Personer med långvarig smärta är en stor patientgrupp inom primärvården i Sverige med olika bakgrund och hälsa. Interdisciplinärt multimodalt smärtrehabiliteringsprogram (IPRP) är en behandlingsmetod som används både i specialist- och primärvård för patienter med långvarig smärta. Denna studie är en retrospektiv registerstudie där svar från självrapporterade enkäter analyserats. Syftet var att undersöka om självskattad hälsorelaterad livskvalitet, fysisk funktion, aktivitetsnivå, ångest och depression skiljer sig mellan patienter med låg respektive hög utbildningsnivå hos de som genomgått IPRP för långvarig smärta inom primärvården i Sverige. Studien undersökte skillnader mellan grupperna både vid baslinje och 1-års uppföljning samt skillnader i förändring däremellan. Resultaten visade statistiskt signifikanta skillnader vid baslinje och 1-års uppföljning vad gäller hälsorelaterad livskvalitet och fysisk funktion. För ångest och depression var skillnaderna enbart signifikanta vid 1-års uppföljning. Skillnaden i förändring mellan grupperna var signifikant för ångest och depression. Gruppen med hög utbildningsnivå skattade högre hälsorelaterad livskvalitet och bättre fysisk funktion. Det var även en mindre andel patienter med diagnosen ångest och depression i den gruppen och de förbättrades i större utsträckning vad gäller ångest och depression. Denna studie indikerar att utbildningsnivå är en bakgrundsfaktor som hälso- och sjukvården bör ta hänsyn till för att bidra till en mer jämlik hälsa i befolkningen. Det behövs mer forskning där resultat jämförs mellan patienter med låg och hög utbildningsnivå som genomgått IPRP för långvarig smärta då detta är en forskningslucka.

Indiana University-Purdue University Indianapolis (IUPUI) / Symptoms of post-traumatic stress disorder (PTSD) are a common comorbidity in veterans seeking treatment of chronic musculoskeletal pain (CMP). However, little is known regarding the mutual influence of PTSD and CMP in this population. Using cross-sectional and longitudinal data from a randomized clinical trial evaluating a stepped care intervention for CMP in Iraq/Afghanistan veterans (ESCAPE), this dissertation examined the relationships between PTSD and CMP along with other factors including depression, anxiety, catastrophizing and health-related quality of life. The Classification and Regression Tree (CART) analysis was conducted to identify key factors associated with baseline PTSD besides CMP severity. A series of statistical analyses including logistical regression analysis, mixed model repeated measure analysis, confirmatory factor analysis and cross-lagged panel analysis via structural equation modeling were conducted to test five competing models of PTSD symptom clusters, and to examine the mutual influences of PTSD symptom clusters and CMP outcomes. Results showed baseline pain intensity and pain disability predicted PTSD at 9 months. And baseline PTSD predicted improvement of pain disability at 9 months. Moreover, direct relationships were found between PTSD and the disability component of CMP, and indirect relationships were found between PTSD, CMP and CMP components (intensity and disability) mediated by depression, anxiety and pain catastrophizing. Finally, the coexistence of PTSD and more severe pain was associated with worse SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Together these findings provided empirical support for the mutual maintenance theory.

Aim of the study is to explore the role caring practices within the nurse-patient relationship, in facilitating effective chronic pain management in the primary health care context. Objectives are to analyse the current caring practices within the nurse-patient relationship during the management of patients with chronic pain within primary health care services; explore the challenges experienced by nurses in primary health care services when managing patients with chronic pain; observe the caring practices within the nurse patient interaction for the patients suffering from chronic pain within the Primary health care setting and explain the nurses‟ caring practices when managing their chronic pain in the primary health care setting. Method The research design for this study is sequential, explanatory and mixed method, which is more appropriate due to the complexity of the phenomenon under study. Findings: Although the survey measured the caring practices subjectively which other studies had done consistently, generally nurses associated caring as their core function within the health profession. Nurses do not actively involve the patients in the development of a treatment plan and as a result the caring behaviours that are intended to benefit the patients are not realised and, thus patients report nurses as not being caring. The results indicated that lack of an inclusive treatment plan, which can only be discovered through the development of the therapeutic NPR, is not given priority in the management of patients with chronic pain Conclusions: Caring should not be seen as concrete execution of the set of activities towards the patient but rather as a joint venture between the nurse and the patient. The strength of the model developed in this study is the identification of the nurses‟ internal readiness to create a caring environment by experiencing the love, faith and hope before engaging with the patient. / Health Studies

The moment-to-moment fluctuations in pain-evoked sensory and emotional qualities, and how the pain experience differs between sexes are not well understood. Therefore, this thesis sought to 1) characterise the temporal profiles of the most prominent noxious heat-evoked sensations, 2) characterise sex differences in these sensations, 3) evaluate the magnitude of sharp pain quality evoked in hairy and glabrous skin, and 4) determine the role of absolute stimulus temperatures on sex differences in pain adaptation and habituation. A broad-based heat pain model was developed for this study that incorporates a temporally-continuous assessment of multiple sensory and affective pain dimensions, including pain, burning, sharp, stinging, cutting, and annoyance evoked by two types (static, dynamic) of repeated prolonged noxious heat stimuli. The salient hypotheses were: 1) Burning sensations have a different temporal profile compared with sharp and other related qualities, 2) The temporal dynamics of heat pain intensity and annoyance differ between males and females, 3) Sex differences in heat pain are associated with specific pain qualities and specific types of skin, and 4) Moderate-high temperatures induce pain adaptation and habituation in females but not in males. The most prominent findings were 1) sharp, stinging and cutting sensations adapted when stimulus intensity was static, but burning sensations were evoked during static and dynamic stimulus phases, 2) pain and annoyance in women were greater than men during the dynamic phases of the first stimulus but less than men during static stimulus phases and on stimulus repetition, 3) the sex difference in pain adaptation occurred with percept-fixed stimulus intensities and with absolute stimulus temperatures, 4) the sex effects associated with dynamic stimuli occurred in hairy but not glabrous skin. These findings give new insights into the relationships between pain intensity, quality and affect and have strong implications for views on sex differences in pain sensitivity.

The moment-to-moment fluctuations in pain-evoked sensory and emotional qualities, and how the pain experience differs between sexes are not well understood. Therefore, this thesis sought to 1) characterise the temporal profiles of the most prominent noxious heat-evoked sensations, 2) characterise sex differences in these sensations, 3) evaluate the magnitude of sharp pain quality evoked in hairy and glabrous skin, and 4) determine the role of absolute stimulus temperatures on sex differences in pain adaptation and habituation. A broad-based heat pain model was developed for this study that incorporates a temporally-continuous assessment of multiple sensory and affective pain dimensions, including pain, burning, sharp, stinging, cutting, and annoyance evoked by two types (static, dynamic) of repeated prolonged noxious heat stimuli. The salient hypotheses were: 1) Burning sensations have a different temporal profile compared with sharp and other related qualities, 2) The temporal dynamics of heat pain intensity and annoyance differ between males and females, 3) Sex differences in heat pain are associated with specific pain qualities and specific types of skin, and 4) Moderate-high temperatures induce pain adaptation and habituation in females but not in males. The most prominent findings were 1) sharp, stinging and cutting sensations adapted when stimulus intensity was static, but burning sensations were evoked during static and dynamic stimulus phases, 2) pain and annoyance in women were greater than men during the dynamic phases of the first stimulus but less than men during static stimulus phases and on stimulus repetition, 3) the sex difference in pain adaptation occurred with percept-fixed stimulus intensities and with absolute stimulus temperatures, 4) the sex effects associated with dynamic stimuli occurred in hairy but not glabrous skin. These findings give new insights into the relationships between pain intensity, quality and affect and have strong implications for views on sex differences in pain sensitivity.

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, 2014. / Background: Myofascial Pain and Dysfunction (MPD) is a diagnosis commonly encountered by practitioners, hence, there are several treatment approaches employed by various practicing physicians. Practitioners are required to perform evidence-based protocols on patients; however, such intervention becomes increasingly difficult with the increasing volume of evidence available with regards to treatment of MPD. A systematic review provides a well-structured, critical analysis of the available protocols, and as such, provides practitioners with an evidence-based summary of the available modalities and the effectiveness of these modalities. Thus, the aim of the study was to systematically review and evaluate the literature to determine the effects of various non-invasive modalities on MPD. Objectives: Studies investigating various non-invasive modalities were identified, evaluated against the inclusion criteria and then reviewed against PEDro criteria to present current available evidence regarding their effectiveness as a source of treatment for MPD. Methods: A literature search was conducted, based on key terms including: active and latent myofascial trigger points, manual therapy, manipulation, acupressure, massage, muscle stretching, ultrasound, transcutaneous electric nerve stimulation, electric stimulation therapy, magnetic field therapy, and exercise therapy. Databases searched were: PubMed, EBSCOhost, Medline, CINAL, Proquest, Health Source, Sport Discus, Science Direct, Springer Link, Google Scholar and Summons. The articles were screened according to inclusion and exclusion criteria, after which a secondary hand and reference searches were performed. Thereafter, the articles were reviewed by four independent reviewers and the researcher. The PEDro Scale was used to determine methodological rigor of the included studies. The results were then analysed and ranked. Results: Following the screening process during data collection for this study, a total of 25 studies were identified and included. The review and ranking of these studies revealed a moderate level of evidence present for the effectiveness of Topical Agents. A limited level of evidence was noted for TENS, Ischemic Compression, Ultrasound, Laser and Other Modalities. Approximately 25% of the reviewed studies involved combination therapies; hence their outcomes cannot be applied to the effectiveness of individual modalities. Conclusion: Upon comparison of the quality of evidence available for the various types of modalities present for the treatment of MPD, it was noted that Topical Agents were supported by a stronger level of evidence than TENS, Ischeamic Compression, Ultrasound, Laser and Other Modalities. However, due to a lack of strong overall evidence for any of these modalities it has been concluded that more research is required to establish which modality is in fact the most effective.

Aim of the study is to explore the role caring practices within the nurse-patient relationship, in facilitating effective chronic pain management in the primary health care context. Objectives are to analyse the current caring practices within the nurse-patient relationship during the management of patients with chronic pain within primary health care services; explore the challenges experienced by nurses in primary health care services when managing patients with chronic pain; observe the caring practices within the nurse patient interaction for the patients suffering from chronic pain within the Primary health care setting and explain the nurses‟ caring practices when managing their chronic pain in the primary health care setting. Method The research design for this study is sequential, explanatory and mixed method, which is more appropriate due to the complexity of the phenomenon under study. Findings: Although the survey measured the caring practices subjectively which other studies had done consistently, generally nurses associated caring as their core function within the health profession. Nurses do not actively involve the patients in the development of a treatment plan and as a result the caring behaviours that are intended to benefit the patients are not realised and, thus patients report nurses as not being caring. The results indicated that lack of an inclusive treatment plan, which can only be discovered through the development of the therapeutic NPR, is not given priority in the management of patients with chronic pain Conclusions: Caring should not be seen as concrete execution of the set of activities towards the patient but rather as a joint venture between the nurse and the patient. The strength of the model developed in this study is the identification of the nurses‟ internal readiness to create a caring environment by experiencing the love, faith and hope before engaging with the patient. / Health Studies

Ma thèse doctorale vise à analyser la fibromyalgie en tant qu’entité prise en charge et traitée par des savoirs et des pratiques biomédicales contemporaines et localisées. Tout en prenant en considération une vision biomédicale transnationale du syndrome, mon terrain de recherche est situé dans le contexte italien. La première partie de la thèse est consacrée à l’analyse de la vision médicale de la douleur chronique sans lésion, également entendue comme la « douleur-maladie » ; elle propose aussi une analyse de la manière dont les formes douloureuses chroniques complexes sont encadrées au niveau législatif et politique dans le contexte national italien. La deuxième partie se concentre sur la fibromyalgie en tant que catégorie médicale. Un premier chapitre analyse comment en biomédecine le syndrome est encadré par un savoir scientifique transnational ; un deuxième chapitre se focalise sur les données collectées pendant la recherche ethnographique. La troisième partie de la thèse examine la construction médicale de la fibromyalgie en tant que syndrome féminin. Elle propose également, dans un deuxième chapitre, le témoignage de Marzia, une femme atteinte de fibromyalgie qui à travers son historie, en s’opposant à une interprétation purement biomédicale de la maladie, définit le syndrome en mode contrastif, changeant et imprévisible. / My PhD thesis aims to analyse the fibromyalgia syndrome understood as an entity defined by contemporary and located biomedical knowledge and practices. While a transnational biomedical vision of the syndrome is analysed, the ethnographic research field is located within the Italian context. The first chapter is focussed on biomedical theories which analyse chronic pain without organic lesions, also framed here by the concept of pain as a disease; it ends by analysing how complex chronic painful states are considered at one legislative and political level in the Italian national context. The second chapter analyses fibromyalgia syndrome seen as a biomedical category. A first section examines how the syndrome is framed by transnational biomedical scientific knowledge; the second section focuses on data collected during the ethnographic research. The third chapter is dedicated to an investigation of the medical reasons that outline fibromyalgia as a female syndrome. It also proposes, in its second section, the testimony of Marzia, a woman affected by fibromyalgia; beyond a purely biomedical interpretation of the disease, through Marzia’s story the syndrome emerges in contrastive, opposite and unpredictable ways. / La mia tesi di dottorato analizza la sindrome fibromialgica intesa come entità presa in carico e trattata da saperi e pratiche biomediche contemporanee e localizzate. Pur focalizzandomi sulla visione biomedica transnazionale della sindrome, il mio terreno di ricerca è situato all’interno del contesto nazionale italiano. La prima parte della tesi è centrata sull’analisi della visione biomedica del dolore cronico senza lesione, inquadrato qui anche nei termini di “dolore-malattia”. Essa propone anche una osservazione di come sono inquadrate nella contemporaneità forme dolorose croniche complesse a un livello più propriamente legislativo e politico all’interno del contesto italiano. La seconda parte della tesi si concentra sulla fibromialgia intesa nei termini di categoria medica. Un primo capitolo analizza come attualmente la sindrome è inquadrata attraverso un sapere scientifico transazionale; un secondo capitolo è focalizzato sui dati raccolti durante la ricerca etnografica. La terza parte della tesi esamina la costruzione medica della fibromialgia nei termini di una sindrome femminile. Propone infine la testimonianza di Marzia, una donna colpita da fibromialgia che, attraverso la sua storia e opponendosi a un’interpretazione puramente biomedica della malattia, definisce la sindrome in modo contrastante, mutevole e imprevedibile.

Na clínica contemporânea, temos nos defrontado com novas expressões de sofrimento, nas quais o corpo ganha destaque. Entre os fenômenos recorrentes encontramos a dor crônica e as fibromialgias. Os estudos sobre esses assuntos apresentam posições distintas: uns consideram tais dores como fenômenos histéricos, outros, como uma manifestação do corpo deprimido. Pretendemos verificar as especificidades das dores crônicas, desde a possibilidade de uma manifestação histérica ou depressiva, mas avançando na hipótese de que elas possam ser manifestações do quadro melancólico. Tomaremos a teoria de Freud como principal fonte dos nossos estudos sobre a melancolia e cotejaremos também autores mais recentes que tratam do fenômeno da dor, particularmente os da psicossomática psicanalítica. Os pacientes que nos mobilizaram a empreender tais estudos foram aqueles que apresentavam traços curiosos: pouca fluidez pulsional, desânimo, dores em vários pontos do corpo, sintomas psicossomáticos, ansiedade bastante expressiva e, geralmente, marcados por uma falta de sentido, conotando, de um lado, traços melancólicos e, de outro, sintomas somáticos. Na melancolia, trata-se de uma perda na vida pulsional enquanto que no sofrimento decorrente de um luto normal, isso não acontece; a libido se desprende do objeto, devido a uma posição ocupada por esse objeto perdido, em que havia um duplo trabalho a ele dirigido, de amor e ódio, portanto passível de ser elaborado, no nível consciente. Nesse mesmo texto, ele mostra que no luto patológico, o objeto perdido mantém-se investido, libidinalmente, tendo como consequência um apego a ele, sem que ele possa ser elaborado, causando, portanto, uma sombra do objeto sobre o próprio ego do sujeito. Isso significa que há um hiper investimento narcísico no objeto, no qual o sujeito se fixa colando nele. Num mundo voltado para o individualismo, para o narcisismo e sem ideais é provável que se estimule mais esse encapsulamento, impedindo o sujeito de se vincular. Na clínica contemporânea os sintomas são mais dessa natureza: são primários, de caráter narcísico, no qual o sujeito se vê encapsulado num mundo vazio e sem significação. Nesse contexto, pensamos ser mais propício falar de sujeitos melancólicos, distinto dos deprimidos, pois estes fazem uma retirada do investimento libidinal, mas mantém uma relação com objeto.

Abstract The aim of this study was to evaluate the results of lumbar spine surgery and determine which factors modify outcome. A follow-up questionnaire, the Beck Depression Inventory (BDI, the Short Form 36 Health Survey (SF-36) and the Oswestry Low Back Disability Questionnaire (ODI) were sent to working-aged patients who had undergone lumbar spine surgery in the Oulu University Hospital between June, 2005 and May, 2008. Those with a BDI ≥ 10 were further classified into either non-melancholic (NmDS) or melancholic depression (MDS) groups. Potential spinal cord stimulation (SCS) candidates were interviewed via telephone. The postal survey was sent to 814 patients, of which 537 (66%) replied. Of these, 361 had undergone disc surgery, 85 stabilizing surgery and 91 decompression. Pain intensity was milder, the frequency of pain more rare, functional disability minimal and quality of life better after disc surgery compared to stabilizing surgery and decompression, which are technically more demanding operations and the patients’ condition are often more serious. Altogether, 213 patients presented with depressive symptoms (DS) defined as having a BDI ≥ 10, and these were further classified into NmDS (n = 153) and MDS (n = 60) subtypes. ODI differed between DS subtypes: those without DS had minimal, NmDS moderate and MDS severe functional disability. Pain was more frequent and more intense among DS patients. In particular, MDS patients suffered from pain, used more pain medication, but received less benefit from it. Disc surgery patients were divided according to body mass index (BMI): normal, pre-obese and obese. Pre-obese and obese patients gained weight during the follow-up. Obese patients had more DS and a worse functional outcome than normal-weighted or pre-obese patients. Of the entire cohort (n = 814), 21 patients received SCS. Eleven respondents underwent SCS treatment after they had replied. Features predicting SCS treatment were daily or continuous pain, higher pain intensity with predominant radicular pain, more severe pain-related functional disability, more DS and reduced benefit from pain medication. The time between lumbar surgery and implantation of a SCS device was extensive. Based on data from phone interviews, it appears that SCS was not offered to all potential candidates. In conclusion, the outcome of lumbar spine surgery was good after disc surgery but less favourable after more demanding stabilizing surgery or decompression. DS, especially of the MDS subtype, and obesity were more often seen in patients with a poorer surgical outcome. SCS treatment was used late and only for patients with very severe pain. / Tiivistelmä Tutkimuksen tarkoitus oli arvioida tuloksia lannerangan kirurgiassa ja kartoittaa tekijöitä, jotka vaikuttavat leikkaustulokseen. Seurantakysely, Beckin depressio¬kysely (BDI), SF-36 elämänlaatukysely ja Oswestryn toiminta¬kyky¬kysely (ODI), lähetettiin työikäisille Oulun yliopistollisessa sairaalassa kesäkuu 2005 - maaliskuu 2008 alaselkäleikatuille potilaille. Beckin depressioasteikko > 10 luokiteltiin ei-melankolisesti masentuneisiin (NmDS) ja melankolisesti masen¬tuneisiin (MDS). Mahdolliset takajuostestimulaatio (TJS) -ehdokkaat haastateltiin puhelimitse. Postikysely lähetettiin 814 potilaalle, joista 537 (66%) vastasi. Näistä 361:lle tehtiin välilevytyräleikkaus, 85:lle stabiloiva leikkaus ja 91:lle juurikanavan avarrusleikkaus. Välilevytyräleikatuilla kipu oli lievempää, harvemmin esiintyvää, toiminnallinen haitta vähäisempää ja elämänlaatu parempaa verrattuna potilaisiin, joille tehtiin vaativampi stabiloiva tai juurikanavan avarrusleikkaus. Kaikkiaan 213 potilaalla oli depressio-oireita (DS, BDI ≥ 10) ja nämä luokiteltiin edelleen NmDS (n = 153) ja MDS (n = 60) alaryhmiin. ODI erottui eri DS alatyyppien välillä: ei-DS-potilailla oli minimaalinen, NmDS-potilailla kohtuullinen ja MDS-potilailla vaikea toiminnallinen haitta. Kipua oli useammin ja voimakkaampana DS-potilailla. Erityisesti MDS-potilaat kärsivät kivuista, käyttivät enemmän kipulääkkeitä ja hyötyivät niistä vähemmän. Välilevytyräleikatut luokiteltiin painoindeksin (BMI) pohjalta normaaleihin, ylipainoisiin ja lihaviin. Ylipainoiset ja lihavat lihoivat seuranta-aikana. Lihavilla potilailla oli enemmän masennusta ja huonompi toiminnallinen tulos verrattuna normaaleihin ja ylipainoisiin. Koko tutkimusryhmässä (n = 814) 21 potilasta oli saanut TJS:n. Yksitoista vastaajaa sai TJS:n kyselytutkimuksen jälkeen. TJS:n saaneilla oli päivittäistä tai jatkuvaa, kovempaa ja pääasiassa jalkaan säteilevää kipua. Kipu aiheutti enemmän toiminnallista haittaa, enemmän masennusta ja nämä saivat vähemmän apua kipulääkityksestä. Aika leikkauksen ja TJS:n asennuksen välillä oli pitkä. Puhelinhaastattelun avulla saatu tieto osoittaa, ettei TJS-hoitoa tarjota kaikille potentiaalisille hyötyjille. Yhteenvetona voidaan todeta, että välilevytyräleikkauksen jälkeen tulos oli hyvä ja vaativampien stabiloivan ja juurikanavan avarrusleikkauksen jälkeen heikompi. DS, etenkin MDS ja lihavuus korostuivat huonommin toipuneissa. TJS-hoitoa käytettiin vain vaikeimmille tapauksille ja odotusajat olivat pitkät.