! "# $%!!&"#! ' ( ) ( (''( * ""#!% ! "#$ % $ $& ' $ ()* + ,+ ) # - . /0 ', 1 %2 () 3 ,) !)4 - +& & )5 $ + 0) "66) ) #- ),57"86" 99!6"9) & % % % : $ $ % $ )& % $ $$ $ + : $$ $ % $ + % + ; )* + + % $ + $ $ % $ % 0 % ; % ) , $ 0 % $ $ % + ) * + $ $ 0$ % ) % )< % $ ; % + % % % %) 5 % % + + + $ $ + % )* % $ + $$ $ $$ $ )* $ + +%$ % $ %$ ) = % % + % % + % % )* % %+ + $ 0 % ) 0 % $ $ + + ) *$ %%% $ $ % % ) !"#$ %&"'()*+*,- >, 3 ! ,,7 ?9 ?? ,57"86" 99!6"9 # ### "98' #@@ )0)@ A B # ### "98( To Hanna, Max and Ellen List of Papers This thesis is based on the following papers, referred to in the text by their Roman numerals: I Holm S, Ljungman G, Söderlund A. Pain in children and adolescents in primary care; chronic and recurrent pain is common. Acta Paediatrica. 2012; 101:1246-5. II Holm S, Ljungman G, Åsenlof P, Söderlund A. How children and ado- lescents in primary care cope with pain and the biopsychosocial factors that correlate with pain-related disability. Acta Paediatrica. 2013; 102:1021-6. III Holm S, Ljungman G, Åsenlöf P, Linton S, Söderlund A. Treating youth in pain: A randomized controlled feasibility trial of a behavioral medi- cine approach in primary care. In manuscript IV Holm S, Åsenlöf P, Ljungman G, Söderlund A. Feasibility of a tailored behavioral medicine intervention for adolescents with persistent pain – the views of adolescents, parents and physical therapists. In manuscript Reprints were made with permission from the publisher. Cover: Maria Eklöw Bosaeus Contents Introduction .............................................................................................. 11 The behavioral medicine perspective ....................................................... 11 Pain in childhood and adolescence ........................................................... 13 Coping with pain ...................................................................................... 15 Pain-related fear ........................................................................................ 17 Self-efficacy .............................................................................................. 17 Parental behavior and children’s pain ...................................................... 18 Pain-related disability ............................................................................... 19 School attendance ..................................................................................... 20 Health-related quality of life ..................................................................... 20 Physical therapy treatment ........................................................................ 21 Behavioral medicine treatment within a physical therapy framework ..... 21 The rationale for this thesis ...................................................................... 22 Aims .............................................................................................................. 23 Methods ......................................................................................................... 24 Settings and recruitment procedure .......................................................... 24 Participants ........................................................................................... 25 Data collection procedures ....................................................................... 28 Description of the interventions in Study III ............................................ 28 Measurements ........................................................................................... 32 Children and adolescents ..................................................................... 32 Pain location ......................................................................................... 33 Pain duration ........................................................................................ 33 Pain intensity ........................................................................................ 33 Pain-related disability .......................................................................... 33 School attendance ................................................................................ 34 Health-related quality of life ................................................................ 34 Coping with pain .................................................................................. 34 Pain catastrophizing ............................................................................. 35 Depression/sadness .............................................................................. 35 Fear of movement ................................................................................ 36 Self-efficacy ......................................................................................... 36 Treatment satisfaction .......................................................................... 36 Parents ................................................................................................. 36 Studies I and II ..................................................................................... 36 Study IV ............................................................................................... 37 Physical therapists ............................................................................... 37 Data management and analyses ................................................................ 37 Ethical approval ........................................................................................ 41 Results ........................................................................................................... 42 Pain conditions in children and adolescents admitted to primary care PT ......................................................................................................... 42 Pain-related disabilities ........................................................................ 42 Health-Related Quality of Life ............................................................ 43 Pain coping strategies .......................................................................... 44 Feasibility of the tailored behavioral medicine treatment .................... 46 Discussion ..................................................................................................... 52 Summary of results .............................................................................. 52 Pain, pain-related disability and health-related quality of life ............. 53 Psychosocial factors and pain .............................................................. 55 The behavioral medicine treatment for adolescents with pain ............. 57 Methodological considerations ............................................................ 59 External validity and transferability ..................................................... 63 Conclusions ................................................................................................... 64 Clinical implications for primary care pain treatment of children and adolescents ........................................................................................... 65 Future research ..................................................................................... 65 Svensk sammanfattning (Swedish summary) ............................................... 66 Acknowledgements ....................................................................................... 68 References ..................................................................................................... 71 Appendix 1 The Behavior medicine treatment ......................................... 88 Appendix 2 The control treatment ............................................................ 94 Abbreviations AUC Area under the receiver operating characteristics curve BMT Behavioral medicine treatment CDI The Children’s Depression Inventory CT Control treatment FBA Functional behavior analysis FDI Functional Disability Inventory HRQoL Health-related quality of life IQR Interquartile range NRS Numerical rating scale PCQ Pain Coping Questionnaire PCS-C The Pain Catastrophizing Scale-Child version PRD Pain-related disability PT Physical therapy PTs Physical therapists RCT Randomized controlled trial TSK-C Tampa Scale of Kinesiophobia for Children SCT Social cognitive theory SEDA Self-Efficacy for Daily Activities SD Standard deviation Introduction The clinical work in pediatric physical therapy provided me with an im- portant insight: There were many children and adolescents with pain de- manding assistance for their pain condition. I was not satisfied with the treatment outcomes, and quite a few patients returned for more physical therapy after some time had elapsed. I felt strongly that there was more to address than a child’s physical problem and studying the pain literature helped me only partly. The literature on PT interventions targeting chil- dren and adolescents with pain in primary care