La recherche dans le domaine de la prise en charge de la douleur, notamment chronique, a un besoind’innovation car les traitements disponibles à l’heure actuelle sont pour la plupart anciens et souventliés à des effets indésirables. Il est maintenant admis que les études précliniques de la douleur ont denombreuses limites : pertinence des modèles, utilisation d’une stimulation douloureuse surajoutée,détermination d’un simple seuil ou délai, prise en compte de la seule composante sensoridiscriminative…De ce fait, certaines molécules efficaces chez l’animal et donc prometteuses, n’ontpas eu les effets escomptés chez l’homme. La base de notre travail de recherche s’attache donc àproposer de nouvelles méthodes d’appréciation de la douleur chronique chez l’animal en prenant encompte ses aspects multidimensionnels. De nombreuses études ont mis en évidence une altération dela qualité de vie chez des patients atteints de douleur chronique. Cette altération se caractérisenotamment par des perturbations émotionnelles et cognitives. Ces paramètres ne sont pas toujours prisen compte chez l’animal dans l’évaluation de traitements antalgiques mais pourrdouleurnt amener denouvelles possibilités et perspectives précliniques. Notre travail a consisté à étudier l’impact de ladouleur sur les comportements spontanés (automatisation du test au formol), la composanteémotionnelle et les capacités cognitives chez le rongeur. Il a été complété par l’exploration du rôle del’amygdale dans les mécanismes impliqués dans ces modifications comportementales.L’amélioration du test au formol a été réalisée dans le but de visualiser au mieux les comportementsspécifiques observés lors d’une douleur aiguë de type inflammatoire. Notre adaptation a permis, chezles mêmes animaux, de pouvoir dissocier l’effet antalgique et l’effet sédatif d’une molécule à l’aided’une méthode automatisée plus rapide et moins subjective.Parallèlement, nous avons apprécié l’impact de la douleur chronique sur la composante émotionnelleet les performances cognitives dans deux modèles de douleur chronique (inflammatoire etneuropathique). Les animaux souffrant de douleur chronique inflammatoire présentent desperturbations plus importantes que les animaux neuropathiques, perturbations pouvant être amélioréespar un traitement pharmacologique. Des études mécanistiques utilisant des micro-injections demorphine au niveau de l’amygdale ont souligné une implication importante du complexe basolatéraldans ces composantes émotionnelles et cognitives de la douleur.Ces nouvelles approches comportementales pourrdouleurnt permettre de mieux caractériser l’impact globalde la douleur chronique chez l’animal et de compléter la batterie de tests couramment utilisés enpréclinique. Ceci pourrait déboucher sur une transposition plus réaliste des résultats obtenus chezl’animal à l’homme, et donc conduire à une meilleure prédictibilité clinique de l’efficacité destraitements. Enfin, la mise en évidence de nouvelles cibles thérapeutiques innovantes implique l’étudedes mécanismes responsables de ces altérations comportementales. / Research in the field of pain management, including chronic pain management, needs innovationbecause available treatments are mostly old and often associated with many side effects. It is now wellrecognized that preclinical studies on pain have many limitations: the relevance of the models, the useof imposed painful stimulations, determination of simple thresholds or delays, taking into account thesensory-discriminative component of pain alone… Indeed, some molecules that are efficient inanimals and that are considered as promising, didn’t have the desired effect in humans. Therefore, thebasis of our research aims to propose new methods to assess chronic pain in animals taking intoaccount its multidimensional aspects. Many studies have shown impaired quality of life in patientssuffering from chronic pain. This alteration is characterized by emotional and cognitive disturbances.These components of pain are not always taken into account in animal when studying analgesictreatments, but could bring new preclinical possibilities and perspectives. Our work consisted instudying the impact of pain on spontaneous behaviours (automated formalin test), emotionalcomponent and cognitive capacities in rodents. This work has been completed by the exploration ofthe role of the amygdala in the mechanisms underlying those behavioural modifications.Improvement of the formalin test was conducted in order to better visualize the specific behaviorsobserved during an acute inflammatory pain. Our adaptation has allowed dissociating the analgesicand sedative effect of a molecule in a same animal, using an automated method which is faster and lesssubjective than the manual method.In the meantime, we assessed the impact of chronic pain on the emotional and cognitive performancesin two models of chronic pain (inflammatory and neuropathic). Animals suffering from chronicinflammatory pain have more important impairments than animal suffering from neuropathic pain,impairments that can be improved with a pharmacological treatment. Mechanistic studies using microinjectionsof morphine in the amygdala have emphasized an important involvement of the basolateralcomplex in these emotional and cognitive components of pain.These new behavioural approaches may help better characterize the overall impact of chronic pain inanimals and complete the battery of tests commonly used in preclinical studies. This could lead to amore realistic transposition of the results obtained from animals to humans, and thus lead to betterpredictability for the clinical efficacy of treatments. Finally, the identification of new targets forinnovative therapies involves the study of mechanisms responsible for these behavioral impairments.

<p>As the number one cause of sick absenteeism and disability pension, musculoskeletal pain is considered a major health problem in Sweden and many other industrialized countries. Medical findings are often insufficient to explain the pain’s intensity or duration, and psychological factors are known to be important in understanding the aetiology and maintenance of pain. The current thesis examines the relationship between non-specific chronic musculoskeletal pain and cognitions, emotions and behaviours. In Study I, chronic pain patients were interviewed about pain experiences and the results indicated that some patients use psychological defences to deal with chronic pain. Study II was an experimental approach set up to study the association between chronic pain and selective memory. In a pictorial memory game, no differences were found between patients and controls in the neutral game. In the pain-related game patients decreased – and controls improved – their performance, a finding discussed in terms of cognitive avoidance. Study III used questionnaire and register data to examine the predictive value of psychosocial variables on sustained pain-related sick absenteeism and the results showed sense of mastery and recovery beliefs to be especially important. The studies are discussed in terms of emotional and defensive coping and it is suggested that defences can be related to excessive activity, which may increase the risk of future relapses. It was suggested that an increased acceptance of pain, at both an individual and a societal level – would favour rehabilitation and return-to-work for those suffering from persistent pain.</p>

<p>This thesis deals with clinical pain intervention research from a behavioural medicine perspective. The general aim was to develop and evaluate an individually tailored treatment protocol focused on pain management in everyday life in people who experience persistent musculoskeletal pain. Another aim was to develop and incorporate an idiographic outcome measure for behavioural goal assessment in the formal evaluation of the clinical significance of treatment outcomes. </p><p>The studies were conducted in a primary health care setting demonstrating a contribution from physical therapists in the field of behavioural medicine. Two separate samples of patients with musculoskeletal pain with a duration exceeding one month, n = 197 (Study I, descriptive and correlational design), and n = 97/82 (Study III/IV, randomized group-study) were included. In addition, four women were recruited for a series of experimental single-case studies (Study II).</p><p>The treatment protocol that was individually tailored to each participant’s behavioural treatment goals and assumed determinants of pain-related disability was more effective in reducing pain-related disability, pain intensity, fear-avoidance, and in increasing pain control when compared to an intervention including physical exercises. The individually tailored treatment was generally more beneficial for resumption of everyday life activity, increasing satisfaction, fulfilling pre-treatment expectations, and in preparing individuals for self-management of pain. The Patient Goal Priority Questionnaire that was elaborated over the course of the project can be used to a) identify and assess behavioural treatment goals, b) elaborate individual functional behavioural analyses relevant for everyday life functioning, and c) determine the clinical significance of treatment outcomes – that is, whether interventions produce outcomes of relevance for each individual’s everyday life. The inclusion of idiographic outcome measures in clinical pain intervention research is necessary and improves the ecological validity of the evaluation of clinical significance. </p>

Groin hernia is common, and each year 200 repairs per 100 000 adult inhabitants are performed in Sweden. Groin hernias are either inguinal or femoral (2-4%). Elective repair is not associated with an excess mortality, but adverse outcomes include recurrence and long-term pain. Emergency procedures have a 4% mortality rate with an increased risk for bowel resection and postoperative complications. The aim of this thesis was to identify risk factors for adverse outcomes and to propose measures to improve groin hernia treatment. Twenty-three per cent of female hernias were femoral. Thirty-six per cent of femoral hernias, and 5% of inguinal hernias, have emergency procedures. Females (OR 1.47) and patients above 65 years-of-age (OR 2.24) were at higher risk for emergency repair. Bowel resection was performed in 23% of emergency femoral repairs, and the 30-day mortality was 10 times that of an age- and gender-matched population. The majority of emergency patients were unaware of their hernia, and one third had previously had no groin symptoms. Femoral repairs were at larger risk for recurrence than inguinal repairs. The surgical techniques with least risk for recurrence were preperitoneal mesh repairs (open HR 0.28, and laparoscopic HR 0.31). Long-term pain was present in 24% of femoral hernia patients, of whom 5.5% described pain interfering with daily activities. The only factor predicting the risk for long-term pain was pain preoperatively. Pain decreased with time. In a randomized study on inguinal hernia, TEP resulted in less pain six weeks after surgery than Lichtenstein repair performed under local anesthesia (LLA). TEP patients were to a larger extent able to perform sporting activities. No difference was seen in intra-operative complications. Femoral hernias should be given high priority for repair and preperitoneal techniques should be used. Earlier diagnosis, in the elective setting, is probably difficult to attain. Heightened awareness in the emergency department is required. TEP is safe, and results in less pain than LLA six weeks after surgery. A widening of indications for TEP in primary inguinal hernia repair is justifiable.

This thesis deals with clinical pain intervention research from a behavioural medicine perspective. The general aim was to develop and evaluate an individually tailored treatment protocol focused on pain management in everyday life in people who experience persistent musculoskeletal pain. Another aim was to develop and incorporate an idiographic outcome measure for behavioural goal assessment in the formal evaluation of the clinical significance of treatment outcomes. The studies were conducted in a primary health care setting demonstrating a contribution from physical therapists in the field of behavioural medicine. Two separate samples of patients with musculoskeletal pain with a duration exceeding one month, n = 197 (Study I, descriptive and correlational design), and n = 97/82 (Study III/IV, randomized group-study) were included. In addition, four women were recruited for a series of experimental single-case studies (Study II). The treatment protocol that was individually tailored to each participant’s behavioural treatment goals and assumed determinants of pain-related disability was more effective in reducing pain-related disability, pain intensity, fear-avoidance, and in increasing pain control when compared to an intervention including physical exercises. The individually tailored treatment was generally more beneficial for resumption of everyday life activity, increasing satisfaction, fulfilling pre-treatment expectations, and in preparing individuals for self-management of pain. The Patient Goal Priority Questionnaire that was elaborated over the course of the project can be used to a) identify and assess behavioural treatment goals, b) elaborate individual functional behavioural analyses relevant for everyday life functioning, and c) determine the clinical significance of treatment outcomes – that is, whether interventions produce outcomes of relevance for each individual’s everyday life. The inclusion of idiographic outcome measures in clinical pain intervention research is necessary and improves the ecological validity of the evaluation of clinical significance.

As the number one cause of sick absenteeism and disability pension, musculoskeletal pain is considered a major health problem in Sweden and many other industrialized countries. Medical findings are often insufficient to explain the pain’s intensity or duration, and psychological factors are known to be important in understanding the aetiology and maintenance of pain. The current thesis examines the relationship between non-specific chronic musculoskeletal pain and cognitions, emotions and behaviours. In Study I, chronic pain patients were interviewed about pain experiences and the results indicated that some patients use psychological defences to deal with chronic pain. Study II was an experimental approach set up to study the association between chronic pain and selective memory. In a pictorial memory game, no differences were found between patients and controls in the neutral game. In the pain-related game patients decreased – and controls improved – their performance, a finding discussed in terms of cognitive avoidance. Study III used questionnaire and register data to examine the predictive value of psychosocial variables on sustained pain-related sick absenteeism and the results showed sense of mastery and recovery beliefs to be especially important. The studies are discussed in terms of emotional and defensive coping and it is suggested that defences can be related to excessive activity, which may increase the risk of future relapses. It was suggested that an increased acceptance of pain, at both an individual and a societal level – would favour rehabilitation and return-to-work for those suffering from persistent pain.

This thesis is on chronic neck pain after a rear impact car injury, so called whiplash associated disorder (WAD). Three empirical studies using positron emission tomography (PET) with different radioligands have been performed. The first study evaluated resting state regional cerebral blood flow (rCBF) in WAD patients and in healthy, pain-free controls, by use of oxygen-15 labeled water. Patients had heightened resting rCBF bilaterally in the posterior parahippocampal and the posterior cingulate gyri, in the right thalamus and in the right medial prefrontal gyrus. Attenuated tempero-occipital blood flow was also observed in the patient group as compared to healthy controls. Alterations in rCBF were related to patients’ neck disability ratings. Study I suggests an involvement of the posterior cingulate, the parahippocampal and the medial prefrontal gyri in WAD. This altered resting state neural activity may be linked to an increased self-relevant evaluation of pain and stress. The second study evaluated central expression of the neurokinin-1 (NK1) receptor in WAD patients and healthy controls. Using a carbon-11 labeled specific NK1 antagonist, the receptor availability was measured. Patients displayed lowered NK1 receptor availability in the insula, anterior cingulate, frontal lobe, hippocampus, amygdala and in the periaqueductal gray matter, consistent with results from animal models of chronic pain. NK1 receptor availability was most reduced in the ventromedial orbitofrontal cortex, where attenuations were linearly related to patients fear and avoidance of movement. Thirdly, carbon-11 labeled D-deprenyl was used to investigate the presence of locally inflamed soft tissue in the cervical neck in WAD patients. Although the retention mechanism of [11C]D-deprenyl is not known, the results suggest that WAD patients have chronic inflammatory processes in the neck, most commonly in the adipose tissue at the spineous process of the second vertebra. In summary, this thesis provides evidence for altered central blood flow and receptor characteristics in WAD patients. Further, WAD patients may also have signs of persistent peripheral tissue damage. Both central and peripheral pain mechanisms have been demonstrated and visualized in patients with whiplash associated disorder.

It is widely accepted that the unique painful and non-painful sensations in neuropathic pain are the result of particular mechanisms, and that specific management strategies for neuropathic pain should be applied to tackle them. Ideally, the treatment of chronic pain should be directed at eliminating the cause of pain, but in reality this is rarely possible. The management of chronic pain is therefore often limited to reducing the intensity of such pain and associated symptoms. Pain is essentially a subjective phenomenon described with patient-specific symptoms and expressed with a certain intensity. It therefore makes sense to examine the value of verbal descriptors and pain qualities as a basis for distinguishing neuropathic pain from other types of chronic pain. Work by Dubuisson and Melzack (1976) and later by Boureau et al. (1990) supported anecdotal opinion that key words might be discriminatory for neuropathic pain. In the last 5 years, much research has been undertaken to develop screening tools for this purpose. These tools are based on verbal pain description with, or without, limited bedside testing. This paper reviews the strengths and weaknesses of such tools.

Bakgrund: SBU (2006) efterfrågade mer evidens för Acceptance and Commitment Therapy, (ACT) mot långvarig smärta då det både är en stor orsak till lidande och en dyr samhällskostnad (87,5 miljarder kr, år 2003). Enheten för Långvarig Smärta – Avdelning, (ELS-A) är den enda vårdavdelningen i Sverige som behandlar långvarig smärta med ACT. Syfte: Att undersöka hur patienter, som för minst ett år sedan genomgått ACT-behandling på en slutenvårdsavdelning med långvariga smärttillstånd som specialitet, upplevde behandlingsmetoden och dess resultat samt sjuksköterskans roll vid behandlingen. Metod: Kvalitativ forskningsintervju med semi-strukturerade frågor tillämpades för datainsamling. Fem färdigbehandlade patienter intervjuades och därefter analyserades intervjuinnehållet i en analysmodell. Resultat: Patienterna ställde sig väldigt positiva och tacksamma till både ACT-behandlingen och resultatet av den. Alla patienter upplevde en minskning av smärtproblematik, medan själva smärtnivån inte påverkats något nämnvärt. Efter avklarad sexveckorsbehandling valde två av fem av patienterna att fortsätta vidareutbilda sig i ACT på egen hand. Patienterna upplevde både positiva och negativa delar med ACT som gruppbehandling, medan ingen ställde sig negativ till individuell träning. Sjuksköterskans roll uppfattades som väsentlig och vital för avdelningens dagliga arbete. Det mest uppskattade med sjuksköterskan var hennes höga kompetens i form av vidareutbildning och yrkeserfarenhet samt hennes ständiga närvaro på avdelningen. Slutsats: ACT som behandlingsmetod uppskattades främst för det multiprofessionella arbetet. Behandlingen gav goda resultat gällande smärtupplevelsen för patienter med diagnosen långvarig smärta. ACT var uppskattat och intervjupersoner fortsatte därför egenbehandlingen efter utskrivning från ELS-A. Sjuksköterskan var en uppskattad person med sin höga kompetens och dagliga närvaro på avdelningen. / Background: SBU (2006) has requested more evidence-based research about the efficiency of Acceptance and Commitment Therapy on chronic pain, a disease that cost Sweden 87,5 million Krona in 2003. ELS-A is today the only department in Sweden where patients diagnosed with chronic pain can enroll for treatment. The treatment at the clinic is based on the philosophy of Acceptance and Commitment Therapy (ACT). Aim: To examine how patients diagnosed with chronic pain, one year after finalized treatment at ELS-A, evaluated the method of treatment, their level of pain today, and what role the nurse had during the enrollment. Method: Qualitative research interviews with semi-structured questions were applied for data collection. Five patients were interviewed and the data was analyzed. Results: The patients were very supportive and grateful both towards the experience of the ACT treatment itself, and the results of said therapies. All five patients experienced a reduction in how their pain previously negatively affected their lives, however the level of pain they felt remained the same. After the six weeks of clinical treatment two out of five of the interviewed patients continued studying the ACT-method independently. The patients all had both positive and negative experiences from the group interactions, and found greater appreciation for the individual treatment. The nurse played an important role in the department's everyday order of business. The nurse's performance during these days of testing was excellent. Her level of higher education, work experience and work ethic during the program was most appreciated by all. Conclusion: ACT treatment was appreciated mainly for the multi-professional team. The treatment gave good results in terms of pain perception in patients with a diagnosis of chronic pain. ACT was appreciated and interviewees therefore continued self-treatment after discharged from ELS-A. The nurse was a popular team-member with her high knowledge and daily presence at the department.

Background: Chronic pain is a condition that approximately 18% of the Swedish population suffers from. This condition affects many aspects of a person´s life and causes psychological, physiological and social suffering. Multimodal treatment is considered the most effective treatment for patients with chronic pain. Patient participation and motivation are very important to treatment. Aim: The aim of this study was to explore patients´ experience of a multimodal chronic pain treatment program regarding their experience of patient participation and interaction with the rehabilitation team. Method: An exploratory qualitative interview study with inductive approach. The data was collected through interviews with nine former outpatients at a pain clinic who underwent the multimodal rehabilitation program for patients with chronic pain. Data was analysed by using manifest content analysis. Results: The participants experienced that they had received a very good treatment from the team as a whole. They also had experienced participation during the rehabilitation program. The experience was built on some requirements being fulfilled, which directly or indirectly contributed to the feeling and experience of receiving help. Human, professional, external and inner conditions contributed to a positive experience regarding patient participation in the program and the good treatment and interaction with the rehabilitation team as a whole. Conclusions: There seem to be a connection between the participants´ experience of good treatment and the help they experience they have received. Apparently, for patients, there is no clear border between rehabilitation and feeling of receiving a good treatment. Participation in the program seems to be based on receiving a good treatment. / Bakgrund: Långvarig smärta är ett tillstånd som cirka 18 % av befolkningen i Sverige är drabbat av. Detta tillstånd påverkar många aspekter i patientens liv och medför stort lidande såväl fysiskt, psykiskt och socialt. Multimodal rehabilitering har visat sig vara den mest effektiva behandlingen för patienter med långvarig smärta. Delaktighet och motivation är grundstenar i behandlingen. Syfte: Syftet med den här studien var att undersöka patienters upplevelse av multimodal smärtrehabilitering avseende bemötande och känsla av delaktighet i behandlingen. Metod: En explorativ intervjustudie med kvalitativ induktiv ansats. Datainsamling skedde genom intervjuer med nio människor som genomgått multimodal rehabilitering. Intervjuerna analyserades med hjälp av manifest innehållsanalys. Resultat: Deltagarna har upplevt genomgående ett mycket gott bemötande och en känsla av delaktighet i behandlingen på smärtrehabiliteringen. Upplevelsen bygger på att vissa förutsättningar uppfylls som direkt och indirekt bidrar till upplevelse av att man får hjälp. Mellanmänskliga, professionella, yttre och inre förutsättningar bidrar till en positiv upplevelse avseende bemötande och känsla av delaktighet. Slutsats: Det tycks finnas en tydlig koppling mellan upplevelse av ett gott bemötande och upplevelsen att ha fått hjälpt. Det tycks inte finnas, i deltagarnas livsvärld, en tydlig skiljelinje mellan rehabilitering och upplevelse av bemötande. Delaktighet tycks bygga på att man upplever ett gott bemötande.