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Chronic pain (> 3 months) is associated with balance impairments and risk of falls. This thesis explored how well the Mini-BESTest captures dynamic balance in patients with chronic pain referred to specialized pain care, focusing on ecological validity and patient perspectives informed by behavioral medicine. It also examined how physical, psychosocial, pharmacological, and behavioral factors relate to dynamic balance and perceived challenges in everyday life.

Specific aims: Studies I–II evaluated the Mini-BESTest’s validity, reliability, and patients’ perspectives on balance. Study III examined patient characteristics and opioid-related factors associated with balance, and Study IV explored characteristics linked to long-term and prescription opioid use disorder (P-OUD).

Methods: All studies included patients with chronic pain referred to specialized pain care. Study I (n = 180) assessed construct validity, and Study II (n = 53 + 15) assessed test-retest reliability and explored perceptions of balance through qualitative interviews. Studies III (n = 179) and IV (n = 339) analyzed dynamic balance and opioid use in relation to biopsychosocial characteristics using regression models.

Results: Studies I and II supported the Mini-BESTest’s construct validity, internal consistency, and test-retest reliability, but did not fully reflect patients’ perceptions of balance in everyday life. In Study III, poorer dynamic balance was associated with oxycodone use, older age, lower education, low pain self-efficacy, and low physical activity. In Study IV, long-term opioid use was linked to longer pain duration, unemployment, more catastrophizing, lower quality of life, and worse dynamic balance. P-OUD was associated with younger age, trauma exposure, catastrophizing, and fear of movement, but not with balance.

Conclusion: The Mini-BESTest is clinically relevant in specialized pain care, given its measurement properties and associations with opioid use and biopsychosocial factors influencing treatment outcomes. However, it does not fully capture balance as experienced in everyday life, leaving unmet needs in assessment and treatment. Based on findings from this thesis, a conceptual model grounded in behavioral medicine is introduced, emphasizing the need for multidimensional approaches reflecting patients’ everyday challenges and abilities to participate in meaningful activities. These findings underscore importance of integrating patient-reported experiences and contextual factors into balance assessment and treatment.