Diss. (sammanfattning) Stockholm : Karol. inst., 2006. / Härtill 5 uppsatser.

Diss. (sammanfattning) Umeå : Univ., 2006. / Härtill 6 uppsatser.

Thesis (Ph.D.)--University of Melbourne, Centre for Neuroscience and Howard Florey Institute, 2009. / Typescript. Includes bibliographical references.

Thesis (Ph.D.)--University of Florida, 2004. / Typescript. Title from title page of source document. Document formatted into pages; contains 102 pages. Includes Vita. Includes bibliographical references.

Thesis (M.S.)--University of Florida, 2004. / Typescript. Title from title page of source document. Document formatted into pages; contains 33 pages. Includes Vita. Includes bibliographical references.

Background: Pain is frequently reported by people with multiple sclerosis (MS). It has been associated with decreased quality of life, psychiatric morbidity, interference with day to day activities, and frequent healthcare attendance. It has been reported by people with multiple sclerosis to be one of their most important symptoms, and available treatments are limited in their effectiveness. Despite this, our understanding of the epidemiology and mechanisms of pain in people with MS are limited. Our understanding of the interactions of central nervous system mechanisms and pain states overall is growing. However, the application of this knowledge to MS is incomplete. Previous studies have shown that the descending pain modulatory system (DPMS) is an endogenous network of cortical and subcortical brain structures which act to limit, or accentuate, an individual’s perception of pain, via descending brainstem pathways. Associated clinical measures include depression, anxiety, and cognitive flexibility. Our understanding of the function or dysfunction of this system in MS is limited. We do not know if the MS disease process may adversely affect the structure or function of the DPMS. Hypothesis: In people with neuropathic limb pain in relapsing remitting MS (RRMS), compared to people with RRMS who do not have pain, there will be disruption of the endogenous descending pain modulatory system. This will manifest as impaired descending inhibition of pain. Aims and Methods Establishing the background using systematic reviews: The first aim of this thesis was to establish the prevalence, natural history and associations of pain (and pain syndromes) occurring in people with MS. The second aim was to explore existing knowledge of how the MS disease process may contribute to pain states, using a systematic review of neuroimaging studies. Prospective clinical study: A case-control study of 47 people with RRMS was then carried out. 31 of these had neuropathic pain in the limbs, and 16 did not have pain. Using targeted assessments, function of the descending pain modulatory system was assessed in the following ways: First: Detailed clinical, behavioural and neuropsychological assessment, focussing on cognitive, behavioural and affective features known to be closely related to the DPMS. Second: MRI imaging of brain structure, focussing on the volume and location of MS lesions, as well as the volume of key grey-matter structures involved in the DPMS. Third: Resting state functional MRI imaging of the brain, focussing on functional connectivity between the rostral anterior cingulate cortex and two other key DPMS structures (dorsolateral prefrontal cortex, and periaqueductal gray). Results: Systematic reviews: Meta-analysis of existing prospective studies confirmed that pain is very common in MS, affecting about 63% of people with MS on average (95%CI between 55 and 70%). Many different types of pain contribute to this overall estimate. No significant associations with disease course or stage emerged. Several neuroimaging studies have assessed people with MS-associated pain using MRI. These studies were often small, and with associated methodological issues. It is likely that location of MS lesions is implicated in aetiology of pain syndromes in some cases, though our overall knowledge is limited. Prospective study: In a prospective study, people with and without pain were matched for age and gender. Furthermore, groups were balanced for a range of other variables. The pain group more frequently received gabapentinoid medications. The presence of pain was significantly associated with increased scores for depression, fatigue and catastrophising, as well as with specific impairments at neuropsychological assessment, including cognitive flexibility. Many of these impairments are directly relevant to existing models of the DPMS. Overall volume of MS lesions was not different in people with pain, though lesions were more likely to occur in the brainstem. Some alterations of grey-matter volumes in people with pain which mirrored studies of pain disorders outside MS were found, but these did not involve structures key to the DPMS. Affected structures included trigeminothalamic nucleus (relative volume increase in pain group), posterior cingulate cortex and parahippocampal gyrus (volume decrease in pain group). Functional connectivity of the rostral anterior cingulate cortex to the periaqueductal grey matter, a key structure in the descending modulation of pain, was stronger in the group without pain. Conversely, functional connectivity to the dorsolateral prefrontal cortex, repeatedly implicated in the DPMS and thought to be involved in cognitive evaluation and flexibility, was stronger in the pain group. MS lesion volume appeared to account for some of this difference in a multivariate analysis. Limitations: Key limitations of this work include cross-sectional design, small sample size, and number of statistical comparisons carried out. Conclusions: Systematic reviews examined the prevalence, natural history and associations of pain in MS, as well as examining existing neuroimaging studies which investigated how the MS disease process could contribute to pain states. A prospective study found evidence of both emotional/affective and cognitive dysfunctions relevant to the hypothesis of dysfunction in the DPMS. Higher likelihood of MS lesions in the brainstem could be relevant to DPMS function. Separately, there were structural grey-matter volume alterations reflecting those found in many pain studies outside MS. Importantly, however, these did not affect key DPMS structures. Resting state functional MRI however demonstrated altered connectivity of core DPMS structures, which may be partly mediated by MS lesion volume. Functional connectivity findings could be consistent with the hypothesis of impaired descending pain inhibition, in people with relapsing remitting MS affected by neuropathic limb pain.

Aim The thesis set out to examine validations of three observational pain assessment tools and establish nurses’ expectations of them and the factors that might influence them within intensive care unit (ICU) settings. Background The guidelines to pain assessment specific to ICU patients have been of great interest to health professionals over the last 20 years. Pain assessment remains a challenge for most ICU patients due to the difficulty of assessing pain with any precision. Evidence suggests that the Behavioural Pain Scale (BPS) and Critical- Care Pain Observation Tool (CPOT) have demonstrated sound psychometric properties. A review of the relevant literature highlighted the fact that no such studies have yet been conducted with a similar homogenous group in Asia. The Wong-Baker Face Pain Rating Scale (FPRS) is currently widely used for nonverbally communicating patients (NVCPs) with pain in ICU settings, and is even recommended for use with children. Valid assessment tools are required for effective pain assessment in ICU settings, particularly in patients who are experiencing communication difficulties. Design An embedded mixed methods design was employed to: 1) translate Chinese versions of BPS and CPOT, 2) test their validity and reliability of in comparison with FPRS, and 3) establish the nurses’ expectations about the three study scales when undertaking pain assessment by using semi-structured focus group interviews. Methods This thesis initially reviews the literature available to select the most appropriate scales for assessing pain in critically-ill NVCPs. The selected scales were then translated into a Traditional-Chinese version using established procedures for the Taiwanese context. Evaluations of the three pain scales were gathered using quantitative measures of pain scores in NVCPs experiencing painless/painful interventions. These were further compared with a few focus groups to establish the feasibility and utility of the three pain scales. The psychometric properties of the pain scales were assessed for reliability by using internal consistency and inter-rater agreement) and for validity by using content validity, concurrent validity, discriminant validity, and responsiveness. The validity was evaluated using ANOVA to compare the changes between the different procedures. The significance level was set at 0.05. As for the analysis of the qualitative data, this study typically follows the path of aggregating the words into themes of information and presenting the diversity of ideas gathered during the data collection. Results For the 2068 observations in 237 patients, there were no statistical differences between the characteristics of the BPS, CPOT, and FPRS groups. Validity was demonstrated by changes from baseline in the scores of the three groups, which were significantly higher during suction (p < 0.001). In regard to the result for the criterion validity, both BPS and CPOT had moderate positive correlations with FPRS. The internal consistency was excellent; the Cronbach’s α was 0.700 for BPS and 0.821 for CPOT when all items were included. The majority of nurses preferred to use BPS to assess pain in their clinical practice. When the nurses were asked how long they needed and how easy they found it to complete the assessments using these tools, they all agreed that each patient assessments were easier and took the least time when they used FRPS. However, the nurses considered that the most effective pain reaction during nociceptive procedures had been assessed by using BPS. Even though all of the participant nurses stated that CPOT provides a detailed item-description about pain behaviour, it also provided the biggest obstacle to use because of its ambiguous indicators. Conclusions BPS, CPOT and FRPS provide potentially useful measurement scales for assessing pain in ICU NVCPs. However, judging from the inconsistencies between the nurses’ replies, the results could reflect a conflict between the need to use a validated measure of pain for NVCPs on the one hand and managing a heavy workload in the ICU on the other. This study opens up an avenue for investigating further the link between the underlying conceptions of pain behaviour and the effectiveness of pain assessments in NVCPs when using an objective pain measurement.

The presented work deals with the issue of non-pharmacological pain relief in patients with thermal trauma. Burn pain is considered to be one of the worst, unlike common surgical pain due to numerous surgical procedures and often large dressing changes. The basis of pain treatment is pharmacotherapy, but an important part are also non-pharmacological methods that can be applied by nurses. The main goal of the study was to find out which available and easy-to-use non- pharmacological methods of pain relief are the most effective according to burn patients. The partial goals were evaluating the impact of fear and anxiety on pain and the question of whether patients' pain is adequately managed. The author's questionnaire, which was partly based on a survey conducted among the patients themselves, was used for the research. A total of 98.3% of respondents gave a positive evaluation of the adequacy of analgesia. Apart from analgesics, the following methods were then identified as the most effective: undisturbed sleep, relief position, rest, close people visits and interviews with the caring staff. The research confirmed that apart from quality sleep human contact is the most important for pain relief. In addition to relieving pain, it also affects the mental state of patients and helps reduce the...

In the United States, 10% to 15% of newborns are admitted to the neonatal intensive care unit (NICU). Painful procedures are unavoidable during NICU care; the neonate experiences approximately 12 painful procedures per day. Inconsistent and/or inappropriate pain management in the NICU remains a problem. The purpose of this study is to identify the prevalent factors that influence the implementation of pain management strategies among nurses who work in a NICU setting in a Central Florida hospital. This study was conducted using a voluntary and anonymous electronic survey. The survey was divided into two sections; the first section designed to describe the sample, and the second section containing a Likert-type scale that assessed the nurses’ general pain knowledge, knowledge of pain assessment, and awareness of accepted pain management strategies. The survey was adapted from previously published research. Results indicate pain was more likely to be addressed when nurses collaborated closely with the attending physician. The majority of nurses were aware of current protocols for pain management on the unit but not all nurses agreed those protocols were adequate. Results also indicated pain assessment education is being provided in the NICU and the nurses feel confident in their skills to assess pain, however, not all nurses agreed that pain is being well managed in their unit. There appears to be a gap between the nurse’s knowledge/skill to assess pain and implementation of strategies to decrease pain. Although it is the nurse’s responsibility to prevent and treat newborn pain in the NICU, not all nurses agreed that newborn pain is well managed in their unit and some believe pain to be an unavoidable experience in the NICU. Nurse-physician collaboration is key to evidence based newborn pain management.

Background: Altered autonomic nervous system (ANS) function has been proposed as a mechanism in the development of central sensitisation (CS) and visceral pain hypersensitivity (VPH). The contribution of the parasympathetic nervous system (PNS) and the factors that mediate differences in sensitisation to acid are unclear and their study will clarify risk factors for oesophageal pain hypersensitivity (OPH) in gastrooesophageal reflux disease. Aims: To investigate psychophysiological and pharmacological manipulation of PNS tone in the development of OPH, and to determine factors which predict the development of OPH to acid infusion in healthy volunteers in a validated model of acid induced OPH. Methods: Pain thresholds to electrical stimulation in the proximal oesophagus were determined before and after a 30-minute distal oesophageal infusion of 0.15 mol/L hydrochloric acid in subjects. Sympathetic (SNS) and PNS parameters were measured at baseline and continuously thereafter. Subjects underwent psychological profiling for anxiety, depression, attachment vulnerability and personality type. Using this model, five studies were undertaken: Study 1 a pilot study to trail modulation suitability for further study used. In Study 2, subjects who demonstrated secondary hyperalgesia in the proximal non-acid-exposed oesophagus performed deep or sham breathing. Study 3 subjects, who did not sensitise to acid, underwent a validated stress test to induce OPH. With Study 4, deep breathing with IV saline (placebo) or atropine (PNS antagonist) was used to evaluate deep breathing’s induced PNS tone in OPH reduction. Study 5, a genetic pilot study, exploring the role of the GCH-1 haplotype in VPH. Results: ANS control’s key role in CS was clarified. Deep breathing increased PNS tone and prevented acid-induced OPH in comparison to sham breathing and confirmed increased PNS tone’s reversal of OPH. Psychological factors of anxiety, alexithymia and attachment status influence ANS modulation of CS. Individuals’ predisposition to VPH due to psychogenetic profiles were clarified and their biopsychosocial role illustrated. Conclusions and Inferences: A mechanistic explanation for the analgesic effect of deep breathing is provided with potential therapeutic implications in the treatment of VPH syndromes. Further clinical study is warranted to develop cost-effective treatments for chronic VPH syndromes.