The primary focus of this thesis is to establish the clinical utility of corticosteroid injections mixed with local anesthetics, when compared to only local anesthetics, for relief of pain in patients with chronic non-cancer pain. Chronic non-cancer pain is common and causes significant pain and suffering to patients, and economic burden to health care system. Injection of steroids is an option, either by targeting the painful structure or the associated neural elements. Steroids are commonly mixed with local anesthetics in the hope of prolonging the pain relief. Since there is no evident inflammation in most chronic pain conditions, and because existing clinical studies do not consistently support its effectiveness in various clinical conditions, the potential value of adding steroids is questionable. This clinical question has been addressed through a comprehensive systematic review and meta-analysis of randomized control trials comparing injections of steroid with local anesthetics against only local anesthetics for chronic non-cancer pain conditions. Our review found that there is paucity of good quality randomized controlled studies specifically addressing this comparison. Although a large numbers of studies were identified, there was a small effect favoring steroids in studies measuring pain relief by dichotomous outcomes. Overall confidence in the effect estimates were limited due to serious concerns of bias, significant heterogeneity and variability in studies, leading to low quality. A majority of the included studies did not aim to capture the full spectrum of adverse effects. Future studies addressing this clinical question should aim to be of optimum size, must aim to limit the threat of bias, and capture all patient important outcomes including pain relief. / Thesis / Master of Science (MSc)

Chronic non-cancer pain (CNCP) is a complex phenomenon that affects multiple dimensions of daily life. Optimal therapies for managing CNCP must, then, demonstrate clinically important benefits that go beyond reductions in pain and adverse events. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) has recommended that clinical trialists who are evaluating treatments for chronic pain consider reporting treatment effects across nine patient-important outcome domains. This thesis begins with an investigation of the extent to which clinical trials evaluating the effects of opioids for CNCP report IMMPACT-recommended core outcome domains. Further, it explores optimal therapeutic strategies for specific CNCP conditions; specifically, it features a systematic review of randomized controlled trials of all pharmacological and non-pharmacological therapies for central post-stroke pain, as well as a plan for a network meta-analysis of all therapies for all chronic neuropathic pain syndromes. Chronic pain is also a common reason for disability, and this thesis concludes with a retrospective cohort study focused on identifying predictors of claim duration following acceptance for disability benefits among Canadian workers. / Thesis / Doctor of Philosophy (PhD)

Bakgrund Smärta är den vanligaste orsaken till att personer söker vård och långvarig smärta är ett omfattande folkhälsoproblem som också är mycket kostsamt för samhället. Långvarig smärta är ett komplext tillstånd som ofta involverar samsjuklighet och som påverkar alla delar av patientens liv. Hälso- och sjukvårdspersonal saknar ofta kompetens kring långvarig smärta och dessutom skiljer sig ofta uppfattningen om smärtupplevelsen mellan patienten och personalen. Därför finns det ett behov av att sammanställa kunskap som ökar hälso- och sjukvårdspersonals förståelse för patienternas upplevelser av bemötandet. Syfte Syftet var att belysa de erfarenheter och upplevelser som patienter med långvarig smärta har av bemötandet från hälso- och sjukvårdspersonal. Metod En icke-systematisk litteraturöversikt som baserats på femton vetenskapliga originalartiklar med både kvalitativ och kvantitativ ansats. Artiklarna söktes fram i databaserna PubMed och CINAHL. Kvalitetsgranskningen har utförts med Sophiahemmet Högskolas bedömningsunderlag. Resultatet sammanställdes med en integrerad dataanalys. Resultat Tre huvudkategorier identifierades: Empatiskt bemötande, Tydlig kommunikation och ärlighet från hälso- och sjukvårdspersonal och Att få vara delaktig. Resultatet visade att patienter med långvarig smärta lägger stor vikt vid delaktighet i deras egen vård, att personalen inte ifrågasätter deras unika upplevelser, tydlig och öppen information från hälso- och sjukvårdspersonalen samt att det finns en förståelse för att de är unika individer med unika behov och erfarenheter. Slutsats Litteraturöversikten gav viktiga insikter i hur patienter upplever olika delar av bemötandet från hälso- och sjukvårdspersonalen. Hur personalen bemöter patienter kan stärka relationen, öka tillfredsställelsen och bidra till att patienterna känner sig sedda och bekräftade i sina smärtupplevelser. Med ökad kunskap om upplevelserna hos patienter med långvarig smärta kan hälso- och sjukvårdspersonal utveckla förståelse och ge vård som är anpassad efter patientens behov där den unika individens upplevelse och erfarenheter står i centrum. / Background Pain is the most common reason for seeking healthcare and chronic pain is an extensive public health problem which also has a high societal cost. Chronic pain is a complex condition which often involves comorbidity and it affects all parts of the patient's life. Healthcare professionals often lack competence regarding chronic pain and the perception of the pain experience often differs between the patients and the healthcare professionals. Therefore there is a need to gather knowledge which will deepen healthcare professionals' understanding of how patients experience their meetings with the professionals. Aim The purpose was to illuminate the experiences that patients with chronic pain have of meeting healthcare professionals. Method A non-systematic literature review based on 15 scientific articles with both qualitative and quantitative methods. The articles were gathered from the databases PubMed and CINAHL. The quality assessment was done using Sophiahemmet University’s assessment matrix. The result was compiled using an integrated data analysis. Results Three main categories were identified: Empathetic treatment, Clear communication and honesty from healthcare professionals and Being involved. The result showed that patients with chronic pain greatly value being involved in their own care, professionals not questioning their unique experience, clear and open communication from the healthcare professionals and also that there is an understanding of how they are unique individuals with unique needs and experiences. Conclusions The literature review provided important insights into how patients experience different parts of the treatment from the healthcare personnel. How the healthcare professionals treat patients can strengthen the relationship, increase patient satisfaction and contribute to making the patients feel heard and seen in their experiences with pain. With increased knowledge about the experiences of patients with chronic pain, healthcare professionals can develop an understanding and give care that is customized for the patient's needs where the unique individual's experiences are at focus.

BackgroundChronic pain affects 70% of individuals with spinal cord injury (SCI), and up to 53% of individuals with SCI experience neuropathic pain that leads to declines in their health and quality of life. Chronic pain can be categorized by phenotypes as neuropathic or nociceptive. Neuropathic pain arises due to nervous system dysfunction, and nociceptive pain originates in the musculoskeletal system in response to noxious stimuli. Moderate-to-vigorous intensity physical activity (MVPA) and virtual reality (VR) have been effective interventions for pain management, however, the circumstances in which these interventions are efficacious for individuals with SCI are not well understood. The objectives of this study were to: 1) investigate the relationships between MVPA and pain phenotypes, 2) investigate the relationships between VR and pain phenotypes, and 3) explore a practical method of measuring MVPA in individuals with SCI. MethodsFor the first objective, one week of physical activity data was collected in the community from 17 individuals with SCI, and daily pain ratings were obtained. Spearman’s correlation analyses were performed to analyze the relationships between MVPA levels and pain intensity. For the second objective, participants engaged in two bouts of immersive VR, and pain intensity was assessed at baseline and following each bout. Friedman analyses of variance tests were conducted to identify changes in pain intensity across VR exposure time in each pain phenotype. For the third objective, a comparison of summary measures for raw physical activity data was conducted. Spearman’s correlation was used to analyze the relationship between ActiGraph Activity Counts and Monitor Independent Movement Summary (MIMS) Units. ResultsIn neuropathic pain, MVPA and pain intensity are negatively correlated. In nociceptive pain, there was no significant correlation between MVPA and pain intensity. A decrease in neuropathic pain was achieved from VR, however no change in nociceptive pain intensity was observed. Total active minutes summarized from raw accelerometer data by Activity Counts and MIMS Units values were strongly correlated, but minutes of MVPA calculated by Activity Counts were only moderately correlated to minutes of MVPA calculated through personalized thresholds with MIMS Units. The responses to VR for each pain phenotype were different. A decrease in neuropathic pain was achieved within a five-minute bout, and this decrease was maintained at the end of both VR sessions, whereas no change in nociceptive pain level was observed. Lastly, Activity Counts and MIMS Units values were strongly correlated (r = 0.94, p < 0.001). Minutes of MVPA calculated by Activity Counts were moderately correlated (r = 0.44, p < 0.001) to minutes of MVPA calculated through personalized thresholds with MIMS Units. ConclusionPain in each phenotype responded differently to both motor activities that were evaluated. These results may assist in the development of personalized pain management approaches through targeted combinations of interventions. By utilizing data from free-living individuals with SCI in the community, the process of personalized thresholds is translatable and describes MVPA levels more accurately and comprehensively than what can be collected in a laboratory setting. This approach can be implemented to optimize MVPA recommendations for individuals with SCI who experience chronic pain. / Biomedical Sciences

Bakgrund: Smärta är ett subjektivt fenomen som kan definieras som en personlig sensoriskt eller emotionellt obehaglig upplevelse relaterad till faktisk eller potentiell skada, där biologiska, psykologiska och sociala faktorer har betydelse. Långvarig smärta definieras som smärta vilken har pågått eller varit återkommande under mer än tre månader. Smärta kan påverka kroppens system och funktioner, såsom sömn, sinnesstämning och kognitiv funktion. En biopsykosocial förklaringsmodell, vilken tillstår smärtproblematiks flerdimensionalitet, är idag vedertagen för att beskriva, bedöma och behandla smärta. Långvarig smärta är en vanligt förekommande diagnos i både industrialiserade och utvecklingsländer. Behandling vid långvarig smärta innefattar farmakologisk behandling men även icke-farmakologiska alternativ, exempelvis psykoterapeutisk behandling, akupunktur eller fysisk aktivitet. Syfte: Syftet var att belysa patienters erfarenheter av icke-farmakologisk smärtbehandling vid långvarig smärta. Metod: Litteraturstudien var av kvalitativ, induktiv ansats och baserades på tio kvalitativa artiklar. Datan bearbetades genom en kvalitativ innehållsanalys. Resultat: Fyra huvudkategorier framkom av analysen; Fysiska erfarenheter, Inverkan på känsloliv och inre förmågor, Resurser och strategier för smärthantering och Inverkande faktorer på användande och effekt. Vanligt förekommande erfarenheter av icke-farmakologisk smärtbehandling, både vid fysikaliska och psykologiska behandlingsmetoder, innefattade förändrade upplevelser av välmående och livskvalitet, samt ökad kunskap och förståelse. Konklusion: Flertalet icke-farmakologiska smärtbehandlingsmetoder gav smärtlindring. Deltagare lade dock genomgående tyngd vid andra erfarenheter relaterade till exempelvis livskvalitet, avslappning, kunskap kring smärttillstånd, relation till vårdgivare samt tillgång till resurser och strategier för smärthantering. Genom förståelse för patienters erfarenheter, kunskap kring långvarig smärta och behandlingsalternativ samt förmåga till relationsbyggande kan sjuksköterskan skapa en förbättrad personcentrerad omvårdnad och bidra till minskat lidande hos patienter med långvarig smärta. / Background: Pain is a subjective phenomenon which can be defined as a personal sensory or emotional experience associated with actual or potential tissue damage, influenced by biological, psychological and social factors. Chronic pain is defined as pain persisting or recurring for three months or longer. Pain can influence the body’s functions, such as sleep, frame of mind and cognitive function. A biopsychosocial explanatory model, which acknowledges pain’s multidimensionality, is an established way of describing, assessing and treating pain. Chronic pain is common in both developed and developing countries. Treatment includes pharmacological therapy as well as non-pharmacological options, for example psychotherapy, acupuncture or exercise movement techniques. Aim: The aim of the study was to illustrate chronic pain patients’ experiences of non-pharmacological pain management. Method: The literature study was done with a qualitative, inductive approach on the basis of ten qualitative articles. A qualitative content analysis was performed to process the data. Result: Four categories were found through the data analysis; Physical experiences, Impact on emotions and inner capabilities, Resources and strategies for pain management and Factors influencing use and effect. Common experiences of non-pharmacological pain management, both physical and psychological treatments, included changed perceptions of well-being and quality of life, as well as increased knowledge and understanding. Conclusion: Multiple non-pharmacological pain management methods gave pain relief. Participants put an emphasis on other experiences related to for example quality of life, relaxation, knowledge of pain mechanisms, caregiver relationships and access to pain management resources and strategies. Through understanding patients’experiences, having knowledge of chronic pain conditions and treatment options and relationship building skills nurses can provide a more person-centered care and can contribute to decreased suffering in patients with chronic pain.

Lower educational attainment has been linked to worse chronic pain outcomes, but the reasons for this relationship are unclear. This study analyzed the relationship between level of education and pain outcomes in patients with musculoskeletal pain, and potential psychosocial mechanisms to explain this relationship. We hypothesized that patients with lower educational attainment would report greater pain intensity and interference, and that pain catastrophizing, anxiety, and depression would mediate the relationship between educational attainment and pain. A total of 843 participants (63% female, 78% White, Mage=55.13), diagnosed with a musculoskeletal pain condition [knee osteoarthritis (29%), back pain (57%), and fibromyalgia (14%)], completed questionnaires including demographics, Brief Pain Inventory (BPI), Pain Catastrophizing Scale (PCS), and Hospital Anxiety and Depression Scales (HADS). Pearson correlations and bootstrapped mediation analyses were conducted to examine the relationships among education, psychosocial, and pain variables. Education was inversely correlated with pain intensity and interference, pain catastrophizing, anxiety, and depression (p < .05). Pain catastrophizing significantly mediated the relationship between education and pain intensity (95%CI [-.05, -.01]), and catastrophizing and depression mediated the effects of education on pain interference (95% CI [-.08, -.01]; 95%CI [-.06, -.01]). Anxiety did not mediate either relationship. These findings indicate that greater pain catastrophizing, and in part depression, partly drive the relationship between lower educational attainment and worse pain outcomes. This work importantly aims to reduce pain disparities and provides direction for psychosocial treatment, suggesting that pain catastrophizing may be a particularly critical target in patients with lower education level. / 2026-02-23T00:00:00Z

Pain catastrophizing (PC) and fear of pain (FOP) are understudied across different race/ethnicity minorities. The association between these constructs and psychological disorders with relation to chronic pain are understudied as well. Prior research indicates that racial/ethnic minority populations may engage in more PC and FOP than white, non-Hispanic populations. These studies, however, have only examined macro-level differences between white, non-Hispanic and minority populations. Less is known about the nuanced differences in PC and FOP across individual racial/ethnic groups (i.e., white vs. Asian vs. Black/African American). The current study explores between-group differences in PC and FOP across diverse racial/ethnic groups of youth with chronic pain while also observing the association between anxiety/depression and PC/FOP in these populations. Youth (ages 11-17) with chronic pain presenting for treatment to a tertiary pediatric pain clinic completed the Pain Catastrophizing Scale (PCS), which includes a total score and subscales (i.e., rumination, magnification, and helplessness) and the Fear of Pain Questionnaire. Racial/ethnic group sizes were as follows: Black/non-Hispanic (N = 29), Hispanic (N = 58), Asian (N = 17), another race/non-Hispanic (N = 37), and Multiracial (N = 15). One-way ANOVAs were conducted to test differences in the PCS total score and subscales as well as FOP among racial/ethnic groups, and Chi-square analyses were conducted to test the association between binary codes of anxiety/depression diagnoses provided in the data repository and the race/ethnicity minorities, respectively. Results revealed non-significant differences in total PCS and PCS subscales across race/ethnicity minority groups. In addition, there were no statistically significant differences in FOP across race/ethnicity minority groups. However, there were some clinically significant differences between mean PCS and FOP scores across certain racial/ethnic minority groups. Finally, no significant associations emerged between anxiety and race/ethnicities or between depression and race/ethnicities. Findings suggest that youth with chronic pain may experience PC and FOP similarly regardless of their racial/ethnic backgrounds. However, these findings were limited by small sample sizes across groups, and future research with larger sample sizes is warranted. These results can inform continued exploration and sensitivity to diversity, equity, and inclusivity issues in healthcare for pediatric chronic pain patients.

Chronic pain affects nearly 48 million Americans (Haggard, Stowell, Bernstein, & Gatchel, 2008). Established guidelines for pain management encourage the use of personality assessment in chronic pain evaluation (Karlin, Creech, Grimes, Clark, Meagher, & Morey, 2005). In relation to the Big Five personality factors, low Openness relates negatively to treatment success, (Hopwood, Creech, Clark, Meagher, & Morey, 2008), and elevated Neuroticism scores also correlate with increased pain levels among individuals in hospital or rehab settings (Ashgari & Nicholas, 2006; Nitch & Boon, 2004). In contrast to these prior studies, this study identifies correlates in a relatively high-functioning population (college students) to further elucidate the connection between chronic pain and personality. This study compares scores on the NEO-FFI (Costa & McCrae, 1992), the West Haven-Yale Multidimensional Pain Inventory (WHYMPI, Kerns, Turk, & Rudy, 1985), and the Pain Catastrophizing Scale (PCS, American Academy of Orthopaedic Manual Physical Therapists, 2010). Significant correlations were found between Neuroticism, Extraversion, and Agreeableness and select subscales of both the WHYMPI and the PCS. A linear regression of scores showed that Neuroticism was very strongly related to WHYMPI scores. In fact, the WHYMPI scores accounted for 67.9% of variance in Neuroticism. Scores on the WHYMPI also correlated with PCS scores. Helplessness and Overall scores significantly correlated to Life Control and certain positive social support scores. The findings of this study emphasize the need for pain clinicians to incorporate psychological assessments, especially concerning Neuroticism, into their evaluations of chronic pain patients.

Fibromyalgi (FM) är en kronisk sjukdom som innebär långvarig smärta, fatigue och hjärntrötthet. Symtomen leder till kognitiva begränsningar som koncentrationssvårigheter och minnessvårigheter samt psykiska ohälsa som ångest och depression. Behandlingen är både farmakologisk och icke-farmakologisk. FM vårdas antigen via primärvården eller via smärtrehabiliterings team. Sjuksköterskor upplever svårigheter vid vården av denna grupp dels på grund av smärtproblematiken dels på grund av bristande kunskap. Syftet var att beskriva personers upplevelse av att leva med fibromyalgi. Litteraturstudien har en beskrivande design. Sökningen genomfördes på Medline via Pubmed och gav 22 vetenskapliga artiklar med kvalitativ ansats. Sedan har11 artiklar tagits fram genom relevans- och kvalitetsgranskning. I resultatet framkom fyra teman; utmaningar i arbetslivet, bristande bemötande från sjukvården, komplexa relationer och svårigheter i det sociala livet och begränsningar i vardagen. Dessa teman visade att FM har en stor inverkan på flera områden i människors liv och har en stor effekt på hur dessa personer upplever livet. Det framkom även att patientgruppen upplever undermåligt bemötande från omvårdnadspersonal däremot när vården är gynnsam upplever patientgruppen en bättre psykisk hälsa. Upplevelsen av att leva med fibromyalgi innebär stora utmaningar inom flera områden i livet. Personer med FM upplever bristande bemötande i sjukvården, däribland ifrågasättande attityder och undermålig kunskap från vårdpersonal. Däremot när vården fungerar fördelaktigt leder den till en bättre psykisk hälsa. Därför är det viktigt att förbättra sjuksköterskors kunskap och förståelse för upplevelsen av att leva med fibromyalgi. / Fibromyalgia (FM) is a chronic disease with chronic pain, fatigue, and brain fog. The symptoms often result in cognitive difficulties such as concentrations and memory difficulties as well as mental illness such as anxiety and depression. Intervention can be both pharmaceuticals as non-pharmaceutical. Healthcare is generally provided through primary care and pain rehabilitation teams for patients with FM. Nurses experience difficulties treating these individuals, partly because of the chronic pain difficulties and partly due to lack of knowledge. The aim was to describe the experience to live with fibromyalgia. This literature review had a descriptive design. The search was conducted on Pubmed and produced 22 qualitative articles. Thereafter the qualitative articles have been exanimated with relevance- and quality templets, 11 articles were selected for the literature review. The main findings are presented as four themes. These were challenges in the workplace, inadequate care from healthcare staff, complex relationships and difficulties in social life and limitations in everyday life. These themes indicate that FM have a great impact on several aspects in an individual’s life thus FM has a major impact on the experience of life. Another finding indicated substandard care from the healthcare staff regarding patients with FM, when the care is favourable these patients experience better mental health. The experience of living with FM consist of challenges in all areas of life. They experience substandard care such as condescending attitudes and a lack of understanding. Beneficial care leads to better mental health. Therefore it´s important to improve nurses’ knowledge and understanding regarding the experience of living with FM.

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