposure to cold air is associated with increased morbidity and mortality in the general population. It is difficult to study the effects of whole-body exposure to cold air under controlled conditions in real life. OBJECTIVES: The aim of this study was to (1) explore and describe the experience of symptoms in humans during experimental and controlled exposures to cold air, by using controlled environmental chamber exposures and qualitative methodology, and to (2) categorise the symptoms. METHOD: The study used a randomised, double blind design, in which 34 subjects undertook rest and moderate-intensity exercise in an environmental chamber set to two or three different temperatures (0, -10, and -17°C) on separate occasions. During the chamber exposures, subjects were interviewed. Qualitative content analysis was selected as the method of analysis. FINDINGS: Subjects reported 50 distinct symptoms during the exposures. The symptoms were grouped into ten sub-categories and two major categories; airway versus whole-body symptoms. CONCLUSION: We have identified a broad range of symptoms in humans undertaking rest and moderate-intensity exercise at sub-zero temperatures. The symptoms and their categories may well be used to more extensively and quantitatively map cold-induced morbidity.

Perceptions of Tuberculosis Among Individuals Born in a High-Endemic Setting, Now Living in a Low-Endemic Setting.

Of all individuals diagnosed with tuberculosis (TB) in Sweden 2015 were 90% born in other countries. Early diagnosis and treatment is essential to avoid TB transmission. Lack of knowledge about TB and anticipated negative social consequences have proved to be significant contributing factors to delay in seeking health care. This study aimed to understand the perception of TB among people originating from a high-endemic region, currently living in a low-endemic region. A qualitative study design, with male and female participants from a high-endemic region divided into focus groups. A semi-structured interview guide was used to elicit their perceptions of TB. A qualitative content analysis was performed on the recorded material from the interviews. The informants noted that their attitude towards individuals with TB had changed, previously they had felt prejudiced towards them whereas now they felt supportive. It seems possible to diminish TB stigma by ensuring suitable health care is available in combination with correct information about transmission, infectiousness and treatment.

Psychometric evaluation of the canine brief pain inventory in a Swedish sample of dogs with pain related to osteoarthritis.

BACKGROUND: To evaluate intervention, implement evidence-based practice and enhance the welfare of dogs with naturally occurring osteoarthritis (OA), access to valid, reliable and clinically relevant outcome measures is crucial for researchers, veterinarians and rehabilitation practitioners. The objectives of the present study were to translate and evaluate psychometric properties, in terms of internal consistency and construct validity, of the owner-reported measure canine brief pain inventory (CBPI) in a Swedish sample of dogs with pain related to OA. RESULTS: Twenty-one owners of clinically sound dogs and 58 owners of dogs with pain related to OA were included in this observational and cross-sectional study. After being translated according to the guidelines for patient-reported outcome measures, the CBPI was completed by the canine owners. Construct validity was assessed by confirmatory factor analysis, by repeating the principal component analysis and by assessing for differences between clinically sound dogs and dogs with pain related to OA. Internal consistency was estimated by Cronbach's α. Confirmatory factor analysis was not able to confirm the factor-structure models tested in our sample. Principal component analysis showed a two-component structure, pain severity and pain interference of function. Two components accounted for 76.8% of the total variance, suggesting an acceptable fit of a two-component structure. The ratings from the clinically sound dogs differed from OA dogs and showed significantly lower CBPI total sum. Cronbach's α was 0.94 for the total CBPI, 0.91 for the pain severity and 0.91 for the pain interference of function. CONCLUSIONS: The results indicate that the translated version of the CBPI is valid for use in the Swedish language. The findings suggest satisfying psychometric properties in terms of high internal consistencies and ability to discriminate clinically sound dogs from OA dogs. However, based on the confirmatory factor analysis, the original factor structure in the CBPI is not ideally suited to measure pain related to OA in our sample and the hypothesis of the presented two-factor structure was rejected. Further research needs to be conducted to determine whether the original psychometric results from CBPI can be replicated across different target groups and particularly with larger sample size.

Differences in Pes Planus and Pes Cavus subtalar eversion/inversion before and after prolonged running, using a two-dimensional digital analysis.

In sports, there is a constant discussion about the hyper-pronation and supination of the foot during loading and its relation to injuries or discomfort. The purpose of the present study was to investigate the possible differences in the subtalar joint in the midstance phase of running, between individuals with Pes Planus and Pes Cavus, after 5 min and 45 min of running. Thirty-four subjects, meeting the requirements for Pes Planus (30 feet) and Pes Cavus (35 feet), according to the criteria for Medial Longitudinal Arch-angle, were included in the study. The calcaneal vertical angle, representing the eversion/inversion of the subtalar joint, was measured using with two-dimensional digital analysis and Dartfish Software with the subjects running barefoot on a treadmill, before and after 45 min of outside running wearing shoes. Both individuals with Pes Cavus and Pes Planus showed a significant increase in the calcaneal eversion (P<0.05) after 45 min of running. Between the groups, there was a significantly greater eversion of the Pes Planus, on the right foot, after 45 min of running (P<0.05) compared to the Pes Cavus. The effect of fatigue evident in the present study suggests that further biomechanical research should be considered when exposing the foot to the repetitive nature of running, conditions most likely responsible for the overrepresented overuse injuries among runners.

Experiences of returning to elite beach volleyball after shoulder injury.

The purpose of this study was to examine beach volleyball players' experience regarding shoulder injury and how it affects their return to play. To achieve the research aims a qualitative design with semi-structured interviews had been conducted, five elite beach volleyball players, four men and one woman aged 27-42 participated in the study. All participants had suffered a severe shoulder injury, with absence from training and competing for at least 28 days. The findings of this study indicate that it is the individual's inner motivation, together with a clear goal and support from the community, family, teammate and coach that are the most important factors when going through rehabilitation and getting back to playing beach volleyball after a shoulder injury. All participants had been affected by their injury in some way; some of the participants had been affected in a positive way since they had become mentally stronger and had developed better volleyball technique after rehabilitation. The conclusions of this study indicate that there are three distinct factors that increase the chances of getting back to playing beach volleyball after shoulder injury; it is the players' self motivation, together with a clear goal and support from the community.

Comparison of Polar® RS800CX heart rate monitor and electrocardiogram for measuring inter-beat intervals in healthy dogs.

UNLABELLED: The aim of the present study was to assess the criterion validity, relative reliability and level of agreement of Polar® RS800CX heart rate monitor measuring inter-beat intervals (IBIs), compared to simultaneously recorded electrocardiogram (ECG) in dogs. METHODS: Five continuous minutes of simultaneously recorded IBIs from Polar® RS800CX and Cardiostore ECG in 11 adult healthy dogs maintaining standing position were analyzed. Polar® data was statistically compared to ECG data to assess for systematic differences between the methods. Three different methods for handling missing IBI data were used. Criterion validities were calculated by intraclass correlation coefficients (ICCs) and corresponding 95% confidence intervals (CIs). Relative reliabilities and levels of agreement were calculated by ICCs and the Bland and Altman analysis for repeated measurements per subject. RESULTS: Correlation coefficients between IBI data from ECG and Polar® RS800CX varied between 0.73 and 0.84 depending on how missing values were handled. Polar® was over- and underestimating IBI data compared to ECG. The mean difference in log transformed (base10) IBI data was 0.8%, and 93.2% of the values were within the limits of agreement. Internally excluding three subjects presenting IBI series containing more than 5% erroneous IBIs resulted in ICCs between 0.97 and 0.99. Bland and Altman analysis (n=8) showed mean difference was 1.8ms, and 98.5% of the IBI values were plotted inside limits of agreement. CONCLUSION: This study showed that Polar® systematically biased recorded IBI series and that it was fundamental to detect measurement errors. For Polar® RS800CX heart rate monitor to be used interchangeably to ECG, by showing excellent criterion validity and reliable IBI measures in group and individual samples, only less than 5% of artifacts could be accepted.

Rheumatoid arthritis patients' experience of climate care.

The purpose of this qualitative study was to understand and examine how patients with rheumatoid arthritis (RA) experience climate care and its effects. A qualitative approach was chosen for the study. Two men and six women were interviewed according to a semistructured interview guide. The text was analyzed using a manifest content analysis. The analysis resulted in four categories and 10 subcategories. The interviewees experienced climate care positively. The training was perceived increasing gradually. The patients felt that they performed to a maximum capacity during training and were impressed by the staff's enthusiasm and encouragement. The patients felt that they were involved in the goal setting and the choice of treatment, and the staff noticed individual needs. There was a feeling among the patients of being acknowledged by the staff. Information about the disease was perceived as individualized. The climate and beautiful surroundings were viewed as encouraging physical activity and a feeling of well-being. Patients made new friends, had fun together and also shared experiences about their disease. Furthermore, the patients described a sense of belonging to a group as well as a feeling of not being the only one that was sick among the healthy. Not having to do everyday tasks and having time to themselves were perceived positively. Several factors contributed to the positive experiences of climate care; climate, environment, physical activity, social context, staff involvement, and information about the disease were described as interacting together and resulting in a sense of well-being. A proposal for future research would be to examine if/how the various factors might interact and affect the RA patients' illness and quality of life.

Experiences of returning to elite alpine skiing after ACL injury and ACL reconstruction.

AIM: To explore the experiences of alpine skiing at the elite level after anterior cruciate ligament (ACL) injury and reconstruction. DESIGN: A qualitative approach where semi-structured interviews were conducted, and an analysis of the manifest content was performed. PARTICIPANTS: Five ski high school students, two male and three female skiers, who had suffered ACL injuries and undergone ACL reconstructions. RESULTS: Seven categories were identified. The participants described their perceived opportunities with regard to returning to alpine skiing after ACL injury and reconstruction as something positive to do with self-belief, being mentally and physically prepared, regaining confidence in their own ability, being given time and using active strategies. In contrast, perceived barriers to a return to elite alpine skiing gave rise to negative feelings, for example, fear, disheartenment, a total lack of or ambivalent confidence in their own ability and the use of passive strategies. CONCLUSION: The two male skiers returned to alpine skiing. They reported confidence in their own ability, active strategies and support on all levels, as well as enhanced physical ability. The female skiers did not return to their pre-injury level of competitive alpine skiing. They stated a lack of support on all levels, deterioration in their physical ability and two out of three reported passive strategies and no or ambivalent confidence in their own ability. The most important factors were family support, support on all levels, access to a physiotherapist and time given.

Validity and reliability of Polar® RS800CX heart rate monitor, measuring heart rate in dogs during standing position and at trot on a treadmill.

UNLABELLED: The aim of the present study was to assess criterion validity, and relative and absolute reliability of Polar® RS800CX heart rate monitor, compared to simultaneously recorded electrocardiogram (ECG) data, in measuring heart rate of dogs during standing position and at trot on a treadmill. METHODS: Heart beats from Polar® RS800CX and Cardiostore ECG were recorded simultaneously during seven continuous minutes in standing position and at trot, in 10 adult healthy dogs. Polar® data was statistically compared to ECG data for a variety of mean beats per minute (BPM), standard deviation and confidence interval. Criterion validity was calculated by Pearson product moment correlation method and intraclass correlation coefficient (ICC2.1). Relative and absolute reliability were calculated by ICC2.1, the Bland and Altman analysis and standard error of measurement (SEM and SEM%). RESULTS: The correlation, criterion validity, between Polar® and ECG data in standing position was r=0.99 (p<0.0005) and at trot r=0.97 (p<0.0005). Polar® data was not significantly different from ECG data. Mean difference between ECG and uncorrected Polar® data was -0.6 BPM in standing position and -0.6 BPM at trot. Polar® was over- and underestimating ECG data. SEM and SEM% in standing were ±2.6 BPM and 3.0%, at trot ±3.8 BPM and 3.1%, indicating that measurement errors were low. CONCLUSION: This study showed that the criterion validity and the instrument reliability were excellent in Polar® RS800CX heart rate measuring system. The equipment seemed to be valid and reliable in measuring BPM in the dogs studied during submaximal cardiovascular conditions such as in standing position and at trot on a treadmill.

Evaluation of a multidisciplinary rehabilitation program with emphasis on musculoskeletal disorders: a 5-year follow-up.

OBJECTIVE: The aim of this study was to perform a 5-year follow-up of a 7-week multidisciplinary rehabilitation program focusing on pain, physical disability, anxiety and depression as well as stress and sick leave and to compare the results from the baseline, a 2-year follow-up and this 5-year follow-up. PARTICIPANTS: Out of 60 participants of the original rehabilitation program 54 were followed-up after 5 years. METHODS: The rehabilitation program was individually adapted and consisted of physical activity in several forms as well as theoretical and practical education. At baseline (start of study) and 2 and 5 years after completion of the rehabilitation program all participants were evaluated in terms of sick leave, pain rating (Visual Analogue Scale), the Disability Rating Index, Hospital Anxiety and Depression Scale, and Stress Test. RESULTS: Between the start of the program and the 5-year follow-up pain rating (P< 0.017) and the rate of full-time sick leave (P< 0.0005) decreased. Physical disability, anxiety, depression and stress were maintained from the 2-year follow-up until the 5-year follow-up. CONCLUSIONS: The rehabilitation program seemed to have had an effect on the participant's ability to manage with symptoms long after the end of the rehabilitation program. Most participants had returned to work, and reported less pain. The improvements made in physical disability and mental health prior to the 2-year follow-up were maintained at the 5-year follow-up occasion.

Back to work: evaluation of a multidisciplinary rehabilitation program with emphasis on mental symptoms; A two-year follow up.

BACKGROUND: The aim of this investigation was to analyze temporal changes in anxiety, depression, and stress in patients with musculoskeletal pain for a period of up to 2 years after a multidisciplinary rehabilitation program, in relation to sick-listing (registered with The Swedish Social Insurance Agency [Forsakringskassan] for sickness benefit). METHODS: Ten persons with full-time sick leave (absence from work for medical reasons) (group 1) and 49 with part-time or no sick leave (group 2) at the end of the 2-year study period participated. It was shown in a previous study that group 1 had higher pain rating and higher subjective physical disability than group 2, with little or no improvement during and after rehabilitation. In the present study, all participants were evaluated with the Hospital Anxiety and Depression scale and a self-rated stress test. RESULTS: Participants with full-time sick leave during the study period (group 1) showed improved stress levels but no change in anxiety and depression levels. Anxiety, depression, and stress changed more favorably in participants with part-time or no sick leave than in those with full-time sick leave. CONCLUSION: The results of this study indicate that investigation and appropriate treatment of psychological symptoms, including anxiety and depression, are important in multidisciplinary rehabilitation of patients with musculoskeletal disorders.

Barriers to and possibilities of returning to work after a multidisciplinary rehabilitation programme. A qualitative interview study.

OBJECTIVE: The aim of this qualitative study was to explore experiences of sick-listed persons of not returning to work during a six-year period after participation in an extensive multidisciplinary rehabilitation programme. PARTICIPANTS: The study comprised ten participants with musculoskeletal disorders, mainly neck and back pain. METHODS: Semi-structured interviews were conducted and analysed by manifest content analysis. RESULTS: This led to identification of three primary categories and six sub-categories, which described the participants' experiences of barriers to and possibilities of returning to work, and indicated what strategies they used to cope with everyday life. The participants described that the main barriers to returning to work were pain and somatic symptoms, fatigue, and not fulfilling the work requirements. Participants considered physical activity a key factor in coping with pain. Most participants thought that they had residual work ability, and could utilise this if they could get a modified job adapted to their own capacity. CONCLUSIONS: Our study highlights the importance of utilising residual working ability at workplaces. Finding flexible work possibilities requires an understanding and supportive attitude on the part of both the employer and the social insurance office.

Two-year outcome of a multidisciplinary vocational rehabilitation programme focused on range of motion of the neck and back.

PURPOSE: To investigate whether improvement of range of motion (ROM) in persons with musculoskeletal disorders, mainly neck and back pain, was associated with a favourable development regarding physical disability, pain, and health-related quality of life (QoL), and whether such development differed between sick-listed and non-sick-listed persons during and up to 2 years after a multidisciplinary rehabilitation programme. METHODS: Ten persons with full-time sick leave (Group I) and 49 with part-time or no sick leave (Group II) at the end of a previous study participated. It was shown in that study that Group I had higher pain rating and higher subjective physical disability than Group II, with little or no improvement during and after rehabilitation. In the present study, all participants were evaluated with neck and back mobility tests: Disability Rating Index (DRI); Pain Intensity Rating on a visual analogue scale (VAS); and Global Self-Efficacy Index (GSI). RESULTS: Cervical and thoracolumbar spine ROM were lower in Group I than in Group II from the start of rehabilitation to a 2-year follow-up. Only Group II showed a temporal improvement in ROM. No changes in DRI, VAS or GSI were found in parallel with corresponding temporal changes in any of the ROM. CONCLUSION: Group II but not Group I improved in active ROM during rehabilitation; further, in Group I active ROM in the cervical and thoracolumbar spine did not improve during the 2-year follow-up. Improvement of ROM showed no correlation with physical disability, pain or QoL.

Back to work - a two-year outcome of a multidisciplinary rehabilitation programme focused on physical function and pain.

PURPOSE: To analyze why some responded positively to rehabilitation and why some did not. METHOD: Sixty participants with musculoskeletal disorders, mainly neck and back pain participated in a 7-week rehabilitation programme which was based on a combination of theoretical and practical education and physical activities. Before and after the programme and 6, 12 and 24 months after completion of the programme all participants were evaluated with the Disability Rating Index (DRI) and Pain Intensity Rating on a Visual analogue scale (VAS). RESULTS: In the participants who had full-time sick leave from the start of the programme to the 2-year follow-up (Group I) self-experienced physical disability and pain ratings were high and showed no decrease and were maintained up until the 2-year follow-up. For the participants who had part-time sick leave or no sick leave (Group II) physical disability and pain ratings were initially lower than in Group I and decreased gradually, (p < 0.01) and (p < 0.05), respectively throughout the 2-year follow-up period. CONCLUSION: Participants in Group I did not benefit from the rehabilitation programme and did not show improvement in their physical disability and pain rating. Group II showed decreased physical disability and pain rating. The decrease was gradual and was maintained up until the 2-year follow-up period. These results may indicate that persons with musculoskeletal pain with severe disability and pain require other rehabilitation programmes than those with moderate symptoms. This research has highlighted the need for development of such programmes.