Patients with chronic pain are generally thought to be physically unfit and less active. Hence, physical reconditioning programs are traditionally proposed to such patients as part of their comprehensive rehabilitation program. Traditional physical fitness evaluation is often implemented in patients with low-back pain. However, most methods have not been validated in that context. We recall and discuss earliest findings in the field of physical fitness tests in patients with low-back pain. Maximal physical tests can be reliable when testing conditions are well defined, standardized and controlled. Reliability, however, does not imply validity. Maximal physical tests as applied to patients with pain should indeed be considered as multidimensional since performance to such tests is often limited by psychological factors as fear-avoidance. Hence, maximal physical tests do not allow valid evaluation of physical fitness in most patients with pain. To obtain valid unidimensional fitness assessment in such patients, submaximal testing should be preferred, which is only possible for cardiorespiratory endurance and body composition assessment. We present our personal contribution to the field. Most of this contribution can be found in 7 previously published papers that are included in our manuscript: • Nielens, H. and L. Plaghki. Evaluation of physical adaptation to exercise of chronic pain patients by a step-test procedure. The Pain Clinic. 1:21-28, 1991 • Nielens, H. and L. Plaghki. Perception of pain and exertion during exercise on a cycle ergometer in chronic pain patients. Clin J Pain. 10:204-209, 1994 • Nielens, H., V. Boisset, and E. Masquelier. Fitness and perceived exertion in patients with fibromyalgia syndrome. Clin J Pain. 16:209-213, 2000 • Nielens, H., T. M. Lejeune, A. Lalaoui, J. P. Squifflet, Y. Pirson, and E. Goffin. Increase of physical activity level after successful renal transplantation: a 5 year follow-up study. Nephrol Dial Transplant. 16:134-140, 2001 • Nielens, H. and E. Masquelier. The role of exercise in the treatment of fibromyalgia: An overview. Int Sportmed J. 2:1-8, 2001 • Nielens, H. and L. Plaghki. Cardiorespiratory fitness, physical activity level, and chronic pain: are men more affected than women? Clin J Pain. 17:129-137, 2001 • Nielens, H., D. Cornet, and F. Rigot. Maximal versus submaximal testing protocols to evaluate fitness of patients with chronic low back pain; abstract. Med Sci Sports Exerc. 34, 2002 We developed an original submaximal cycle ergometer test that allows calculation of an original Physical Working Capacity index, the PWC65%/kg and an original Rate of Perceived Exertion index, the RPE65%. We evaluated the reliability and the validity of the PWC65%/kg as a cardiorespiratory endurance index. We also present and discuss our results obtained in chronic pain patients with those indexes. Clearly, male patients with severe chronic pain are more affected than females in terms of physical fitness and activity, probably due to socio-cultural factors. Exertion perception of most patients with low-back pain and/or sciatica seems normal. However, females with fibromyalgia present with a very significant distortion of exertion perception. Physical reconditioning combined with education seems helpful in most patients with chronic pain directly through fitness improvement but also through the major cognitive change it contributes to generate.

This thesis deals with a behavioural medicine approach to the management of patients with persistent musculoskeletal pain in primary health care physical therapy. The main aims of the thesis were; to develop, and evaluate the psychometric properties of, a screening instrument for risk of disability and; to evaluate the implementation and effects of a targeted and tailored treatment. The studies comprise four samples of patients with musculoskeletal pain exceeding one month. All subjects were recruited when consulting physical therapists in Swedish primary health care settings. For development and evaluation of the Pain Belief Screening Instrument (PBSI) four samples were used; two samples (n1 = 215 and n2 = 93) in Study I, one sample (n = 168) in Study II, and one sample (n = 45) in Study III. For evaluation of implementation and effects of targeted and tailored treatment the 32 patients who completed treatment in Study III were used. In Study IV treatment documents of 18 patient cases from Study III were studied to evaluate treatment integrity. The concurrent and predictive validity of the PBSI was good, and the instrument was therefore used to define subgroups with either a high or low risk for disability. A low treatment dosage of a tailored treatment for low risk patients was tried and found equally efficient as a longer treatment focusing physical exercise. Subjects who received a treatment tailored to individual patient characteristics perceived a better global outcome of treatment compared to subjects in the control group. However, no between-group differences in the disability measures were found. The evaluation of treatment integrity displayed low therapist adherence to the treatment rationale for the tailored treatment. The studies demonstrate ways to systematically integrate a behavioural medicine approach and physical therapy. The results indicate efficiency in managing patients with persistent musculoskeletal pain in primary health care.

The principal aim of the present thesis was to prospectively follow (clinical status and ultrasound + Doppler findings) the patellar tendons in the young elite volleyball players at the Swedish National Centre for high school volleyball in Falköping. In an Olympic weightlifter with chronic painful jumper´s knee, the effects of treatment with sclerosing injections followed by early instituted very heavy weightlifting training, was also evaluated. First, in a prevalence study, we demonstrated that the clinical diagnosis patellar tendinopathy-jumper’s knee, together with structural tendon changes and vascularisation in the painful area of the tendon, was demonstrated in 12/114 tendons in Swedish junior elite volleyball players, but not in any tendons of individually matched (age, height and weight) not regularly sports active controls. Structural tendon changes alone was demonstrated among the volleyball players but also among the controls. In a 7 months prospective study of a total of 120 tendons, we demonstrated that the clinical diagnosis patellar tendinopathy-jumper’s knee was associated with neovessels/vascularity in the area with structural tendon changes in 17/19 tendons. Seventy tendons that at start were clinically normal, and had normal ultrasound + Doppler findings, remained clinically normal after 7 months with intensive training and playing volleyball. In a 3-year prospective study it was demonstrated that normal clinical tests and normal ultrasound + Doppler findings at school start, indicated a low risk (8%) for these players to sustain patellar tendinopathy-jumper’s knee during the 3 school years with intensive training and playing. In a case study, involving an Olympic elite weightlifter with chronic painful patellar tendinopathy-jumper’s knee, successful treatment with ultrasound and Doppler-guided injection of the sclerosing agent polidocanol, allowed for pain-free very heavy weight training two weeks after treatment. Further heavy weightlifting training on a daily basis, preparing for European Championships, was done without causing tendon rupture and/or pain. Key words: Jumper’s knee, Patellar tendinopathy, Chronic pain, Ultrasonography, Doppler, Neovascularisation, Volleyball, Weightlifting

There are numerous indications of possible involvement of the autonomic nervous system in the genesis of chronic pain. The possibility exists that sympathetic activation is related to motor dysfunction and changes in sensory processing, which have otherwise been implicated in musculoskeletal disorders. The primary aim of the thesis has been to investigate autonomic regulation at rest and in response to laboratory tests of autonomic function in subjects suffering from chronic pain in different localisations (lower back, neck-shoulder and neck-jaw), as well as to study the relations between autonomic regulation, proprioceptive acuity and clinical data. Secondary aim has been to assess autonomic regulation in fit, pain-free subjects in response to experimentally induced pain and in occupationally relevant settings. A total of 194 subjects suffering from chronic pain participated [low back pain (LBP) n=93; non-traumatic neck pain (NT) n=40, Whiplash associated disorder (WAD) n=40, Whiplash with temporomandibular dysfunction (WADj) n=21]. Each chronic pain group was subjected to a battery of autonomic function tests combining cognitive (Stroop Colour-Word conflict tests), physical (handgrip), sensory (unpleasant sound) and motor tasks (chewing tests) as well as the activation of reflex pathways (paced breathing and the orthostatic test) and compared to an age- and gender balanced control group. Autonomic regulation was also assessed in exposure to experimentally induced muscle pain in healthy subjects (n=24) in order to describe acute pain reaction. Further assessment was carried out during monotonous repetitive work and dynamic work in healthy subjects (n=10) and in a three-day monitoring of ambulance personnel (n=26) in occupational settings. Autonomic regulation was evaluated using cardiovascular (heart rate and heart rate variability, local blood flow and blood pressure), respiratory (breathing rate) electrodermal (skin conductance), muscular (trapezius and masseter EMG) and biochemical (insulin, cortisol, catecholamines) variables. Proprioceptive acuity was assessed using active-active repositioning tests. Pain levels were assessed using Visual-analogue or Numerical Rating scales. General health was evaluated through the Short-Form SF-36 Health Related Quality of Life questionnaire and Self-Efficacy Score questionnaires, whereas dysfunction was evaluated using the Oswestry Low Back Pain questionnaire, Pain Disability and Neck Disability Index questionnaires, the McKenzie evaluation and primary healthcare diagnoses. Self-reports of pain, stress and exertion were acquired prior to, during and post-testing. Chronic pain subjects were characterised by increased sympathetic and decreased parasympathetic activity as reflected in heart rate (LBP, WAD, WADj), heart rate variability (LBP, WAD, WADj), blood pressure (WADj) and electrodermal activity (LBP). In general, WAD showed more pain and dysfunction than NT, with lower self-efficacy and health-related quality of life. Differential reactivity was observed only in WAD, with increased responsiveness to sensory stimuli (heart rate variability, electrodermal activity), and motor tasks (heart rate) and a decreased response to cognitive challenge (heart rate variability, electrodermal activity). A significant part of WADj subjects showed sensorimotor impairment and low endurance in chewing tests, concomitant with a cardiovascular response that correlated with pain levels. Proprioceptive acuity was not found to be impaired among subjects suffering from chronic pain, and there were no indications of significant individual response specificity. Response to experimentally induced muscle pain in healthy subjects was also characterised by a prominent cardiovascular component. In simulated occupational settings autonomic activation and transient insulin resistance were detected in healthy subjects following monotonous repetitive work, with no similar effects following dynamic exercise. Modest deviations in circadian heart rate variability patterns during workdays were detected in ambulance personnel reporting more pronounced musculoskeletal symptoms, with no such effects on work-free days. Autonomic balance observed in chronic pain subjects was characterised by a trend towards increased sympathetic activity in comparison with pain-free controls. Moderate signs of affected reactivity to autonomic function tests were observed in patients with WAD, however no specific reaction patterns have been observed in any chronic pain group. Correspondence between the intensity of pain and autonomic activity was observed in acute pain and in chronic pain groups characterised by higher pain levels. As indicated by autonomic and neurohormonal changes in the recovery from real and simulated work, further studies with physiological monitoring of the effects of work-related stress are warranted for better understanding of the mechanism of musculoskeletal disorders.

Inguinal hernia repair is the most common operation in general surgery. Its main challenge is to achieve low recurrence rates. With the introduction of mesh implants, first in open and later in laparoscopic repair, recurrence rates have decreased substantially. Therefore, the focus has been shifted from clinical outcome, such as recurrence, towards patient-experienced endpoints, such as chronic pain. In order to compare the results of open and laparoscopic hernia repair, a randomised multicentre trial - the Swedish Multicentre trial of Inguinal hernia repair by Laparoscopy (SMIL) - was designed by a study group from 11 hospitals. Between November 1996 and August 2000, 1512 men aged 30-70 years with a primary inguinal hernia were randomised to either laparoscopic (TEP, Totally ExtraPeritoneal) or open (Lichtenstein) repair. The primary endpoint was recurrence at five years. Secondary endpoints were short-term results, frequency of chronic pain and a cost analysis including complications and recurrences up to five years after surgery. In total, 1370 patients, 665 in the TEP and 705 in the Lichtenstein group, underwent operation. With 94% of operated patients available for follow-up after 5.1 years, the recurrence rate was 3.5% in the TEP and 1.2% in the Lichtenstein group. Postoperative pain was lower in the TEP group up to 12 weeks after operation, resulting in five days less sick leave and 11 days shorter time to full recovery. Patients in the TEP group had a slightly increased risk of major complications. Chronic pain was reported by 9-11% of patients in the TEP and 19-25% in the Lichtenstein group at the different follow-up points. Hospital costs for TEP were higher than for Lichtenstein, while community costs were lower due to shorter sick leave. By avoiding disposable laparoscopic equipment, the cost for TEP would be almost equal compared with Lichtenstein. In conclusion, both TEP and Lichtenstein repair have advantages and disadvantages for the patient. Depending on local resources and expertise both methods can be used and recommended for primary inguinal hernia repair.

Sammanfattning Fibromyalgi har betraktats ända framtill våra dagar som en ren psykosomatisk sjukdom som uppkom utan känd orsak. Sjukdomen innebar en ständig smärta och en oändlig trötthet/ utmattning. Det fanns ingen behandling för sjukdomen bara lindra symtomen. Syftet med denna litteraturstudie var att beskriva hur kvinnor med fibromyalgi upplevde sin livssituation. Metoden som användes var en litteraturstudie med beskrivande design. Artiklarna kvalitetsbedömdes, innehållet sammanställdes och resulterade i fyra kategorier. Resultatet som rörde dem fysiska aspekterna av livssituation visade att smärta, trötthet/utmattning och sömnlöshet var vanligt förekommande symtom i kvinnornas vardag som påverkade deras livskvalitet. Symtomen hindrade dem från att leva ett aktivt liv samt delta i sociala aktiviteter. De psykiska aspekterna inom livssituationen visade att kvinnorna med fibromyalgi gav uttryck för en längtan efter det liv de levt innan sjukdomen och den förlorade identiteten. De sociala aspekterna visade att kvinnorna med fibromyalgi hade en önska att få spendera mer tid tillsammans med familjen. Sjukdomen hade också en negativ inverkan på förhållande och separationer var inte ovanligt. Arbetet prioriterades högt och arbetslivet uppskattades som stimulerande. Bristen på synliga symtom vid sjukdomen  gjorde att kvinnorna blev ifrågasatta av personer i omgivningen och sjukvårdspersonal. Under de existentiella aspekterna föll de positiva sidorna med sjukdomen in. Kvinnorna började reflektera över alla måsten och plikter i livet samt lärde sig att prioritera på ett bättre sätt. / Abstract Fibromyalgia has considered until to day as a psychosomatic disease that emerged without any known cause.The main symptoms are constant pain and an abnormal feeling of fatigue or exhaustion. There are no treatment for the illness it just alleviated the symptoms. The aim of this study was the describe how women with fibromyalgi experienced their life-situation.The method used was a literature study with a descriptive design. The articles were quality-tested, the content put together/compiled and resulting in four categories as follows.The result involving the physical aspects of life-situation showed that pain, tiredness and sleeplessness was commonly occurring symptoms in women´s daily life which affected their quality of life.The symptoms prevented women from living an active life and actively taking part in social activites. The psychological aspects of life-situation showed that women with fibromyalgia expressed a longing for the life they lived before the illness and the lost identity. The social aspects showed that the women wished to spend more time with their families. The disease had negative effects on their relationships and separation was not unusual. Work was highly prioritised and estimated as stimulating. The deficiency on visible symptoms of the disease made that the women became questioned by persons in their environment and by health-personal. The positive sides of the disease was found in the existential aspects. The women started to reflect about their duties in life and learned how to prioritise on a better way.

Syfte - Syftet med studien var att utifrån litteraturen beskriva hur patienter med långvarig smärta upplever och vill bli bemötta inom sjukvården samt vilken kvalitet de till studien valda artiklarna hade rörande urval. Metod – 13 artiklar rörande patienter med långvarig smärta sammanställdes i en litteraturstudie. Artiklarna söktes i Pubmed samt Cinahl. Huvudresultat – I resultatet framkom det att patienter upplever både positiva och negativa upplevelser gällande bemötande i vården. Negativa upplevelser som beskrevs var exempelvis att personalen inte lyssnade på patienterna samt att de kände sig misstrodda. Patienterna beskrev positiva upplevelser när personalen tog sig tid till att lyssna och skapa en förståelse. Patienterna upplevde och önskade att det kunde möjliggöra ett ökat samarbete mellan personal och patient så att en ökad förståelse för patienternas smärta kunde skapas. Slutsats – Det förekom både positiva och negativa upplevelser hos patienter med långvarig smärta av bemötande inom vården. För att sträva mot positiva upplevelser krävs ett samarbete samt att alla parter blir accepterade som en del av vården. Personalen behöver mer utbildning och riktlinjer för att kunna hantera smärta hos patienter. Studien visar på viktiga aspekter gällande bemötande som kan öka förståelsen för patienter med långvarig smärta.

STUDY OBJECTIVE: To explore individual and social factors that could predict health care utilisation and medication among people with chronic pain in an unselected population. DESIGN: A mailed survey with questions about pain and mental symptoms, disability, self care action, visits to health care providers, and medication. SETTING: General populations in two Swedish primary health care (PHC) districts. Medical care was given in a state health system. PARTICIPANTS: A random sample (from the population register) of 15% of the population aged 25-74 (n = 1806). MAIN RESULTS: Among people reporting chronic pain 45.7% (compared with 29.8 of non-chronic pain persons, p < 0.05) consulted a physician and 7.2% (compared with 1.2%, p < 0.05) a physiotherapist during three months. Primary health care was the most frequent care provider. High pain intensity, aging, depression, ethnicity, and socioeconomic level had the greatest impact on physician consultations. Alternative care, used by 5.9%, was associated with high pain intensity and self care. Use of self care was influenced by high pain intensity, regular physical activity, and ethnicity. Alternative care and self care did not imply lower use of conventional health care. Women reporting chronic pain consumed more analgesics and sedatives than corresponding men. Besides female gender, high pain intensity, insomnia, physician consultation, social network, and self care action helped to explain medication with analgesics. Use of herbal remedies and ointments correlated to self care action, visit to an alternative therapist, high pain intensity, and socioeconomic level. CONCLUSIONS: The presence of chronic pain has an impressive impact on primary health care and medication. Various therapeutic actions are common and are partly overlapping. The use of health care among people with chronic pain depends above all on pain perception and intensity of pain but is also affected by ethnicity, age, socioeconomic level, and depressive symptoms. Among people with chronic pain use of analgesics is common in contrast with other types of pain relief (acupuncture, physiotherapy) suitable for treating chronic pain symptoms.

Aim: The aim of this study was to highlighting the experiences of individuals of non-pharmacological treatment for chronic pain. Method: The study was designed as a literature review with aim to review and compile the articles results. This study has been based on a systematic literature search of supplementing out of an unsystematic search were 11 articles were found. Results: The participants in the studies had experienced a good effect out of non-pharmacological treatments for their pain and a improved quality of life. Based on participants´ experiences of treatment two categories occurred: body awareness and relaxation. Body awareness arose through treatments like yoga, mindfulness meditation and CBT. Relaxation occurred through treatments, like music, heat, massage and meditation. Conclusion: This study highlights how non-pharmacological treatments is experienced by individuals with chronic pain and two key areas have been identified. This study thereby contributes with important knowledge for nurses in their nursing with individuals suffering from chronic pain.

Bakgrund: Långvarig smärta är en subjektiv upplevelse som förkommer hos mellan 40 till 50 procent av den svenska befolkningen. Den kroppsliga förändringen som smärtan innebär påverkar identiteten, kontakten med världen och med andra människor. Att hantera smärtan och livssituationen är en utmaning som olika människor hanterar på olika sätt. Bristen på objektiva tecken bidrar till att stigmatisering av patienter med långvarig smärta förekommer såväl i privata relationer som i vårdrelationer. Syfte: Syftet med denna litteraturstudie är att beskriva hur patienter med långvarig smärta upplever och hanterar sin livssituation. Metod: För denna litteraturöversikt har elva vetenskapliga, kvalitativa artiklar analyserats. Artiklarna har relevans för syftet. Efter genomläsning med fokus på respektive studies resultatdel identifierades nyckelfynd. Likheter och skillnader mellan studierna identifierades och dessa fick utgöra nya teman och kategorier i resultatet i denna litteraturöversikt. Resultat: Resultatet presenteras i form av tre teman; upplevelser av den förändrade kroppen, hantering av en förändrad livssituation och smärta som en subjektiv, osynlig upplevelse. Att leva med långvarig smärta innebär inte bara att upplevelsen av kroppen förändras utan även att tillgången till världen förändras. Resultatet visar olika sätt på vilka patienter upplever och förhåller sig till dessa förändringar. Då smärta är en subjektiv och osynlig upplevelse adderar detta ytterligare svårigheter i mötet med andra människor. Diskussion: Katie Erikssons ontologiska hälsomodell används som teoretisk utgångspunkt i diskussionen. Långvarig smärta hade förändrat livet för patienterna i vår studie. Att integrera denna förändring var en process som olika patienter handskades med på olika sätt. Långvarig smärta kan innebära ett mångdimensionellt lidande för patienter och att enbart fokusera på en kroppslig nivå är inte tillräckligt. Erikssons hälsomodell belyser även den själsliga och den andliga dimensionen. Det är avgörande att låta patienten berätta om sina upplevelser och sin situation för att identifiera de områden som är viktiga för patientens liv och hälsa.