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  • 1. Grooten, Wilhelmus Johannes Andreas
    et al.
    Tseli, Elena
    Karolinska Institutet.
    Äng, Björn
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska institutet; Uppsala universitet.
    Boersma, Katja
    Stålnacke, Britt-Marie
    Gerdle, Björn
    Enthoven, Paul
    Elaborating on the assessment of the risk of bias in prognostic studies in pain rehabilitation using QUIPS-aspects of interrater agreement2019In: Diagnostic and Prognostic Research, ISSN 2397-7523, Vol. 3, article id 5Article in journal (Refereed)
    Abstract [en]

    Background: Many studies have been performed to identify important prognostic factors for outcomes after rehabilitation of patients with chronic pain, and there is a need to synthesize them through systematic review. In this process, it is important to assess the study quality and risk of bias. The "Quality In Prognosis Studies" (QUIPS) tool has been developed for this purpose and consists of several prompting items categorized into six domains, and each domain is judged on a three-grade scale (low, moderate or high risk of bias). The aim of the present study was to determine the interrater agreement of the risk of bias assessment in prognostic studies of patients with chronic pain using QUIPS and to elaborate on the use of this instrument.

    Methods: We performed a systematic review and a meta-analysis of prognostic factors for long-term outcomes after multidisciplinary rehabilitation in patients with chronic pain. Two researchers rated the risk of bias in 43 published papers in two rounds (15 and 28 papers, respectively). The interrater agreement and Cohen's quadratic weighted kappa coefficient (κ) and 95% confidence interval (95%CI) were calculated in all domains and separately for the first and second rounds.

    Results: The raters agreed in 61% of the domains (157 out of 258), with similar interrater agreement in the first (59%, 53/90) and second rounds (62%, 104/168). The overall weighted kappa coefficient (kappa for all domains and all papers) was weak: κ = 0.475 (95%CI = 0.358-0.601). A "minimal agreement" between the raters was found in the first round, κ = 0.323 (95%CI = 0.129-0.517), but increased to "weak agreement" in the second round, κ = 0.536 (95%CI = 0.390-0.682).

    Conclusion: Despite a relatively low interrater agreement, QUIPS proved to be a useful tool in assessing the risk of bias when performing a meta-analysis of prognostic studies in pain rehabilitation, since it demands of raters to discuss and investigate important aspects of study quality. Some items were particularly hard to differentiate in-between, and a learning phase was required to increase the interrater agreement. This paper highlights several aspects of the tool that should be kept in mind when rating the risk of bias in prognostic studies, and provides some suggestions on common pitfalls to avoid during this process.

    Trial registration: PROSPERO CRD42016025339; registered 05 February 2016.

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  • 2.
    Tseli, Elena
    Karolinska Institutet.
    Interdisciplinary rehabilitation in patients with chronic pain: prognostic factors and effectiveness2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Interdisciplinary multimodal pain rehabilitation (IMPR) is currently considered best practice for combatting chronic pain. However, it is believed that health-related outcomes could be improved with more adequately tailored treatment programs, but consensus of what grounds these adaptations should be based on is yet to be reached. Well-powered evaluations of naturalistic, real-world practices provide an evidence base for the evaluation of important characteristics that may facilitate the informed development of IMPR. The aim of the present work was to meta-synthesize existing evidence and add new data to the body of published evidence on prognostic factors for a positive outcome in patients receiving rehabilitation for chronic pain. An additional aim was to evaluate the effectiveness of different IMPR program durations on health-related quality of life in this major patient group.

    Methods: Published international evidence of prognostic factors for physical functioning after IMPR was evaluated through a systematic review and meta-analyses (Study I), followed by the investigation of the inter-rater reliability of the Quality in Prognostic Studies tool (QUIPS), used in the Risk of Bias assessment (Study II). Prognostic factors (Study III) and effectiveness (Study IV) of Swedish pain specialist IMPR on physical and mental functioning and related measures of disease impact were investigated using large-scale nationwide data obtained from the Swedish Quality Registry for Pain Rehabilitation.

    Results: Meta analyses showed, with moderate to low levels of evidence, that better physical functioning at follow-up was predicted by high levels of self-reported functioning, low levels of emotional distress and cognitive-behavioral risk factors, and high levels of cognitive- behavioral protective factors. Pain-related factors (intensity and chronicity) were not associated. Weak to moderate inter-rater agreement emerged for QUIPS, and suggestions for improving the inter-rater agreement and functionality were presented. Swedish registry data showed the most important prognostic factors were retaining a connection with work, having high optimistic treatment expectations, sense of control, and less interference from pain. Pain itself was of secondary significance. Also for improvement of physical functioning, better initial mental wellbeing was of importance, while for mental functioning the opposite emerged. Results on within-group effectiveness showed improvements on all outcomes, while no between-group comparison emerged on short (4-9 wks) vs. moderate (10 wks) vs. long (11-18 wks) IMPR program duration.

    In summary, evidence for prognostic factors was identified, providing suggestions for the targeting of modifiable factors in clinics and in future clinical trials. Clearly, the quality assessment of published results needs systematic consensus work between assessors. Work connection, treatment expectations, levels of physical and emotional health, and coping strategies played an important prognostic role but were not consistent for physical and emotional functioning, suggesting a complex prognostic picture for the overall understanding of improvement. Finally, IMPR is effective across a biopsychosocial specter, but treatment duration seems not to play an important role.

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  • 3.
    Tseli, Elena
    Karolinska institutet.
    Multidisciplinär rehabilitering vid långvarig smärta: Multidisciplinär rehabilitering vid långvarig smärta. Utvärdering av effekter och prognostiska faktorer2019Conference paper (Other academic)
  • 4.
    Tseli, Elena
    et al.
    Karolinska Institutet.
    Grooten, Wilhelmus Johannes Andreas
    Stålnacke, Britt-Marie
    Boersma, Katja
    Enthoven, Paul
    Gerdle, Björn
    Äng, Björn
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska institutet.
    Predictors of multidisciplinary rehabilitation outcomes in patients with chronic musculoskeletal pain: protocol for a systematic review and meta-analysis2017In: Systematic Reviews, E-ISSN 2046-4053, ISSN 2046-4053, Vol. 6, no 1, article id 199Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Chronic musculoskeletal pain is a major public health problem. Early prediction for optimal treatment results has received growing attention, but there is presently a lack of evidence regarding what information such proactive management should be based on. This study protocol, therefore, presents our planned systematic review and meta-analysis on important predictive factors for health and work-related outcomes following multidisciplinary rehabilitation (MDR) in patients with chronic musculoskeletal pain.

    METHODS: We aim to perform a synthesis of the available evidence together with a meta-analysis of published peer-reviewed original research that includes predictive factors preceding MDR. Included are prospective studies of adults with benign, chronic (> 3 months) musculoskeletal pain diagnoses who have taken part in MDR. In the studies, associations between personal and rehabilitation-based factors and the outcomes of interest are reported. Outcome domains are pain, physical functioning including health-related quality of life, and work ability with follow-ups of 6 months or more. We will use a broad, explorative approach to any presented predictive factors (demographic, symptoms-related, physical, psychosocial, work-related, and MDR-related) and these will be analyzed through (a) narrative synthesis for each outcome domain and (b) if sufficient studies are available, a quantitative synthesis in which variance-weighted pooled proportions will be computed using a random effects model for each outcome domain. The strength of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation.

    DISCUSSION: The strength of this systematic review is that it aims for a meta-analysis of prospective cohort or randomized controlled studies by performing an extensive search of multiple databases, using an explorative study approach to predictive factors, rather than building on single predictor impact on the outcome or on predefined hypotheses. In this way, an overview of factors central to MDR outcome can be made and will help strengthen the evidence base and inform a wide readership including health care practitioners and policymakers.

    SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016025339.

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  • 5.
    Tseli, Elena
    et al.
    Karolinska Institutet.
    Grooten, Wim
    Gerdle, Björn
    Lo Martire, Riccardo
    Karolinska Institutet.
    Äng, Björn
    Karolinska Institutet; Karolinska University Hospital; Center for Clinical Research Dalarna.
    Study Protocol: Multimodal rehabilitation in patients with chronic muskuloskeletal pain: a nationwide multicentre evaluation of effectiveness in routine care2015Conference paper (Refereed)
  • 6.
    Tseli, Elena
    et al.
    Karolinska Institutet.
    Stålnacke, B-M
    Boersma, K
    Enthoven, P
    Gerdle, Björn
    Äng, Björn
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska Institutet; Karolinska University Hospital.
    Grooten, Wim
    Predictors of multidisciplinary rehabilitation outcome in chronic musculoskeletal pain: a systematic review and meta-analysis, in process2017Conference paper (Refereed)
  • 7.
    Tseli, Elena
    et al.
    Karolinska Institutet.
    Stålnacke, Britt-Marie
    Boersma, Katja
    Enthoven, Paul
    Gerdle, Björn
    Äng, Björn
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska institutet; Center for Clinical Research Dalarna.
    Grooten, Wilhelmus Johannes Andreas
    Prognostic factors for physical functioning after multidisciplinary rehabilitation in patients with chronic musculoskeletal pain: a systematic review and meta-analysis2019In: The Clinical Journal of Pain, ISSN 0749-8047, E-ISSN 1536-5409, Vol. 35, no 2, p. 148-173Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: This systematic review aimed to identify and evaluate prognostic factors for long-term (≥6▒mo) physical functioning in patients with chronic musculoskeletal pain following multidisciplinary rehabilitation (MDR).

    METHODS: Electronic searches conducted in MEDLINE, PsycINFO, EMBASE, CINAHL, Web of Science, and Cochrane CENTRAL revealed 25 original research reports, published 1983-2016, (n=9436). Potential prognostic factors relating to initial pain and physical and psychological functioning were synthesized qualitatively and quantitatively in random effects meta-analyses. The level of evidence (LoE) was evaluated with GRADE.

    RESULTS: Pain related factors (intensity and chronicity) were not associated with function/disability at long-term follow up, OR=0.84, 95% CI: 0.65-1.07 and OR=0.97, 95% CI: 0.93-1.00 respectively (moderate LoE). A better function at follow up was predicted by Physical factors; higher levels of initial self-reported functioning, OR=1.07, 95% CI: 1.02-1.13 (low LoE), and Psychological factors; low initial levels of emotional distress, OR=0.77, 95% CI: 0.65-0.92, low levels of cognitive behavioural risk factors, OR 0.85, 95% CI: 0.77-0.93 and high levels of protective cognitive behavioural factors, OR=1.49; 95% CI: 1.17-1.90 (moderate LoE).

    DISCUSSION: While pain intensity and long-term chronicity did not predict physical functioning in chronic pain patients after MDR, poor pre-treatment physical and psychological functioning influenced the prognosis negatively. Thus, treatment should further target and optimize these modifiable factors and an increased focus on positive, psychological protective factors may perhaps provide an opening for yet untapped clinical gains.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/.

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  • 8.
    Tseli, Elena
    et al.
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska Institutet.
    Vixner, Linda
    Dalarna University, School of Education, Health and Social Studies, Medical Science.
    Lo Martire, Riccardo
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska Institutet.
    Grooten, Wilhelmus J A
    Gerdle, Björn
    Äng, Björn
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska Institutet; Center for Clinical Research Dalarna - Uppsala University, Falun.
    Prognostic factors for improved physical and emotional functioning one year after interdisciplinary rehabilitation in patients with chronic pain: Results from a national quality registry in Sweden2020In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 52, no 2, article id UNSP jrm00019Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate prognostic factors for physical and emotional functioning following interdisciplinary multimodal pain rehabilitation, by targeting patients' baseline characteristics and health measures.

    METHODS: A prospective cohort of 2,876 patients from 38 specialist clinics across Sweden, who were completing interdisciplinary multimodal pain rehabilitation programmes, was followed through the Swedish Quality Registry for Pain Rehabilitation, from initial assessment to 12-month follow-up. Using logistic regression, baseline data were regressed to predict improvement in Physical functioning and Emotional functioning, fused by principal component analyses using the 36-item Short Form Health Survey (SF-36) and the Hospital Anxiety and Depression Scale (HADS).

    RESULTS: Employment status emerged as having the largest effect sizes in both Physical functioning and Emotional functioning; Working: odds ratio (OR) 2.05 (95% confidence interval (95% CI) 1.64-2.56) and OR 1.59 (95% CI 1.27-1.98), respectively. Strong beliefs in restored health, better initial emotional health, lower levels of pain and pain interference, and younger age all predicted Physical functioning. European origin, higher levels of general activity, and sense of life control all predicted Emotional functioning. Worse initial physical and emotional health predicted the corresponding dependent outcomes.

    CONCLUSION: Employment was consistently found to be an important prognostic factor, suggesting the significance of avoiding delay in interdisciplinary multimodal pain rehabilitation. A positive treatment expectancy was of importance. In general, multidimensional measures indicated that better initial status was more favourable; however, inconsistency implies a complex prognostic picture.

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  • 9.
    Tseli, Elena
    et al.
    Karolinska Institutet.
    Vixner, Linda
    Dalarna University, School of Education, Health and Social Studies, Medical Science.
    Lo Martire, Riccardo
    Karolinska Institutet.
    Grooten, Wim
    Gerdle, Björn
    Äng, Björn
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska Institutet; Center for Clinical Research Dalarna - Uppsala University.
    Prognostic Factors for 12-month Outcome After Interdisciplinary Treatment in Patients with Chronic Pain: a Prospective Multicenter Cohort Study2019Conference paper (Refereed)
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  • Other style
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  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
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