published_or_final_version / Nursing Studies / Master / Master of Philosophy

Introduction: Chronic pain after whiplash trauma (chronic WAD) to the neck is still a common clinical problem in terms of pain management, rehabilitation and insurance claims. In contrast to the increased knowledge concerning mechanisms of chronic pain in general, no clinical guidelines exist concerning assessment, pain control and rehabilitation of patients with chronic WAD. Aim: The general aim of this thesis was to use experimental techniques to better understand the complex mechanisms underlying chronic pain after whiplash trauma. The specific aims of papers I and II were mainly to use analgesic drugs with different target mechanisms alone or in combinations to assess their effects on pain intensity (VAS). Experimental pain techniques were used in all studies to assess deep tissue sensitivity (electrical, mechanical and chemical stimuli). Paper IV aimed at assessing deep tissue sensitivity to mechanical and chemical stimulation. The aim in paper III was to investigate if biochemical changes in interstitial muscle tissue (trapezius muscle) could be detected in WAD patients. Materials and Methods: The thesis is based on three different groups of patients with chronic WAD. In paper III and IV two different groups of healthy controls also participated. All patients were initially assessed in the pain and rehabilitation centre. In paper I (30 patients) and II (20 patients) two different techniques of drug challenges were used. In paper I: morphine, ketamine and lidocaine were used as single drugs. In paper II: remifentanil, ketamine and placebo were used in combinations and together with experimental pain assessments. Microdialysis technique was used in paper III (22 patients from study IV and 20 controls). In paper IV (25 patients and 10 controls) a new quantitative method, computerized cuff pressure algometry, was used in combination with intramuscular saline. In all papers, experimental pain techniques for deep tissue assessment (except cutaneous electrical stimulation in paper I) were used in different combinations: intramuscular hypertonic saline infusion, intramuscular electrical stimulation and pressure algometry. Results and Conclusion: There are multiple mechanisms behind chronic whiplash-associated pain, opioid sensitive neurons, NMDA-receptors and even sodium channels might play a part. A significant share of the patients were pharmacological non-responders to analgesic drugs targeting the main afferent mechanisms involved in pain transmission, this implies activation of different pain processing mechanisms (i.e. enhanced facilitation or changes in the cortical and subcortical neuromatrix). Experimental pain assessments and drug challenges together indicate a state of central hyperexcitability. Ongoing peripheral nociception (paper III), central sensitization and dysregulation of pain from higher levels in the nervous system may interact. These findings are likely to be present early after a trauma, however it is not possible to say whether they are trauma-induced or actually represents pre-morbid variations. Clinical trials with early assessments of the somatosensory system (i.e., using experimental pain) and re-evaluations, early intervention (i.e. rehabilitation) and intensified pain management could give further knowledge.

Syfte och frågeställningar: Syftet med studien var att undersöka sambanden mellan rörelserädsla och olika aspekter av fysisk funktionsförmåga hos en grupp personer med långvarig smärta som genomgått multimodal rehabilitering. Studien utgick från tre frågeställningar som gäller: 1. Sambandet mellan rörelserädsla och fysisk funktionsförmåga före rehabilitering. 2. Om rörelserädsla före predicerar fysisk funktionsförmåga efter rehabilitering. 3. Rörelserädslans och den fysiska funktionsförmågans gemensamma bidrag till uppnådda resultat efter rehabilitering. Metod: Studien genomfördes som en korrelationsstudie med pretest-posttest gruppdesign och kvantitativ ansats. 38 personer, 6 män och 32 kvinnor, som genomgått multimodalrehabilitering ingick i studien. Data samlades in före och efter rehabiliteringsperioden med hjälp av väl beprövade självskattningsformulär och objektiva test. Rörelserädsla skattades med hjälp av Tampa Scale of Kinesiophobia. För fysisk funktionsförmåga användes delar ur Test Instrument for Profile of Physical Ability (TIPPA); bedömning av den egna fysiska funktionsförmågan, gångsträcka och snabbgång. Dessutom användes Multidimensional Pain Inventory för att skatta smärtans inverkan på aktivitet och smärtintensitet. Utifrån datans skalegenskaper gjordes icke parametiska sambandsanalyser. Resultat: De viktigaste resultaten från studien var att rörelserädsla före rehabiliteringen, utöver påverkan av skattningen av den egna fysiska funktionsförmågan, hade ett starkt samband med bedömningen av den egna förmågan efter rehabiliteringens avslut. Höga värden för rörelserädsla gav en sju gånger högre risk för låg bedömning av den egna förmågan efter rehabilitering. Dessutom visade resultaten att de patienter som har en kombination av hög rörelserädsla och låg bedömning av den egna fysiska funktionsförmågan före rehabilitering i mycket mindre grad uppnådde en bra funktionsförmåga efter rehabilitering, jämfört med patienter som enbart hade hög rörelserädsla eller låg bedömning av den egna förmågan. Utöver dessa resultat hade alla fysiska funktionsmått hämtade ur TIPPA ett samband med varandra. Däremot sågs inget samband mellan vare sig rörelserädsla eller fysisk funktionsförmåga och påverkan på aktivitet eller smärtintensitet. Slutsats: Resultaten tyder på att det är viktigt att sammanväga rörelserädsla och bedömningen av den egna fysiska funktionsförmågan för att hitta rätt fokus i, och rimliga mål för, rehabiliteringen. Kort sagt understryker resultaten att det är viktigt att individuellt anpassa rehabiliteringsinsatser efter patientens unika svårigheter. / Aim: The aim of this study was to investigate the correlations between kinesiophobia and different aspects of physical ability in a group of persons with longstanding pain who participated in interdisciplinary rehabilitation. This study answered three questions dealing with: 1. The correlation between kinesiophobia and physical ability before the rehabilitation. 2. If kinesiophobia before predicts physical ability after rehabilitation. 3. The joint contribution between kinesiophobia and physical ability to achieved results after rehabilitation. Method: This study was carried out as a correlational pretest-posttest group design with quantitative approach. 38 persons, 6 male and 32 female, who participated in interdisciplinary rehabilitation were part of this study. Data was collected before and after the rehabilitation period, with well tested self-rating instruments and objective tests. Kinesiophobia was rated with Tampa Scale of Kinesiophobia. For physical ability parts of Test Instrument for Profile of Physical Ability (TIPPA) were used; self-assessment of current physical ability, walking distance and speed walking. Also Multidimensional Pain Inventory was used to rate the pain impact on activity and pain intensity. Due to scale properties non-parametric correlational analysis were being used. Results: The most important results from this study were that kinesiophobia before rehabilitation, in addition to the influence of self-assessment of current physical ability, had a strong correlation to self-assessment of current physical ability after rehabilitation. High scores on kinesiophobia gave seven times higher risk to low self-assessment of current physical ability after rehabilitation. It was also found that those patients with a combination of high kinesiophobia and low self-assessment of current physical ability before rehabilitation in much lower extent reached a good ability after rehabilitation, compared to patients who either have high kinesiophobia or low self-assessment of current physical ability. In addition to these results all the physical ability measures from TIPPA were correlated to each other. But no correlations were being found between kinesiophobia or physical ability to impact on activity and pain intensity. Conclusions: These results indicate that it is important to put the measures of kinesiophobia and self-assessment of current physical ability together in consideration to find the right focus, and reasonable goals, in rehabilitation. In short the results underline the importance of individually customized actions in rehabilitation to the unique difficulties of each patient.

Due to the subjective nature of pain and the profound debilitating effects of pain for a growing number of people, there are many challenges to approaching and fully addressing its problems. The traditional biomedical model of health limits its treatment focus to the physical components of pain. Biomedicine provides useful and effective short-term relief of bodily symptoms, but usually cannot cure pain that persists in both mind and body over time. Because chronic pain is often accompanied with discomfort, depression, and other significant life impairments, health researchers have recently conceptualized more comprehensive models to address pain. In the bio-psycho-social-spiritual health model, chronic pain is assessed and treated in the context of a person’s overall quality of life, considering biological, psychological, social, and spiritual health conditions. This movement towards adopting integrative health care models can also provide patient guidance needed for developing inner resources to adapt to pain, as well as recover from and prevent disease. Self-compassion comes from a fertile field of inquiry emerging out of a wider conception of health that includes spirituality. The construct is based on three related components that can assist a person living with pain: (a) being kind to oneself while in pain or suffering, (b) perceiving difficult times as shared human experiences, and (c) holding painful thoughts and feelings with mindfulness, instead of over-identification. Measured using the Self-Compassion Scale, it demonstrates positive associations with a variety of health indicators. However, a direct relationship with chronic pain has not yet been examined. In applying recent research in quality of life (QoL) and self-compassion to a chronic pain patient population, the purpose of this study is twofold: (a) to produce a comprehensive assessment of bio-psycho-social-spiritual QoL conditions (b) to examine differences in QoL with the presence of self-compassion and determine its potential moderating effect on life impairments due to pain. From this project, the QoL conditions that are affected by chronic pain and the moderation effect of self-compassion will be understood better so that more effective treatment and prevention procedures can be developed for people living with pain from long-term disease conditions. / text

Temporomandibular Disorder(s) (TMD), a common cause of chronic pain affecting the face and jaw, profoundly impacts interactions as fundamental to human existence as smiling, laughing, speaking, eating, and intimacy. Since landmark anthropological research on TMD in the 1990s, considerable changes have occurred in the way TMD is thought about and responded to. Knowledge about TMD among dentists and physicians has increased since publication of the Research Diagnostic Criteria (RDC-TMD), and a well-funded TMJ association now advocates for research and support of the condition. On the other hand, concerns in the medical world about increases in chronic pain and associated risks of misuse of pain medications have increased. Physicians are trained to perform a gatekeeper role, preventing those patients at-risk of becoming drug abusers from gaining access to opioid pain medications. These differing contextual factors and my focus on a group of participants drawn from a complementary and alternative medicine (CAM) trial, rather than from a pain clinic, provide an expanded and updated view of TMD. I present analyses of semi-structured, open-ended interviews with 44 participants interviewed multiple times over the course of their participation in an NIH-funded trial evaluating Traditional Chinese Medicine (TCM) for TMD. In contrast to earlier studies of participants who were consumed by an endless search for diagnosis and treatment, these participants were largely focused on coping and "just dealing with" the daily experience of severe pain. Three articles comprise the body of work presented in this dissertation. Topics include the Works of Illness, the Paradox of Hope, and the construction of moral identity through consumption of over-the-counter (OTC) medications. First, using a "works of illness" framework, I draw attention to the considerable work sufferers undertook to manage competing demands of social and physical risk imposed by chronic pain. I refer to these forms of work as the work of stoicism and the work of vigilance and identify double binds created in contexts that call for both. Multiple voices in the narratives of sufferers are highlighted as essential to the construction of a positive identity in the face of illness. In more in-depth exploration of the work of hope, hope is revealed as a fundamental and paradoxical aspect of autobiographical work. I describe multiple forms of hope in a typology of ways of hoping and raise as an issue the manner in which the paradox of hope--keeping hopes in check while also avoiding despair-- intersects with participant expectations in the trial. I suggest this may have an impact on the placebo effect. Trade-offs between physical harm reduction and reducing potential harm to one's identity produce narratives of harm justification as pain sufferers work to describe their use of OTC medications as minimal and responsible. Sufferers in this study, describing medications as "just over-the-counter" or "not real pain medication" distanced, themselves from association with the addictive potential of prescription pain medications. Participants avoided harm to their identities by consuming OTC pain medications as idioms of self-care. This case study provides important lessons about the experience of chronic pain in the USA. While much attention has been directed at overuse and addiction to pain medication, less has focused on the experience of those soldiering through pain and navigating paradoxes between social and physical demands. This study also directs attention to anthropology's potential contribution to drug trials, to the necessity of studying hope as well as expectations, and to how both impact the placebo response.

ABSTRACT Purpose: The purpose of the study was threefold. Firstly, to investigate if a four week program in pain rehabilitation had any effect on how much individuals with persistent pain worked and their degree of kinesiophobia. Secondly, to study if there was a correlation between how much these individuals worked and their degree of kinesiophobia. Thirdly, to study if there was a correlation between the change in these variables. Method: 112 patients who had participated in a four week rehabilitation program took part in the study. The study had a retrospective design, which was based on a review on medical records and consisted of three minor parts. The first part had a quasi-experimental comparative design and the other two parts had non-experimental cross-sectional correlative designs. Kinesiophobia was analyzed with the Swedish version of the Tampa Scale of Kinesiophobia (TSK-SV). How much a patient was working was measured in percent. Results: Both work status and kinesiophobia had improved significant in every measurement. The highest improvement in the variable of kinesiophobia was discovered by the end of the program in pain rehabilitation and by the twelve month follow-up in the variable about how much patients was working. Analysis with Spearman’s rang correlation coefficient showed a weak statistical significant correlation between how much individuals work and their degree of kinesiophobia in the twelve months follow-up. There was however no statistical significant correlation between the change of how much individuals worked and the change of their degree of kinesiophobia, neither in the two nor in the twelve months follow-up. Conclusions: This is one of the first studies that have been done who investigate the correlation between kinesiophobia and how much individuals with persistent pain are working and it shows that there is a need to continue to investigate the correlation between them, both for the individual as well as for the society in general and if possible also study what importance self-efficacy has in this context.

Syfte: Syftet med denna studie är att bland patienter med långvarig smärta, som är remitterade till en smärtmottagning, undersöka förväntningar avseende det första besöket, i vilken utsträckning patienterna anser att dessa uppfylldes samt att undersöka vilka förväntningar patienterna har på den fortsatta vården och kontakten med Smärtmottagningen. Metod: En empirisk studie med kvalitativ deduktiv ansats. Datainsamling skedde genom att tio personer intervjuades på Smärtmottagningen efter deras första besök. Materialet bearbetades med manifest innehållsanalys. Resultat: Patienter vid Smärtmottagningen hade i olika stor utsträckning förväntningar inför det första besöket och den fortsatta vården. Patienterna ansåg i varierande utsträckning att deras förväntningar på det första besöket hade uppfyllts, dock uttryckte alla patienter att minst någon förväntning uppfyllts. Gällande den fortsatta vården förväntade sig patienterna bland annat smärtlindring, stöd samt att upprätta en kontakt med Smärtmottagningen. Slutsats: Patienter vid en smärtmottagning har förväntningar på vården och att känna till dessa kan underlätta mötet med patienten för sjukvårdspersonalen. Föreliggande studie ger en inblick i tio patienters förväntningar och huruvida de blivit uppfyllda och tyder på att det är av värde att fråga patienter om deras förväntningar. Detta är något som smärtmottagningar kan överväga att implementera i vården. / Aim: The aim of this study was to investigate expectations on the first appointment among patients with chronic pain referred to an outpatient pain clinic. The aim was also to investigate to which extent the expectations on the first appointment were fulfilled and to investigate the patients’ expectations on the continuing care and contact with the outpatient pain clinic. Method: An empirical study with qualitative design was used. The data was collected through interviews with ten patients after their first appointment at the clinic. Data was processed using manifest content analysis. Result: The patients had expectations in various extents prior to their first appointment and on the further care. The patients thought that their expectations were fulfilled to various extent, however all patients expressed that at least one expectation had been fulfilled. Regarding the continuing care the patients expected, among other things, to receive functioning pain treatment and support as well as to establish a contact with the outpatient pain clinic. Conclusion: Patients have expectations and awareness of these among the medical staff might facilitate the meeting between the medical staff and the patient. This study provides an insight in ten patients’ expectations and to which extent they have been fulfilled. The study also suggests that it would be of value to ask patients about their expectations, which outpatient pain clinics can consider implementing.

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Aktuellen Umfragen zufolge leiden in Deutschland elf Millionen Erwachsene an chronischen Schmerzen. Die Therapie der betroffenen Patienten und die Verhinderung der Chronifizierung ist daher eine wichtige Aufgabe unserer Zeit. Multimodale Schmerztherapien haben in der Behandlung chronischer Schmerzstörungen gute Ergebnisse gezeigt. Über den Effekt dieser Behandlung auf die Optimierung beziehungsweise Reduzierung der schmerzbezogenen Medikation wurde bisher kaum berichtet. Zusätzlich zu den bekannten Ergebnisparametern wie Schmerzintensität, Funktionserleben, Depression, Angst und Lebensqualität wurde daher in diese Studie auch die Veränderung der Medikation nach Behandlung beziehungsweise zum Zeitpunkt einer Ein-Jahres-Katamnese erfasst. Die schmerzbezogene Medikation wurde mit der sogenannten Medication Quantification Scale (MQS) bewertet, die eine Möglichkeit darstellt, die Medikamenteneinnahme gemäß Stoffgruppe, Dosis und potentieller Toxizität in einer einzigen vergleichbaren Maßzahl zu quantifizieren. Die Studie konnte zeigen, dass multimodale Schmerzbehandlungen zu guten bis sehr guten, weitgehend anhaltenden Effekten und einer hohen Patienten-Zufriedenheit führen. Es konnte darüber hinaus eine relevante Reduktion der schmerzbezogenen Medikation erreicht werden, die in den meisten Fällen noch ein Jahr später konstant blieb. Patienten, bei denen während des Programms eine Reduzierung der Medikamente erreicht werden konnte, hatten zudem die besseren Therapieergebnisse im Vergleich zu den Gruppen mit gleicher oder höherer Medikation.

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