Self-regulation is the capacity to exert control over cognition, emotion, behavior, and physiology. Since chronic pain interferes with the ability to self-regulate, the primary goal of this study was to examine, in rodents, the effects of chronic pain on self-regulation processes. Sixteen male Sprague-Dawley rats were divided into two groups: (1) chronic constriction injury of the infraorbital nerve (CCI-ION) and (2) naïve. Testing confirmed that CCI-ION animals had significant mechanical allodynia compared to naïve animals (p<0.001). A two-part self-regulation behavioral paradigm consisting of a cued go/no-go task and a subsequent persistence task was developed based on human paradigms. In the cued task, both groups made fewer incorrect lever presses in post-surgery trials (p<0.001); naive animals had a greater decrease in number of incorrect presses than CCI-ION animals (p=0.06). Similarly, both groups had a larger correct to total lever presses ratio in post-surgery trials (p<0.001); naïve animals had a greater increase than CCI-ION animals (p=0.06). In the persistence task, naïve animals experienced a greater decrease in lever presses (p=0.08) than did CCI-ION animals (p=0.66). These results suggest that animals experiencing chronic pain were not able to learn as well as naïve animals, and may have difficulty responding to novel environmental demands.

Mindfulness is a way of managing chronic pain and its consequences as it fosters anaccepting approach to pain that can be beneficial in several aspects of life affected bypain. This study sought to examine whether an online mindfulness training programcould reduce the experience of pain, increase acceptance of pain, and increase qualityof life in a group of individuals suffering from chronic pain. The study was arandomized controlled trial with a partly active control group. Initially 52 participantswere randomized to the intervention group and 55 to the control group. The drop outrates were high, 21 participants from the intervention group and 40 participants fromthe control group completed post measurement. Increased levels of mindfulness,reduced pain related distress, and heightened pain acceptance, as well as increasedquality of life, was observed in the intervention group. A strong tendency towards aperceived reduction of pain intensity was also evident in the intervention group. Asthe mindfulness program had positive effects on the overall experience of pain it mayserve as a cost‐effective and useful method of dealing with chronic pain. / Mindfulness är ett sätt att hantera kronisk smärta och dess konsekvenser då det lär uten accepterande inställning till smärta som kan vara till hjälp i flera aspekter av livetpåverkade av smärta. Denna studie undersökte huruvida ett online‐baseratmindfulnessprogram kunde minska upplevelsen av smärta, öka acceptans av smärtaoch öka livskvaliteten hos en grupp individer med kronisk smärta. Studien varrandomiserad och kontrollerad med en delvis aktiv kontrollgrupp. Initialtrandomiserades 52 deltagare till experimentgruppen och 55 deltagare tillkontrollgruppen. Bortfallet var högt, 21 deltagare från experimentgruppen och 40deltagare från kontrollgruppen fullgjorde eftermätningarna. Ökade nivåer avmindfulness, reducerat smärtrelaterat lidande, ökad acceptans av smärta såväl somökad livskvalitet återfanns i experimentgruppen. En stark tendens till minskadupplevd smärtintensitet var också tydlig hos experimentgruppen. Dåmindfulnessprogrammet hade positiva effekter på den övergripande upplevelsen avsmärta kan det fungera som en kostnadseffektiv och användbar metod att hanterakronisk smärta.

Neural activity within the brain underlies complex behavior that allows us to interact with our environment. The anterior cingulate cortex (ACC) is believed to mediate appropriate behavioral responses by integrating emotional and cognitive information about external stimuli. If this understanding is correct, then neural activity within the ACC must therefore correlate with behavioral output in response to external experience. The aim of this thesis is to bridge mechanisms identified in vitro with behaviors observed in vivo to determine the neural substrates of ACC mediated behavior. This thesis focuses on glutamatergic receptors that have been established as mediators of excitatory transmission in the ACC. Through a combination of behavioral, pharmacological, biochemical, and electrophysiological methods, this thesis examined how behaviors observed in mouse models of fear learning, chronic pain, and itch correspond with in vitro observations of ACC neuronal activity. Three sets of experiments are presented. The first set investigated cortical LTP-like mechanisms, and assessed whether they could mediate fear learning. These sets of experiments provide in vivo evidence that trace fear learning requires rapid, NMDA receptor dependent, cortical AMPA receptor insertion. The second set of experiments investigated the contribution of forebrain CREB-mediated transcription in behavioral manifestations of chronic pain. These experiments show that forebrain overexpression of CREB is sufficient to enhance mechanical allodynia in animal models of chronic inflammatory or neuropathic pain. Lastly, the final set of experiments show that pruritogen-induced scratching corresponds with enhanced excitatory transmission in the ACC through KA receptor modulation of inhibitory circuitry. Through investigations of multiple behaviors linked to ACC activity, this thesis presents evidence that manifestations of behavior can be observed at the molecular level, and indicates that molecular mechanisms involved in ACC synaptic activity are a good target for translational research into pathological conditions that are related to abnormal ACC activity.

When considering the impact of chronic pain on society as a whole, the statistics on the prevalence and societal costs associated with this phenomenon are nothing short of staggering. Traditionally, the research on chronic pain has predominately focused on the neurobiology of pain, pharmaceutical management of chronic pain, as well as the epidemiolgy and etiology of pain. However, relatively less attention has been given to the actual lived experience of individuals suffering from chronic pain, and a notable void was found to exist in the literature in terms of how one’s pain experience might be affected by the absence of an accepted diagnosis. The purpose of this qualitative study, therefore, was to explore, describe, and understand the experience of individuals who find themselves in this challenging situation, asking the fundamental question: “What is the experience of living with undiagnosed chronic pain?” In this study’s investigation of the aforementioned research question, five individuals living with undiagnosed chronic pain participated in semi-structured research interviews. These interviews generated rich experiential descriptions from the participants (captured via interview transcripts), and the resulting data was analyzed using a hermeneutic phenomenologic framework. This analysis generated 10 themes that were deemed to be ‘essential’ to the experience of living with undiagnosed chronic pain. Once these themes were compared with extant chronic pain studies, it was noted that this study’s themes of ‘I have tried everything’ and ‘Feeling exasperated’ had not been previously identified as independent phenomenologic themes, and as such, they offer a unique contribution to the literature. Although there remains a certain degree of ambiguity regarding whether these experiential themes are equally applicable regardless of whether or not one’s chronic pain is associated with an identified diagnosis, it would not seem to be overreaching to speculate that these lived experiences might be more potent if one were lacking a diagnosis to adequately ‘explain’ their chronic pain. However, it was acknowledged that for this assertion to be defendable, future studies would need to be done in a manner that enables stronger comparisons between the experiences of chronic pain sufferers who have, and do not have, an accepted diagnosis. In terms of implications for praxis, an overarching motivation of the researcher was to generate new knowledge that would not only be applicable in counselling settings, but would also have value across disciplines, positively affecting psychological-counselling, medicine, and physical rehabilitative disciplines in terms of promoting deeper levels of empathic understanding regarding the experience of living with undiagnosed chronic pain, thereby giving a voice to this underrepresented portion of the greater chronic pain population.

Denna studie undersökte samsjuklighet mellan smärta och social ångest i en smärtpopulation genom klusteranalys. Syftet var att undersöka om det fanns en undergrupp bland smärtpatienter som skattade högt på social ångest samt högt på upplevd invalidering före och efter smärtbehandling. Syftet var vidare att se om denna undergrupp skattade annorlunda vad gäller funktion jämfört med smärtpatienter med låg grad av social ångest samt se hur individer rörde sig mellan kluster över tid. Data bestod av självskattningsformulär från 157 smärtpatienter. Resultatet visade att det fanns en undergrupp som skattade högt på social ångest och upplevd invalidering. Individer i denna undergrupp hade lägre funktion innan såväl som efter behandling och tenderade att stanna kvar i de undergrupper som skattade högt på social ångest. / Comorbidity between pain and social anxiety in a sample of chronic pain patients was examined with cluster analysis. The purpose was to examine if there was a subgroup among pain patients that scored high on social anxiety and perceived invalidation before and after pain treatment. An additional purpose was to analyze if this subgroup scored differently on functioning compared to other pain patients and to explore movements between clusters over time. Data was based on self-report questionnaires from 157 pain patients. The results revealed an existing subgroup which scored high on social anxiety and perceived invalidation. The clusters with high social anxiety showed a lower level of functioning before and after pain treatment. These individuals tended to remain in the clusters scoring high on social anxiety over time

Building on theoretical frameworks that conceptualize the body as a material and symbolic entity, this thesis examines how women use their bodies to mediate the conditions of their social and cultural environment. Canadian women who occupy social locations marked by their involvement in one of three socially and economically marginalized service occupations (hairdressing, sex trade and restaurant work) were interviewed using a body-mapping methodology. The purpose was to reveal how quotidian experiences such as feeling inadequate, incompetent, lonely, disenfranchised or dissatisfied are embodied as physical pain and illness. The research shows that women give meanings to these experiences by acting on and reflecting cultural beliefs about health, work, the body and the flexibility and potential for recreating the self. In particular, the Canadian women in the study are influenced by discursive ideas that they have the option (and indeed the personal responsibility) to `transform,' `change,' `control,' and `reshape' themselves.

Av Sveriges befolkning har cirka 40-50 procent någon gång upplevt långvarig smärta. För hälso- och sjukvårdspersonal kan den långvariga smärtan vara utmanande då fokusering inte bara kan ske mot smärtan utan måste inkludera hela den komplexitet som uppstår med flera olika faktorer. Syftet med litteraturstudien var att beskriva individens upplevelse av att leva med långvariga smärta. Metoden som användes var litteraturstudie där resultatet baseras på sju kvalitativa artiklar och en kvantitativ artikel. Ur dessa framkom tre kategorier: Känslomässiga förändringar, Förändrad vardag och Omgivningens bemötande. I resultatet framkom det att långvarig smärta leder till livsförändringar och för att finna en acceptans krävs en inre omdefiniering. Individen och närstående kan känna en påfrestning då ansvarsroller i vardagslivet byts ut. För att få stöd måste smärtan demonstreras och att känna misstrohet från omgivningen är vanligt. Att bli respekterad, uppskattad och förstådd i sitt lidande är de mest väsentliga för individen. Då den långvariga smärtan existerar i alla olika åldrar är det viktigt att sjuksköterskan har kunskap om fenomenet och dess uttrycksformer, är uppmärksam och lyhörd. Vidare forskning om den långvariga smärtan som inte är kopplad till sjukdom krävs för att få en djupare kunskap om smärtans komplexitet. / About 40-50% of the population of Sweden has sometimes experienced chronic pain. The chronic pain can be a challenge for the healthcare professionals and focus must include all the complexity that arises and not only the pain itself. The purpose of the literature study was to describe the individual´s experience of living with chronic pain. The method used was a literatur study where the result represented by seven qualitative articles and one quantitative article that were chosen for a review. Out of these, three categories emerged: emotional changes, changes in daily life and surroundings treatment. The result of the study showed that chronic pain leads to life changes and to be able to find an acceptance, it requires an inner redefinition for the individual. Since the responsibility roles in everyday life are changed, a strain between the individual and relatives can arise. To get support the pain must be demonstrated and a common feeling is mistrust from the environment. The most significant for the individual is to be respected, appreciated and being understood in their suffering. When the chronic pain exists in all different ages it is important that the nurse has knowledge of the phenomenon and it´s manifestations, attentive and perceptive. To be able to get a deeper knowledge of the complexity of the pain further research about chronic pain, which is not linked to a specific disease, is required.

This study seeks to understand how collaborative information communication technologies (cICT) are used to support knowledge translation and optimize physician’s roles in chronic pain management. A survey was developed and distributed to 170 physicians in two chronic pain mentoring networks in Ontario and Nova Scotia. With a response rate of 74.1% the study identified the use of a broad variety of cICTs; with email as the most used. A majority of respondents (85.0%) used email to support discussions and 69.8% found it to be valuable in learning about chronic pain management. A higher frequency of email (adjusted OR=10.70, 95% CI: 2.84-40.33) and number of cICTs (adjusted OR=2.93, 95% CI: 1.19-7.21) used to communicate in the networks were associated with more interactions. These results highlight how cICTs can support the interactions and learning that are part of the knowledge translation process in optimizing the roles of physicians in chronic pain management.

This study seeks to understand how collaborative information communication technologies (cICT) are used to support knowledge translation and optimize physician’s roles in chronic pain management. A survey was developed and distributed to 170 physicians in two chronic pain mentoring networks in Ontario and Nova Scotia. With a response rate of 74.1% the study identified the use of a broad variety of cICTs; with email as the most used. A majority of respondents (85.0%) used email to support discussions and 69.8% found it to be valuable in learning about chronic pain management. A higher frequency of email (adjusted OR=10.70, 95% CI: 2.84-40.33) and number of cICTs (adjusted OR=2.93, 95% CI: 1.19-7.21) used to communicate in the networks were associated with more interactions. These results highlight how cICTs can support the interactions and learning that are part of the knowledge translation process in optimizing the roles of physicians in chronic pain management.

Background: Chronic pain, defined as non-malignant pain emanating from the musculoskeletal system, may limit everyday activities, social functioning and the quality of social and working life for individuals, creating disability as well as incurring high economic and public costs for society. Controlled studies show that cognitive-behavioural interdisciplinary rehabilitation has a positive effect on functioning in patients who have been disabled by chronic non-malignant pain conditions. Positive outcomes described include lower pain intensity, less preoccupation with pain, greater independence and lower consumption of healthcare. On the other hand, the return to work rate varies. To facilitate comparisons on the national level and to enable audit spirals for single programmes as part of the ongoing quality assurance in healthcare the Swedish Quality Registry for Pain Rehabilitation (SQRP) has aggregated data since 1998 on all patients referred to the majority of Swedish rehabilitation units. The aim of this dissertation was to improve the knowledge base of pain rehabilitation in Sweden using the validated self-reported instruments of pain and its consequences included in the SQRP. Methods: The SQRP data were collected before, at the end and 1 year after the intervention for all individuals included, and concerns self-reported demographic variables, pain intensity, activities, thought patterns, impact of pain on daily life and life satisfaction. Individual sick leave data were collected from the Swedish Social Insurance after 1 year. Data collected from 19833 patients (6002 men and 13831 women) of which 7289 participate in work ability improving programmes, were used. Results: The results of four studies included in this thesis showed that the SQRP provided a basis for scientific works since it use the validated self-report instruments of pain and its consequences and contain a large amount of patient’s data. However, a lack of follow-up data from some units influenced the opportunity of to analyse long-term outcomes. Nevertheless, the SQRP was a useful tool to audit and evaluate as well as to propose optimising of pain rehabilitation. It seemed that contextual factors such as patients’ own beliefs and expectations, education, gender, actual sick leave and employment situation had more importance for the effect of rehabilitation programme than pain characteristics, depression or activity limitation. The Multidimensional Pain Inventory (MPI) scale scores and MPI coping profiles might be used for assessing the outcomes of treatment interventions. A reduction of MPI scale scores for Pain severity and Interference decreased the risk of being on full-time sick leave. On the other hand, the MPI coping profiles Dysfunctional, among both men and women, and Interpersonally distressed, among women, were associated with higher odds of being on full-time sick leave. Conclusions: Attending cognitive-behavioural interdisciplinary pain rehabilitation programmes in Sweden resulted in improvements of the MPI scales after completing a pain rehabilitation programme and this improvement was sustained after 1 year. Moreover, these programmes decreased the levels of full-time sick leave 1 year after completed programme. The findings suggest also the need to tailor rehabilitative strategies differently for men and women as well as for different pain coping profiles.