Bakgrund   Långvarig smärta är smärta som varat längre än tre månader, och utgör ett folkhälsoproblem som medför stora kostnader för samhället. Dessutom har tillståndet hög samsjuklighet vad gäller psykisk ohälsa och påverkar livskvaliteten negativt. Vårdpersonal upplever att de saknar kunskap om långvarig smärta och ser patientgruppen som komplex. De barriärer som finns i vårdandet av patienter med långvarig smärta kan leda till brister i såväl bemötandet som i det personcentrerade förhållningssättet. Syfte Syftet var att beskriva hur patienter med långvarig smärta upplever hälso- och sjukvårdspersonalens bemötande. Metod Designen icke-systematisk litteraturöversikt användes för att besvara syftet. Datainsamlingen skedde genom sökning efter artiklar i databaserna CINAHL och PubMed. Artiklarna kvalitetsgranskades innan det slugiltiga urvalet. Resultaten från 15 artiklar analyserades enligt en integrerad analysmetod. Litteraturöversikten utfördes i enlighet med Helsingforsdeklarationen.    Resultat Resultatet presenteras i fyra kategorier som beskriver upplevelser kring olika aspekter av bemötande ur patienternas perspektiv. Kategorin om upplevelser av kommunikation handlade om samtalet och informationen från personalen. I kategorin om partnerskapet beskrevs upplevelser av delaktighet, tillit, stöd och kontinuitet. I en kategori beskrevs känslan av att inte vara önskad inom vården som kom från att patienterna kände sig förminskade, missförstådda, ifrågasatta samt övergivna av hälso- och sjukvården. I samma kategori framkom att patienterna kände att de måste agera på ett visst sätt och att det fanns en kunskapsbrist hos personalen. Patienterna hade även en önskan att bli sedda som individer och att bli tagna på allvar, vilket beskrevs i den sista kategorin. Slutsats Patienterna hade blandade negativa och positiva upplevelser av hälso- och sjukvårdspersonalens bemötande. De brister som fanns i bemötandet kan förklaras som en avsaknad av ett personcentrerat förhållningsätt. Möjligen påverkas bemötandet negativt av kunskapsbrist och omedvetna fördomar hos hälso- och sjukvårdpersonalen. Även organisatoriska brister skulle kunna bidra till ett försämrat bemötande av patienter med långvarig smärta. / Background Long-term pain is pain that has lasted for longer than three months. It is seen as a public health issue and comes at a large cost to Swedish society. The condition also has a high comorbidity especially with psychiatric disease, and a negative impact on quality of life. Health professionals experience that they have a lack of knowledge about long term pain and view the patient group as complex. The barriers that exist in caring for these patients can lead to a lack of person-centered care.  Aim The aim was to describe how patients with long-term pain experience their meetings with health professionals. Method A non-systematic literature review design was used for this study. The data was collected from two databases, CINAHL and PubMed. A review of the quality of the articles was carried out before the final selection. The results from 15 articles were analysed using an integrated analysis. The literature review was made in accordance with the Declaration of Helsinki.  Results The results are presented using four categories describing different aspects of meetings between patients and health professionals. The category relating experiences of communication included conversation with and information from the staff. Within the category about partnership between patients and health professionals, experiences of participation, trust, support, and continuity were described. In one category the patient’s perception of not being wanted in healthcare was described, it came from feelings of being diminished, misunderstood, questioned, and abandoned by the health-care system. It emerged that long-term pain patients felt they must act in a certain way and also that there was a lack of knowledge on the part of the staff. The patients also wanted to be seen as individuals and taken seriously, which was described in the last category. Conclusions The patients had both negative and positive experiences of their meetings with health professionals. The shortcomings that existed in the meeting can be explained by a lack of a person-centered approach. It is also possible that meetings are negatively affected by a lack of knowledge and by unconscious prejudices among health professionals. Organizational shortcomings could also be contributing to less successful meetings with patients suffering from long-term pain.

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Recording of heart rate variability (HRV) is a noninvasive and continuous measurement method that allows investigating the autonomic nervous system (ANS) and its reaction to environmental influences. For a precise measurement of HRV data, a carefully chosen study design and environment is required to minimize secondary influences. One major influence to be avoided is movement. However, in the daily routine and for some scientific questions, movement can often not be avoided. If so, a manual or automated method to differentiate between artifacts caused by body movement and the actual psychophysiological effect is needed to ensure the data quality. In this approach, a chest-worn sensor was developed, that measures the heart rate using a single lead ECG and filters the measured change of the HRV caused by movement. Data from an integrated accelerometer is used to detect upper body movements that affect the resting heart rate. The movementcorresponding time stamps are then used to filter the Interbeat Intervals (IBI) accordingly. Functionality and effectiveness of the sensor system have been tested against state-of-the art sports- or clinical devices in varying scenarios. As our test series showed, motion filtering has a decisive effect when motion occurs, two-thirds of all cases showed a significant effect of motion filtering, with small to medium effect sizes for the parameters SD2, SD2/SD1, and SDNN. Thereby, automatic filtering of motion artifacts can help to significantly reduce the need for costly post-processing of distorted data sets. The results show a better data quality of HRV measurement, a method that is commonly used for the investigation of physiological processes in the field of chronic pain, psychology, psychiatry, or sports medicine.

Chronic pain is common and a burden for both the individual and society. In chronic pain, the pain has lost its function as a warning system and instead has become a disease in itself. Neurobiologically, several areas of the brain are involved, but to gain a broader understanding of the long-term pain, the biopsychosocial model is the best starting point. In line with thisand many scientific studies since the late 90's, psychological factors have proven to be an important factor in the development and maintenance of chronic pain. Interdisciplinary multimodal rehabilitation programs (IMMRP) are the treatment currently given to patients with long-term pain in the specialized pain rehabilitation. When the IMMRP has been reviewed, patients have shown improvement over time, but it is not possible to say whether it is the IMMRP or which parts of the IMMRP that explain the improvement (1). In this licentiate thesis, I have studied the importance of psychological factors in the rehabilitation of patients with chronic pain. This has been done in three studies reported in three published articles. All the studies have been close to the clinic and have been performed on patients in the specialized pain rehabilitation care in Sweden. The first article studied the effect of the multimodal investigation (MMI). More specifically, it was investigated whether alliance building and feelings of validation in patients with chronic pain affected their acceptance of pain, pain management, catastrophic thoughts, and depression. This was performed in a "single case" study on six patients in MMI. The results showed that despite good alliance and sense of validation, acceptance increased only in one patient and no improvement was seen in pain management, catastrophizing, and depression. In study two, subgroups of patients with chronic pain were studied. The subgroup analysis showed that patients referred for IMMRP could be divided into groups with different profiles regarding emotional problems and pain avoidance. These profiles were important for how the patients relatedto their pain and the results of IMMRP. The results of the study can increase the understanding of which patients should be selected for IMMRP and how the treatment can be adapted to the patients' needs. In study three, opioid treatment in patients with long-term pain who were referred to IMMRP was studied. The result showed that opioid prescribing was common and 55% of the participants received at least one prescription for opioids during the two years after the first assessment. It also turns out that there was a connection between individual patient characteristics (especially pain and depressive symptoms) and opioid prescription. Understanding how individual patient characteristics relate to prescribing patterns and long-term opioid use is an important prerequisite for managing opioid prescribing and the basics for preventing overuse. Overall, this licentiate thesis shows that MMU has no therapeutic effect on patients with long-term pain. It also shows that patients with chronic pain are a heterogeneous group that can be divided into subgroups based on psychological characteristics. The subgroups, in turn, had different ways of managing their pain and absorbing the treatment offered. In addition, it emerged that opioid prescribing was common among patients with long-term pain and that there was a link between opioids and patient characteristics.

Chronic pain is a significant public health problem. A large portion of those with chronic pain have had their acute postsurgical pain transition into a chronic postsurgical pain state. The mechanisms contributing to pediatric persistent postsurgical pain is not well understood; however, there is empirical support in the adult literature to suggest that psychosocial factors play a significant role in the maintenance and exacerbation of post-surgical pain. Recent research by our group found high pain prevalence rates up to 5-years post-surgery among children undergoing spinal fusion surgery, particularly among those reporting poor pre-surgical mental health. The current study aims to extend this research by exploring psycho-social functioning and pain among children (10-21 years) who underwent major orthopedic surgery and their parents (n=21 dyads; data collection is ongoing). Measures administered 1-3 years post-surgery included pain ratings, the Bath Adolescent Pain Questionnaire (Child; Parental Impact), Fear of Pain Questionnaire, Functional Disability Inventory, and the Adult Responses to Child Symptoms. Preliminary results found that 52% of patients reported pain in the moderate-severe range in the past 6 months. Additionally, increased child pain was associated with greater child-reported functional disability (p<.01), pain-specific anxiety (p<.01), and fear of pain (p<.05), as well as worse overall emotional functioning (p<.05). Parents of children with increased pain reported worse parental strain (e.g., "found my relationship with my child difficult," p<.05). Identifying correlates of poor long-term outcomes in children with postsurgical pain may prevent the development of chronic pain into adulthood. With recent economic costs of adult chronic pain estimated to be between $560-$635 billion per year research on the role of persistent pain in children is of upmost importance in order to positively impact pre-surgical preparation, postsurgical care, and in potentially preventing disabling pain into adulthood for a population at considerable risk. This investigation was supported by the Boston Children's Hospital Career Development Fellowship Award (CS).

Background: The consequences of continued opioid abuse among patients treated with opioid substitution therapy (OST) are serious and can result in abnormal cardiovascular function, overdose, and mortality. Conflicting evidence exists that both implicates and refutes the role of chronic non-cancer pain (CNCP) as a major risk factor for continued opioid abuse within the addiction treatment setting. This thesis aims to 1) evaluate the impact of chronic pain on the treatment outcomes of patients with opioid addiction receiving OST, 2) determine whether a clinical or inflammatory profile exists to distinguish pain in this population, 3) explore the sources of heterogeneity in previous studies examining this question, 4) determine the best therapy for patients with chronic pain, and 5) evaluate the most effective treatment for opioid addiction. We anticipate chronic pain to be an important predictor of continued opioid abuse such that patients with comorbid pain will require careful consideration when managed on OST. Methods: We systematically reviewed the literature to determine the impact of pain in opioid addiction patients receiving methadone maintenance treatment (MMT). We determined the clinical and inflammatory profile of MMT patients using data from the Genetics of Opioid Addiction (GENOA) research collaborative between the Canadian Addiction Treatment Centres (CATC) and the Population Genomic Program. GENOA is a prospective cohort study aimed to determine the genetic, biological, and psychosocial determinants of treatment prognosis for opioid addiction patients receiving MMT. GENOA recruits patients ≥ 18 years of age meeting the DSM-IV criteria for opioid dependence. All GENOA participants are receiving MMT for the management of opioid addiction. Baseline data from the GENOA pilot study (n=235) were used to evaluate the impact of pain on illict opioid use behaviour and determine the clinical and inflammatory profile of patients with comorbid pain. We explored sources of heterogeneity in previous studies using data from the full-phase GENOA study (n=444), examining the prognostic value of different pain measures for predicting illicit opioid use. We then performed a multiple treatment comparison of all opioid substitution and antagonist therapies in efforts to determine the best intervention for improving treatment outcomes for patients with comorbid pain. We lastly determined the most effective treatment for opioid addiction by performing a network meta-analysis using data from a systematic review of opioid maintenance therapy trials. Results: Our initial systematic review confirmed a lack of consensus in the literature, whereby some studies suggest pain increases risk for illicit opioid use and other studies suggest pain has no effect on substance use behaviour. Findings from the analysis of GENOA pilot data confirmed chronic pain to be an important predictor of sustained opioid abuse and also showed patients with pain to have elevated Interferon-Gamma. Using data from the GENOA prospective cohort study we determined the Brief Pain Inventory (a commonly used pain measurement in pervious studies) to be highly sensitive with poor prognostic value. Our final reviews propose 1) there is limited evidence to suggest any OST is superior for managing patients with comorbid pain, and 2) heroin and high-dose methadone are the most effective treatments for improving treatment retention. The final systematic review and network meta-analysis in this thesis also highlights a major problem in the treatment of opioid use disorders, primarily the lack of consensus as to what outcomes matter for determining success in patients with addiction. Conclusion: Patients with comorbid pain and addiction are at high-risk for continued opioid abuse and should be managed closely by clinicians administering OST. Contention in the previous literature likely resulted from the use of pain measurements with poor prognostic value. No OST demonstrated superiority for managing patients with chronic pain. While our findings indicate heroin is the most effective treatment across multiple endpoints, we use this thesis to provide readers with 1) a sense of the feasibility issues associated with heroin administration, 2) a summary of the limitations of this evidence base, and 3) recommendations for how to improve the addiction trials’ design for future research. / Thesis / Doctor of Philosophy (PhD)

Bakgrund: Fibromyalgi är ett primärt smärttillstånd, vilket innebär att smärtan utgör själva sjukdomen. Individer med fibromyalgi drabbas ofta av fördomar och ifrågasättande då sjukdomen inte går att bevisa med blodprov eller röntgen samt frågetecken kring etiologin. Behandling riktad mot sjukdomens orsak finns ännu inte, den behandling som erbjuds är endast symtomlindrande. Sjuksköterskan har en viktig roll i att hjälpa patienten att hitta strategier för minskad smärta, stötta patienten i att identifiera och ägna sig åt hälsofrämjande åtgärder, dela med sig av kunskap och information gällande smärttillståndet samt enligt ordination genomföra farmakologisk och icke-farmakologisk behandling.  Syfte: Syftet var att beskriva personers upplevelser av att leva med fibromyalgi.  Metod: En litteraturöversikt genomfördes baserad på tio kvalitativa vetenskapliga artiklar. Databaserna Pubmed och Cinahl Complete användes till datainsamlingen och resultatet analyserades enligt Fribergs metod.  Resultat: Utifrån dataanalysen framkom fyra huvudteman: kroppen som ett fängelse, en ny identitet, att anpassa sitt liv till sjukdomen och erfarenheter av bemötande. Resultatet visade att fibromyalgi innebar stora förändringar i privatliv, arbetsliv, i relation till andra och i relationen till sig själv.  Slutsats: Bristande bemötande inom vården och begränsningar i vardagen hade störst inverkan på livskvaliteten och skapade isolering, lidande och psykisk ohälsa. Resultatet kan kopplas till bristande kunskap och forskning kring sjukdomen vilket resulterar i en ifrågasättande attityd, stigmatisering och ineffektiva behandlingar. Genom att öka medvetenhet och kunskap inom ämnet kan vården förbättras avsevärt, vilket i sin tur kan leda till en förbättrad livskvalitet för dem som lever med fibromyalgi. / Background: Fibromyalgia is a primary pain condition, meaning the pain constitutes the illness itself. Individuals with fibromyalgia often suffer from prejudice and questioning as the disease cannot be proven by blood tests or X-rays and lack of knowledge regarding etiology. There is yet no treatment for the illness, only symptom relief. The nurse has an important role in helping the patient find strategies for reduced pain, supporting the patient in identifying and engaging in health-promoting measures, sharing knowledge and information regarding the illness and, according to prescription, implement pharmacological and non- pharmacological treatment.  Aim: The aim was to describe people’s experiences of living with fibromyalgia.  Method: A literature review based on ten qualitative scientific articles was conducted. Databases Pubmed and Cinahl Complete were used for data collection and the results were analyzed according to Friberg’s method.  Results: Based on the data analysis, four themes emerged: the body as a prison, a new identity, adapting life to the disease and experiences of social interactions. The results showed that fibromyalgia led to big changes in private life, work life, in relation to others and in relation to oneself.  Conclusions: Inadequate approach in healthcare and limitations in everyday life had the biggest impact on the quality of life and created isolation, suffering and mental illness. The result can be linked to a lack of knowledge and research about the illness, which results in a questioning attitude, stigmatization and ineffective treatments. By increasing awareness and knowledge on the subject, healthcare can be significantly improved, which can lead to an improved quality of life for those living with fibromyalgia.

Introduction : Le stress peut avoir des effets paradoxaux sur la douleur, soit une hyperalgésie et une hypoalgésie. Un cadre intégratif issu de la littérature sur le stress identifie les caractéristiques des stresseurs qui déclenchent une réponse physiologique du stress : la perception de Contrôle faible, l’Imprévisibilité, la Nouveauté et la menace à l'Égo (C.I.N.É.). Ces caractéristiques ont été examinées individuellement en relation avec la douleur, mais il y a un manque d'intégration de ce cadre dans la recherche sur les associations entre le stress et la douleur. Cette étude visait à 1) examiner les caractéristiques du stress quotidien et 2) examiner les associations entre les fluctuations quotidiennes de l’intensité du stress, les caractéristiques C.I.N.É. et l'intensité de la douleur chez les adultes vivant avec une douleur lombaire chronique. Méthodes : Les participants (n=181) ont rempli des journaux électroniques trois fois par jour pendant une semaine. Les journaux incluaient une évaluation de l'intensité de la douleur (échelle numérique 0-10) et des caractéristiques du stress (intensité avec l’échelle numérique (0-10), type (stress attribué à la douleur, à la pandémie, à autre chose ou mixte) et caractéristiques C.I.N.É. avec l’échelle analogue (0-100)). Résultats : Les résultats d'une équation d'estimation généralisée (p < 0,001) ont montré que les participants rapportaient une plus grande proportion de caractéristiques C.I.N.É. lorsque le stress était dû à plus d’un type de stresseur (douleur et autre) que lorsque le stress était dû seulement à la douleur (contrôle : β = -0,02 et nouveauté : β = -0,02). Les résultats d'un modèle multiniveau montraient que le moment de la journée, l'intensité initiale de la douleur, la fluctuation du stress et l'attribution du stress (douleur vs autre) étaient associés à l’intensité de la douleur (p < 0,05). La perception d’avoir peu ou pas de contrôle sur une situation était associée à une plus grande intensité de la douleur (β= 0,003, p <0,05). Moins la caractéristique de la nouveauté était perçue dans une situation, plus l’intensité de la douleur était grande (β = -0,004, p < 0,05). Discussion : Cette étude fournit une cible d'intervention innovante dans le domaine de la douleur chronique, à savoir les caractéristiques C.I.N.É. et les fluctuations du stress : nous pourrions aider les individus à mieux comprendre leur vulnérabilité individuelle au stress et à en améliorer sa gestion. / Introduction: Stress can have paradoxical effects on pain, namely hyperalgesia and hypoalgesia, among people living with chronic pain. An integrative framework from the stress literature identifies central characteristics of stressors that trigger a physiological stress response: Sense of low control, Threat to ego, Unpredictability and Novelty. While these characteristics have been examined individually in relation to various pain outcomes, there is a lack of integration of the framework within investigations of the associations between stress and pain. This study aimed to 1) examine the characteristics of daily stress and 2) examine the daily associations between stress characteristics and pain intensity among adults living with chronic low back pain. Methods: Participants (n=181) completed daily diaries three times a day for one week. The diaries included an assessment of pain intensity (Numeric Rating Scale-11) and of stress characteristics (intensity using the NRS-11, type (stress attributed to the pain, the pandemic, other or mixed) and STUN characteristics using the Visual Analogue Scale-100). Results: Results of a generalized estimation equation (p < 0.001) showed that participants reported a greater proportion of their stress attributable to several STUN characteristics when stress was due to a mix of stressors (pain and other) compared to when it was due to only pain (control : β = -0,02 and novelty : β = -0,02). Results of a multilevel model showed that time of day, initial pain intensity, stress fluctuation and stress attribution (pain vs. other) were associated with pain intensity (p < 0.05). The perception of having little or no control over a situation was associated with greater pain intensity (β= 0.003, p < 0.05). The less novelty was perceived in a situation, the greater the pain intensity (β = -0.004, p < 0.05). Discussion: Pain assessment and treatment focus on reducing pain intensity. This study provides an innovative target of intervention in the field of chronic pain, namely the STUN characteristics and stress fluctuations: If the sources of stress can’t be directly eliminated, we could help individuals better understand their individual vulnerability to stress and improve its management.

Bakgrund Kronisk smärta är ett vanligt förekommande tillstånd och leder till lidande hos individen och kostnader för samhället. Det är vanligare med kronisk smärta bland kvinnor än bland män. Kvinnor och mäns hälsa påverkas på liknande sätt av biologiska och genusrelaterade faktorer, men kvinnors hälsa är särskilt utsatt då kvinnor runt om i världen blir diskriminerade på grund av sociokulturella faktorer. Hälsa och välbefinnande kan även påverkas av hur man blir bemött i hälso- och sjukvården, då bemötandet kan ses som en viktig del för vårdandet. Syfte Syftet var att beskriva hur kvinnor som lever med kronisk smärta upplever bemötandet från hälso- och sjukvårdspersonal. Syfte Syftet var att beskriva hur kvinnor som lever med kronisk smärta upplever bemötandet frånhälso- och sjukvårdspersonal.  Metod En icke-systematisk litteraturöversikt användes, där 17 vetenskapliga artiklar med kvalitativ ansats studerades. Datainsamlingen gjordes i PubMed och CINAHL med relevanta sökord för studiens syfte. Kvalitetsgranskning av valda artiklar har gjorts med hjälp av Sophiahemmet Högskolas bedömningsunderlag för vetenskaplig klassificering och kvalitet. En integrerad analys användes för att sammanställa och analysera resultatet. Resultat I resultatet identifierades två huvudkategorier; Upplevelser av bristfälligt bemötande och Upplevelser av tillmötesgående bemötande. Upplevelser av att bli misstrodd eller att inte bli tagen på allvar, att smärta normaliseras och hälso- och sjukvårdspersonalens kunskapsbrist bidrog till upplevelser av bristfälligt bemötande, medan upplevelser av att bli lyssnad på, förstådd och inkluderad präglade de det tillmötesgående bemötandet av hälso- och sjukvårdspersonal. Slutsats Upplevelser av ett bristande bemötande från hälso- och sjukvårdspersonal hindrar främjandet av hälsa och välbefinnande för kvinnor med kronisk smärta. Upplevelsen av tillmötesgående bemötande bidrar till en positiv upplevelse och grundas i personcentrering med ett holistiskt perspektiv på individen och delat beslutsfattande. Denna kunskap bidrar till en ökad insikt för sjuksköterskor om vad som påverkar en negativ-, respektive positiv upplevelse i bemötandet samt bidrar till att främja hälsan samt öka välbefinnandet och självkänslan hos kvinnor med kronisk smärta. / Background  Chronic pain is a common condition and leads to suffering for individuals with additional costs to society. Chronic pain is more common among women than men. Women's and men's health are similarly affected by biological and gender-related factors, but women's health is particularly vulnerable. In a global context women’s health is affected by discrimination based on socio-cultural factors. Health and well-being can also be affected by how one is treated by healthcare professionals, as the treatment can be seen as an essential part of caregiving. Aim The aim was to describe how women living with chronic pain experience treatment from healthcare professionals. Method A non-systematic literature review was carried out, where 17 scientific articles with a qualitative approach were studied. The data collection was done in PubMed and CINAHL with relevant keywords for the study. Quality review of selected articles has been done with the help of Sophiahemmet University's assessment documents for scientific classification and quality. An integrated analysis was used to compile and analyze the results. Results In the result, two main categories were identified; Experiences of inadequate treatment and Experiences of accommodating treatment. Experiences of not being believed or taken seriously, of pain being normalized and the healthcare staff's lack of knowledge contributed to the experience of inadequate treatment, while experiences of being listened to, understood, and included marked the positive experiences of accommodating treatment. Conclusions Perceptions of mistreatment by healthcare professionals impeded the promotion of health and well-being for women with chronic pain. Person-centredness with a holistic approach and shared decision-making were identified as being parts of the accommodating treatment experience. Having knowledge and understanding about this issue contributes to an increased insight for nurses about what influences a negative and positive experience in the treatment and contributes to promoting the health, well-being, and self-esteem of women with chronic pain.

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