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Chronic pain is one of the most common health conditions, affecting nearly six million Canadian adults. Despite abundant research on chronic pain in general, there is limited knowledge on how racialized immigrant women experience living with chronic pain and how this relates to their broader social circumstances. The purpose of this qualitative, exploratory study is to understand living with chronic disabling pain as situated in and contextualized by the lived experiences of immigrant women residing in Ottawa, Ontario, and to explore the perspectives of the women's care partners as well as physicians providing care for chronic pain. Semi-structured interviews were conducted with 24 participants. The dissertation is guided by the social determinants of health framework and an intersectional lens. Four interconnected themes from the data analysis have been generated: (1) The trajectory and meaning of pain; (2) Reasons for pain and triggering factors; (3) Pain consequences; and (4) Coping and control. Findings indicate that chronic pain is a subjective, complex, biopsychosocial, and multidimensional phenomenon. Pain is a deeply personal experience linked with meaning. Results also highlight an association between the distribution of the social determinants of health during the life course and pain. Furthermore, the pain has profound, multidimensional impacts on the women and their families, and its treatment is a challenging task for health care professionals. In addition, the findings show that pain is often poorly recognized, underestimated, and inadequately managed. Finally, the results illustrate the perseverance and incredible resilience of the women and their carers. The findings provide several implications for policy, research, and practice.

Syfte. Studiens syfte var att retrospektivt undersöka vilka kliniska variabler, bedömda under specialistundersökning av orofacial smärta, som kan förutsäga närvaro av en störd central smärtmodulering (DCPM). Material och metod. DC/TMD-data hämtades ur patientjournaler från 86 patienter som undersökts på Orofaciala smärtenheten på Malmö Universitet under perioden september 2012 till och med december 2013. Undersökta variabler omfattade smärtintensitet, smärtutbredning, smärtrelaterad nedsatthet, psykosociala variabler, refererad smärta samt kliniska fynd under somatosensoriska undersökningar. Baserat på denna data delades patienterna upp i en DCPM-grupp och en grupp utan DCPM. Allodyni, hyperalgesi, dysestesi, wind-up, regional/generell smärtutbredning samt eftersensation ansågs vara markörer för DCPM. Icke-parametriska statistiska analyser användes och en sannolikhetsnivå på P<0,05 ansågs vara signifikant. Resultat. Graden av ospecifika fysiska symptom och antalet refererande smärtor var signifikant högre i DCPM-gruppen. Den multivariata logistiska regressionen visade att ospecifika fysiska symptom, stress, smärtduration, smärtintensitet, smärtrelaterad nedsatthet, antalet refererande smärtpunkter, maximal gapning med och utan smärta, ångest samt antalet smärtinducerande käkrörelser var signifikanta marörer för DCPM (LR Chi2 = 26.89, p = 0.003, Pseudo R2 = 0.29). Slutsats. Denna studie indikerar att stress, ångest, smärtduration, smärtintensitet, smärtrelaterad nedsatthet, antalet refererande smärtpunkter, maximal gapning med och utan smärta samt antalet smärtinducerande käkrörelser är associerat med DCPM hos patienter med orofacial smärta. / Objective. To retrospectively investigate clinical variables that can predict the presence of disturbed central pain modulation (DCPM). Material and methods Medical records of 86 patients examined at the Orofacial Pain Unit at Malmö University from September 2012 to December 2013 were examined regarding pain intensity, pain distribution, pain-related disability, psychosocial variables, referred pain as well as somatosensory changes. Based on these variables, the patients were divided into a disturbed central pain modulation (DCPM) group and a non-DCPM group. Allodynia, hyperalgesia, dysesthesia, increased wind-up, regional/general pain distribution and aftersensation were considered as markers for DCPM. Non-parametric statistics were used and a probability level of P<0.05 was considered as significant. Results. The degree of unspecific physical symptoms and the number of sites eliciting pain referral were significantly higher in the DCPM group. In the multivariate regression model, the independent variables physical symptoms, stress, pain duration, characteristic pain intensity, pain-related disability, number of sites with referred pain, maximum mouth opening with and without pain, anxiety, and number of pain eliciting jaw movements significantly predicted DCPM (LR Chi2 = 26.89, p = 0.003, Pseudo R2 = 0.29). Conclusion. This study indicates that stress, anxiety, orofacial pain and its consequences, unspecific physical symptoms and jaw dysfunction are clinical signs of DCPM in patients with orofacial pain. Also, high number of palpations sites with referred pain over the masseter and temporal muscles and the TMJ indicate presence of DCPM.

Pediatric chronic pain is a common developmental health problem with negative effects that can influence youth throughout their lives. Cognitive behavioral therapy is an efficacious treatment for pain management; however, treatment compliance among adolescents is a major problem. Emerging research suggests that some family-level factors play a role in treatment engagement and outcomes. Moreover, adolescents with greater coping and resilience strategies are more likely to benefit from treatment. However, it is not clear to what extent (a) other family factors predict short-term (3-month) and long-term (6-month) treatment compliance among adolescents with chronic pain, (b) adolescent-level factors predict treatment compliance, and (c) family-level factors interact with adolescent-level factors to predict treatment compliance (i.e., through moderating pathways). In addition, the association of family-level risk factors and adolescent-level resilience factors with functional impairment needs to be further investigated. To address these gaps, the current study explored factors that may predict treatment compliance and functional impairment within a multidisciplinary pediatric pain management program. Sixty-four adolescents (M = 15.00 ± 1.69 years; 85.9% female; 84.4% Caucasian, 6.3% African American/Black, 1.6% Hispanic/Latino, 1.6% Asian, 4.7% Mixed Race, 1.6% “Other”) diagnosed with chronic pain and their primary caregivers were assessed at three time points: their initial intake in the program (N=64), 3-months post-intake (n=62), and 6-months post-intake (n=61). Most family-level and adolescent-level factors, as well as the interaction of these factors, did not predict improved treatment compliance. However, consistent with prior research, several family-level and adolescent-level factors were associated with increased functional impairment among this sample. Study limitations and statistical concerns warrant that these findings be interpreted with caution. Results contribute to our understanding of the importance of family-level factors within the developmental context of adolescence, while also highlighting the need for investigating other relevant influences towards treatment compliance and functional impairment. Delineating such characteristics can inform assessment, as well as tailor treatment targets, recommendations, and outcomes among adolescents with chronic pain within a multidisciplinary treatment setting. / Psychology

This dissertation is informed by lived experience of disability, artistic practice, and medical practice. My dissertation is also intended to be a model of how to bring to bear professional expertise, personal history, and personal obligations on scholarship. An inter-field survey of critical lenses within the humanities is developed, making for a heterogeneous model of engagement for scholars interested in studying medicine and medical representations in literature and other artistic genres and forms. A fusion of fields is created, demonstrating that many different approaches can be brought to bear – a deliberate choice because medicine is in need of critique from the humanities. Settler/bioscientific epistemologies are unpacked alongside Indigenous epistemologies. Metaphor, intersubjectivity, Indigenous place-thought, and disability studies are also deployed. I develop a way to link all of these pieces when they use the representation of pain as a common cause. I respectfully consider Indigenous knowledge without defining same or clinicalizing their knowledges. Ultimately, I develop a pain poetics. / Thesis / Doctor of Philosophy (PhD)

Indiana University-Purdue University Indianapolis (IUPUI) / Compared to people who are White and have high socioeconomic status (SES), those who are Black and have low SES are more likely to receive suboptimal pain care. One potential contributor to these disparities is biased provider decision-making—there is compelling evidence that providers are influenced by patient race and SES when making pain treatment decisions. According to the dual process model, people are more likely to be influenced by demographic stereotypes, including implicit beliefs, when they are under high cognitive load (i.e., mental workload). One stereotype belief relevant to pain care is that Black and low SES people are more pain tolerant. Aligned with the dual process model, providers who are under high cognitive load and have strong implicit beliefs that Black and low SES people are more pain tolerant may be particularly likely to recommend fewer pain treatments to them. To test this hypothesis, I recruited physician residents and fellows (n=120) to make pain treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the providers were randomized to the high cognitive load group in which they were interrupted during the decision task to make conversions involving hypertension medications for another patient. Remaining providers completed the task without being interrupted. Providers’ implicit beliefs about race and SES differences in pain tolerance were measured with two separate Implicit Association Tests (IATs). Multilevel modeling indicated that providers recommended stronger medications to low than high SES patients (OR=.68, p=.03). There was also a significant interaction between patient SES and cognitive load (OR=-.56, p=.05) and a trending interaction between patient race and cognitive load (OR=1.7, p=.07). Under low cognitive load, providers recommended more pain treatments to high SES (vs. low SES) and Black (vs. White) patients, but under high cognitive load, providers recommended more pain treatments to low SES (vs. high SES) patients and equivalent treatment to Black and White patients. There were no three-way interactions between patient demographics (race or SES), cognitive load, and providers’ implicit beliefs (race-pain or SES-pain IAT scores). However, there was a trending interaction between patient race and race-pain IAT scores (OR=2.56, p=.09). Providers with stronger implicit beliefs that White people are pain sensitive and Black people are pain tolerant recommended more pain treatments to White patients and fewer pain treatments to Black patients. Lastly, there was a trending effect that providers with stronger implicit beliefs that high SES people are pain sensitive and low SES people are pain tolerant recommended stronger medications in general (OR=13.03, p=.07). Results support that provider cognitive load is clinically relevant and impacts clinical decision-making for chronic pain for racially and socioeconomically diverse patients. Future studies are needed to further understand the impact of cognitive load on providers’ pain care decisions, which may inform evidence-based interventions to improve pain care and reduce disparities.

Bakgrund Smärta som varar längre än tre månader klassas som långvarig. Denna smärta kan leda till funktionsnedsättning och ökar behovet av vård och sjukskrivning. Långvarig smärta påverkar personer fysiskt och psykosocialt. Det kan leda till ångest och depression. Copingstrategier är de metoder som en individ kan använda sig av för att hantera sin smärta. Syfte Syftet var att belysa erfarenheter av copingstrategier hos patienter med långvarig smärta. Metod Designen för detta arbete var en icke-systematisk litteraturöversikt. Litteratursökningarna gjordes i databaserna PubMed, PsycInfo och CINAHL. De 12 artiklar som inkluderades i resultatet granskades med stöd av Sophiahemmet Högskolas bedömningsunderlag. Den dataanalysmetod som användes i denna litteraturöversikt var en integrerad analys. Resultat Resultatet delades in i tre huvudkategorier: fysiska copingstrategier, mentala copingstrategier och sociala copingstrategier. De huvudfynd som hittades var att träning som copingstrategi kunde vara mycket hjälpsamt för smärthantering men kunde även leda till ökad smärta och ångest. Vila och planering gjorde mycket för patienters energi. Andlighet och inställning bidrog till en ökad acceptans. Relationer, emotionellt stöd och sysselsättning visade sig vara effektiva copingstrategier. Slutsats Många olika typer av copingstrategier användes av patienter, men det framkom att ingen copingstrategi passade alla. Denna litteraturöversikt visade att det kan vara svårt för vården att rekommendera copingstrategier. Dock visade det sig att en sjuksköterska behöver vara lyhörd i mötet med patienter med långvarig smärta och bör kunna förmedla kunskap kring copingstrategier. Vidare kan sjuksköterskan fungera som stöd och guida patienter till att hitta de strategier som fungerar för dem. / Background Pain that lasts longer than three months is classified as chronic. This pain can lead to disability and increases the need for healthcare and sick leave. Chronic pain can affect individuals physically and psychosocially. It can lead to anxiety and depression. Coping strategies are the methods an individual can use to manage their pain. Aim The aim was to illustrate experiences of coping strategies in patients with chronic pain. Method The design of this study was a non-systematic literature review. Literature searches were conducted in the databases PubMed, PsycInfo, and CINAHL. The 12 articles included in the result were reviewed using the assessment tool from Sophiahemmet University. The data analysis method used in this litterature review as an integrated analysis. Results The results were divided into three main categories: physical coping strategies, mental coping strategies and social coping strategies. The key findings were that exercise as a coping strategy could be very helpful for pain management but could also lead to increased pain and anxiety. Rest and planning significantly benefited patients' energy. Spirituality and mindset contributed to increased acceptance. Relationships, emotional support, and employment were shown to be effective coping strategies. Conclusions Many different types of coping strategies were used by patients, but it emerged that no coping strategy suited everyone. This literature review showed that it can be challenging for healthcare providers to recommend coping strategies. However, it was found that a nurse needs to be responsive in the encounter with a patient with chronic pain and should be able to convey knowledge about coping strategies. Furthermore, the nurse can serve as a support and as a guide to aid patients in finding the strategies that work for them.

Prolonged computer work is associated with high rates of neck and shoulder pain symptoms, and as computers have become increasingly more common, it is becoming critical that we develop sustainable interventions targeting this issue. Static muscle contractions for prolonged periods often occur in the neck/shoulder during computer work and may underlie muscle pain development in spite of rather low relative muscle load levels. Causal mechanisms may include a stereotypical recruitment of low threshold motor units (activating type I muscle fibers), characterized by a lack of temporal as well as spatial variation in motor unit recruitment. Based on this theory, although studies have postulated that individuals with chronic neck-shoulder pain will show less variation in muscle activity compared to healthy individuals when engaged in repetitive/monotonous work, this has seldom been verified in empirical studies of actual computer work. Studies have rarely addressed temporal patterns in muscle activation, even though there is a consensus that temporal activation patterns are important for understanding fatigue and maybe even risks of subsequent musculoskeletal disorders. This study applied exposure variation analysis (EVA) to study differences in temporal patterns of trapezius muscle activity as individuals with and without pain performed computer work. The aims of this study were to: Assess the reliability of EVA to measure variation in trapezius muscle activity in healthy individuals during the performance of computer work; Determine the extent to which healthy subjects differ from those with chronic pain in trapezius muscle activity patterns during computer work, measured using EVA. Thirteen touch-typing, right-handed participants were recruited in this study (8 healthy; 5 chronic pain). The participants were asked to complete three 10-minute computer tasks (TYPE, CLICK and FORM) in two pacing conditions (self-paced, control-paced), with the healthy group completing two sessions and the pain group completing one. Activation of the upper trapezius muscle was measured using surface electromyography (EMG). EMG data were organized into 5x5 EVA matrices with five amplitude classes (0-6.67, 6.67-20, 20-46.67, 46.67-100, >100% Reference Voluntary Exertion) and five duration classes (0- 1, 1-3, 3-7, 7-15, >15 seconds). EVA marginal distributions (along both amplitude and duration classes) for each EVA class, as well as summary measures (mean and SD) of the marginal sums along each axis were computed. Finally, “resultant” mean and SD across all EVA cells were computed. The reliability in EVA indices was estimated using intra-class correlation coefficients (ICC), coefficient of variation (CV) and standard error of measurement (SEM), computed from repeated measurements of healthy individuals (aim 1), and EVA indices were compared between groups (aim 2). Reliability of EVA amplitude marginal sums ranged from moderate to high in the self-paced condition and low to moderate in the control-paced condition. The duration marginal sums were moderate in the self-paced condition and moderate to high in the control-paced condition. The summary measures (means and SDs) were moderate to high in both the self-paced and control-paced condition. Group comparisons revealed that individuals with chronic pain spent longer durations of work time in higher EVA duration categories, exhibited larger means along the amplitude, duration and in the resultant, and higher EVA SD in the amplitude and duration axes as compared to the healthy group. To our knowledge, this is the first study to report on the reliability of EVA applied specifically to computer work. Furthermore, EVA was used to assess differences in muscle activation patterns as individuals with and without chronic pain engaged in computer work. Individuals in the pain group seemed to exhibit prolonged sustained activation of the trapezius muscle to a significantly greater extent than controls, even though they did not experience pain during the performance of the computer tasks (as obtained through self-reports). Thus, these altered muscle recruitment patterns observed in the pain subjects, even in the absence of task-based pain/discomfort, are suggestive of chronic motor control changes occurring in adaptation to pain, and may have implications for the etiology of neck and upper-limb musculoskeletal disorders. / Master of Science / This study aims to assess the reliability of exposure variation analysis (EVA) to measure variation in trapezius muscle activity in healthy individuals during the performance of computer work, and to determine the extent to which healthy subjects differ from those with chronic pain in trapezius muscle activity patterns during computer work, measured using EVA. Muscle activation was recorded for eight healthy individual and five suffering from chronic neck-shoulder pain. The data were then categorized into amplitude and continuous time categories, and summary measures of resulting distributions were calculated. These measures were used to assess the reliability of participant responses to computer work of healthy individuals, as well as quantify differences between those with and without chronic pain. We found that individuals with pain activated their neck-shoulder muscles for longer continuous durations than healthy individuals, thus showing an inability to relax their muscles when performing work.