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Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder. Cortical thinning of the anterior mid-cingulate cortex (aMCC) and insula has been previously reported in IBS (Davis et al., 2008). The aim of the present study was to examine cortical and subcortical structural gray matter integrity in IBS with particular attention to individual disease symptoms and personality characteristics such as pain catastrophizing. Eleven IBS patients and 16 age-matched healthy subjects (female, right-handed) underwent structural MRI. Voxel Based Morphometry and Cortical Thickness Analysis revealed that the IBS group had increased gray matter density in the hypothalamus, cortical thinning in the aMCC, strong (r = -66; p=0.015), a negative correlation between dorsolateral prefrontal cortex and pain catastrophizing and anterior insula thickness was positively correlated to pain duration (r = 0.77, p=0.003) when controlling for age. These abnormalities may contribute to chronic pain in IBS.

Aims: To determine the test-retest reliability and responsiveness of a new computerized 20-item pain measure, SUPER-KIDZ, in children with juvenile idiopathic arthritis (JIA). Methods: A single centre prospective cohort study of JIA patients aged 8-18 years was performed. For each SUPER-KIDZ item, test-retest reliability analysis was done in patients expected to have stable pain, and responsiveness was evaluated after intra-articular steroid injection(s). Results: Fifty-one subjects were included. Good internal consistency (α=0.73-0.92) was demonstrated for the 3 SUPER-KIDZ domains. Acceptable test-retest reliability (intraclass correlation coefficient or kappa ≥0.80) was found for 15 SUPER-KIDZ items. At 2 weeks post-injection, 16 items were responsive to change in pain (standardized response mean=0.66-0.82, significant Wilcoxon signed rank and linear mixed model). Conclusions: The majority of the SUPER-KIDZ items have acceptable test-retest reliability and responsiveness properties. If validity is demonstrated, this measure could be implemented as a standardized comprehensive pain tool for JIA patients.

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder. Cortical thinning of the anterior mid-cingulate cortex (aMCC) and insula has been previously reported in IBS (Davis et al., 2008). The aim of the present study was to examine cortical and subcortical structural gray matter integrity in IBS with particular attention to individual disease symptoms and personality characteristics such as pain catastrophizing. Eleven IBS patients and 16 age-matched healthy subjects (female, right-handed) underwent structural MRI. Voxel Based Morphometry and Cortical Thickness Analysis revealed that the IBS group had increased gray matter density in the hypothalamus, cortical thinning in the aMCC, strong (r = -66; p=0.015), a negative correlation between dorsolateral prefrontal cortex and pain catastrophizing and anterior insula thickness was positively correlated to pain duration (r = 0.77, p=0.003) when controlling for age. These abnormalities may contribute to chronic pain in IBS.

Aims: To determine the test-retest reliability and responsiveness of a new computerized 20-item pain measure, SUPER-KIDZ, in children with juvenile idiopathic arthritis (JIA). Methods: A single centre prospective cohort study of JIA patients aged 8-18 years was performed. For each SUPER-KIDZ item, test-retest reliability analysis was done in patients expected to have stable pain, and responsiveness was evaluated after intra-articular steroid injection(s). Results: Fifty-one subjects were included. Good internal consistency (α=0.73-0.92) was demonstrated for the 3 SUPER-KIDZ domains. Acceptable test-retest reliability (intraclass correlation coefficient or kappa ≥0.80) was found for 15 SUPER-KIDZ items. At 2 weeks post-injection, 16 items were responsive to change in pain (standardized response mean=0.66-0.82, significant Wilcoxon signed rank and linear mixed model). Conclusions: The majority of the SUPER-KIDZ items have acceptable test-retest reliability and responsiveness properties. If validity is demonstrated, this measure could be implemented as a standardized comprehensive pain tool for JIA patients.

Objectives: To explore the pain mechanism and the origin of the pain and to evaluate a short-term pain relief treatment in women suffering from CPP persisting after childbirth in order to enable physiotherapeutic intervention. Material and methods: Thirty-six parous women with chronic pelvic pain persisting after childbirth were recruited at the Department of Physiotherapy, SundsvallHospital and by advertisements in newspapers and 29 parous women without chronic pelvic pain were recruited from an organized gynaecological screening at a midwifery surgery. All women were provoked by intra-pelvic palpation of 13 predetermined intra-pelvic landmarks. The provoked pain distribution was expressed in pain drawings and the pain intensity verbally on a Likert scale.Also, in a randomised controlled trial the 36 women with chronic pelvic pain were allocated to bilateral injection treatment with either triamcinolone or saline solutions, given once on the ischial spine with follow-up after four weeks. Results: Referred pain provoked on intra-pelvic landmarks follows a specific pattern. In general, pain provoked by palpation of the posterior intra-pelvic landmarks was mostly referred to the sacral region and pain provoked by palpation of the ischial and pubic bones was mostly referred to the groin and pubic regions. In women with chronic pelvic pain the provoked pain distribution area and pain intensity were magnified as compared to women without chronic pelvic pain. In the clinical trial decreased pain intensity, decreased distribution of pain and improved physical function was achieved among the triamcinolone treatment group as compared to the saline treatment group. Also, a positive correlation was shown between reduced pain intensity and improved function. Conclusions: Referred pain patterns provoked on intra-pelvic landmarks in women with chronic pelvic pain persisting after childbirth are consistent with sclerotomal sensory innervations and indicates allodynia and central sensitisation. This suggests that pain mapping can be used to evaluate and confirm the pain experience and contribute to diagnosis. Also, the pain intensity provoked by stimulation of the intra-pelvic landmarks is suggested to be useful to differentiate women with chronic pelvic pain from those without. Corticosteroid treatment to the ischial spine resulted in decreased pain and increased function.

Systematic Review: Chronic pain and insomnia are highly comorbid, and evidence suggests a reciprocal relationship between these. CBT-I has been shown to improve sleep in those with chronic pain, therefore the potential of improved sleep leading to improvements in pain symptoms is a possibility. This led to the question: Does CBT-I improve pain symptoms in those with chronic pain and insomnia? A systematic review of the literature was conducted resulting in eight papers regarding six studies. Evidence was moderate that CBT-I improved sleep and pain related disability, but did not improve self reported pain levels. This discrepancy between improvements in pain related disability and no changes in self-reported pain levels led to the research question for the empirical element of the current thesis. Empirical Element of Thesis Objective: Chronic low back pain (CLBP) is a common form of chronic pain that affects a large population each year. Chronic pain and insomnia are highly comorbid conditions, yet knowledge about how patients perceive their interaction is limited. This qualitative study aims to inform our understanding of the patient experience with particular reference to beliefs and attributions surrounding pain, poor sleep and their interaction. Methods: 11 outpatients from a chronic pain clinic were recruited who suffered CLBP as their main symptom, and who had subsequently developed insomnia as a result. Data were analysed using Interpretative Phenomenological Analysis (IPA). Results: Qualitative analysis produced five super-ordinate themes: 1) the privacy of pain and solitude of sleep; 2) sleep/pain interaction; 3) night-time thinking; 4) adjustment and acceptance; and 5) self-management. Discussion: The first three themes combine to create the individual experience of CLBP: the visceral, emotional experience; the pre-existing and shifting beliefs; and the thought content. Once this is in place, the individual can reflect on what this means to them, and through acceptance, move through to adjustment. The individual accepts elements of their current experience, but where they see the opportunity to take control, these adjustments are translated into actions relating to self-management. These themes suggest CBT-I should be adapted to include pain specific beliefs to form a CBT for Insomnia and Chronic Pain (‘CBT-CPI’).