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Bakgrund:Långvarig smärta definieras som smärta som kvarstår i över 3 månader. Det är vanligt förekommande i befolkningen och många söker vård för sina problem. Smärta är ett komplext begrepp som har inverkan på många olika faktorer hos individen men även en inverkan på samhället och dess resurser. Detta kan innebära utmaningar vid handläggning och framför allt vid val av behandling. Syfte:Syftet var att utforska kliniskt resonemang vid val av behandling för patienter med långvariga smärttillstånd hos en grupp fysioterapeuter i primärvården. Metod:Studien är en kvalitativ studie baserad på semistrukturerade intervjuer som analyserades med kvalitativ innehållsanalys.   Resultat:Det som ansågs spela stor roll för valet av behandling var behandlaren och patientens egenskaper och erfarenheter, relationen mellan dem samt analysen inför behandling. De riktlinjer som användes ansågs vara ett stöd men också svåra att applicera då behandlingen alltid behöver individanpassas i och med att patientgruppen är komplex. Möjlighet till samverkan ansågs vara viktigt för att bredda perspektivet och erbjuda patienten fler behandlingsalternativ. I behandlingsupplägget var målet alltid att öka funktionsnivå, vilket påverkade resonemanget kring val av behandling. Ökad kunskap hos patienten samt en ökad förmåga till smärthantering var ofta första steget. Slutsats:Många faktorer spelar in i det kliniska resonemanget för val av behandling för patienter med långvarig smärta. Erfarenhet hos behandlaren ansågs avgörande för beslutet och man kan därmed tänka sig att det är extra viktigt att nyexaminerade får möjlighet att samverka med kollegor med mer erfarenhet av patientgruppen. / Background:Chronic pain is defined as pain that remains in more than 3 months. Chronic pain is a widespread problem worldwide and there are many people who seek health care for their problems. Pain is a complex syndrome which impacts several aspects of the individual's life but also the society, which brings challenges in the assessment and the choice of treatment.  Purpose:The purpose of the study was to explore physiotherapists' clinical reasoning when choosing a treatment for patients with chronic pain in primary care.  Method:The study is a qualitative method based on semi-structured interviews which was analyzed with a qualitative content analysis.  Results:Factors that played a big part in the choice of treatment were the physiotherapist and the patient characteristics and experiences, the relationship between them and the significance of the examination. The guidelines that were used were considered to support the choice but were also seen to be difficult to apply, as the treatment always needs to be individualized because of the complexity in the patient group. The ability of cooperation was considered as a key factor to broaden the perspective and offer the patient different treatment alternatives. The treatments intended to increase function, knowledge and pain-management which had an impact on the clinical reasoning. Conclusion:Many factors play a part in the clinical reasoning for choosing treatment for patients with chronic pain. The physiotherapists experience was a crucial part of the decision and therefore it could be of importance that newly graduated physiotherapists get the possibility to cooperate with colleagues who have more experience of the patient group.

Background: According to the Center for Disease Control and Prevention, approximately 1.6 to 3.8 million Americans suffer a sports related concussion each year. Concussion is defined as a transient alteration of the brain structure caused by a direct or indirect force. During the last decade, a vast amount of clinical research on the long term effects of repetitive head trauma has occurred, especially on the subject of chronic traumatic encephalopathy (CTE), depression and dementia. Objective: The purpose of this literature review is to examine the literature pertaining to multiple concussion and the long-term effects of multiple concussion such as neurodegenerative diseases and psychological. Methods: A literature review was conducted using an electronic search of the following databases: MEDLINE, Cochrane Database of Systematic Reviews, and SportDiscus. The key search terms included were concussion, "sport concussion" and "sports concussion". One of the above three terms needed to be in conjunction with one of the following key search terms: depression, dementia, "mild cognitive impairment", "chronic traumatic encephalopathy" (CTE), or "psychological disorder". Additional inclusion criteria also included studies that targeted the adult athlete population who had sustained more than one concussion. Studies only were included if they were peer-reviewed, in the English language, and were published after 1990. To be included in the review, the study must have examined the long term effects of repetitive concussion. Results: The research completed to date suggests there is a strong correlation between the number of concussions an athlete suffers and the long-term ramifications of neurodegenerative and psychological disorders. However, more research is needed.

Chronic pain disorders are estimated to affect a significant proportion of the global population. These disorders are often debilitating and pose a substantial challenge to the everyday life of those affected. Modern medicine has made great strides in understanding the physiological processes involved in chronic pain. However, chronic pain is more than merely a physiological process. Chronic pain is an embodied mode of being-in-the-world that manifests in multiple aspects of lived experience, from the ability to perform day-to-day tasks to the relationship between body and self. Consequently, it is essential to cultivate a rich appreciation of chronic pain as a lived experience. To rely solely on physiological knowledge in conceptualizing chronic pain precludes the development of such an appreciation. This work examines the ways that phenomenology can be leveraged to broaden the current medical understanding of chronic pain to better incorporate subjective experience. As a rigorous methodology for studying embodied consciousness, phenomenology provides the theoretical and conceptual tools to form a rich description of chronic pain's lived experience. First, a brief history of theories of pain is presented to contextualize the development of modern medical understandings of chronic pain. Following this, the writings of three classical phenomenologists—Husserl, Heidegger, and Merleau-Ponty—are presented, and key phenomenological concepts are introduced. Phenomenology is then used to examine the lived experience of chronic pain. Finally, means of integrating phenomenology into the current medical framework are explored.

INTRODUCTION: There is uncertainty in the prevalence of chronic non-cancer pain (CNCP) in military veterans. A systematic review and meta-analysis was conducted to elucidate this issue, and examine potential effect modifiers of CNCP prevalence. Additionally, chronic pain is a pervasive and debilitating condition that disproportionately affects military veterans. We recently completed a qualitative study of Canadian veterans living with chronic pain to identify their research priorities; however, the generalizability of our findings was uncertain. METHODS: MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science were searched from 2013 to January 21, 2021, for observational studies reporting “chronic pain” or pain ≥ 3 months in military veterans. The random-effects meta-analysis was used for pooling data, the Grading of Recommendations, Assessment, Development and Evaluations approach was used for rating quality of evidence, and the Instrument to Assess the Credibility of Effect Modification Analyses was used to rate credibility of the subgroup analyses. Furthermore, from January to March 2021, we emailed a 45-item cross-sectional survey to a list of Canadian veterans that asked about the relative importance of 20 research priorities regarding chronic pain. We explored for statistical significance between male and female responses for any item in which the proportion of endorsement showed a ≥10% difference. RESULTS: 41 observational studies with 5,550,375 military veterans were included. The overall pooled CNCP prevalence is 34% (95% confidence interval (CI) 25% to 45%). However, significant subgroup effect was found for type of prevalence measure (generic or specific) among military veterans (test of interaction p=0.007, moderate subgroup credibility): the pooled generic CNCP prevalence of 43%, 95% CI 29% to 57% (Low-certainty evidence) vs. the pooled specific type of CNCP prevalence of 14%, 95% CI 6.7% to 23% (Moderate-certainty evidence). A multivariable meta-regression model adjusted for proportion lost to follow-up found the type of prevalence measure to be the only significant predictor of CNCP prevalence (p < 0.0001). 313 of 699 Canadian military veterans living with chronic pain completed ≥50% of the survey (45% response rate). Respondents were predominantly male (77%) with a median age of 52 (interquartile range [IQR] 44-58). All 20 research priorities listed in the survey were endorsed as very important by ≥52% of respondents, and three received endorsement by ≥85%: (I) optimizing chronic pain management after release from the military; and (II) identifying and (III) treating mental illness among veterans living with chronic pain. Women were more likely than men to endorse research on post-surgical care for chronic pain prevention or research on holistic care for chronic pain. Men were more likely than women to endorse research on physical activity or exercise for chronic pain. Individuals with higher gross income (≥$80,000) were less likely to endorse research into physiotherapy for chronic pain, or chiropractic for chronic pain compared to those with lower gross income. Individuals with greater age are less likely to endorse research on medical cannabis for chronic pain. CONCLUSIONS: The overall prevalence of CNCP is 34% among military veterans. For generic CNCP, the prevalence is 43%; for a given subtype of CNCP, the prevalence is 11%. Methodologically robust studies are required to more precisely determine CNCP prevalence. The most salient research priorities among our respondents were optimizing chronic pain management during service and after discharge from the military, including co-morbid mental illness. Differences in gender, gross income, and age are implicated in the endorsement of therapy-related priorities, which include surgery, physical activity or exercise, chiropractic, and medical cannabis. Our findings provide insight into the research priorities of Canadian military veterans living with chronic pain. These findings should be considered by granting agencies when formulating calls for proposals, and by researchers who wish to undertake research that will address the needs of military veterans living with chronic pain. / Thesis / Master of Science (MSc)

Background: Cannabis is increasingly used for management of chronic pain; however, the benefits and harms of this therapy remain uncertain. We conducted a systematic review to inform harms associated with inhaled cannabis for chronic pain. Methods: We searched MEDLINE, EMBASE, PsychInfo, and Web of Science for non-randomized studies reporting on harms associated with inhaled cannabis use, from inception to October 6, 2021. We used random-effects models for meta-analyses and assessed the certainty of evidence using the GRADE approach. Results: We identified 29 eligible studies enrolling 174,562 participants that reported 145 adverse events. Moderate certainty evidence suggests inhaled cannabis use is probably associated with dry mouth (prevalence: 56%; 95%CI 49 to 64), thirst (prevalence: 44%; 95% CI 33 to 55), fatigue (prevalence: 38%; 95%CI 31 to 45), nausea (prevalence: 17%; 95%CI 8 to 27), increased appetite (prevalence: 13%; 95%CI 9 to 18), dizziness (prevalence: 10%; 95%CI 6 to 14), diarrhea (prevalence: 9%; 95%CI 3 to 18), confusion (prevalence: 9%; 95%CI 5 to 13), mood changes (prevalence: 8%; 95%CI 4 to 15), hallucinations (prevalence: 7%; 95%CI 4 to 10), amnesia (prevalence: 6%; 95%CI 3 to 11), impaired coordination (prevalence: 5%; 95%CI 4 to 6), and disorientation (prevalence: 3%; 95%CI 1 to 7). Moderate certainty evidence shows that, compared to non-users, inhaling cannabis is probably associated with increased risk of shortness of breath (risk difference [RD]: 7%; 95%CI 4 to 10). Conclusions: Our review found moderate certainty evidence that dry mouth, thirst, and fatigue are probably frequently experienced with inhaled cannabis use. Several other adverse events are also probable associated with inhaled cannabis use but were less common. Rigorously conducted cohort studies are needed to inform harms associated with inhaled medical cannabis for chronic pain. / Thesis / Master of Science (MSc) / Increasing recognition of harms associated with long-term opioid therapy for management of chronic pain has generated enthusiasm for alternatives, including medical cannabis which is often consumed through inhalation. This review assesses the harms associated with the use of inhaled cannabis for management of chronic pain. Among serious adverse events, we found that inhaled cannabis is likely associated with amnesia, disorientation, impaired coordination, hallucinations, confusion, dizziness, chronic wheeze, and shortness of breath. Inhaled cannabis may be associated with palpitations, paranoia, anxiety, and cannabis dependence. The effects of inhaled cannabis on lung cancer, depression, and psychosis were uncertain. Among less serious adverse events, we found that inhaled cannabis is likely associated with thirst, fatigue, increased appetite, nausea, mood changes, diarrhea, and dry mouth. Inhaled cannabis may be associated with red eyes, vomiting, phlegm, asthma, and cough. The effects of inhaled cannabis on euphoria and irritability were uncertain.

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