An understanding of pain presupposes that the sufferer is able to use a language which is understood by all. Pain is always described in the language of experience and this experience, encountered by all, is nevertheless lived alone. The interpretive process provides the framework for this study which explores the experiences of five persistent pain sufferers. They have not had their pain validated by diagnosis and persistent pain has become the centrepiece of their existence. The use of epiphany moments illuminates an understanding of the essence of persistent pain experiences, and sufferers are provided with a voice to tell their own stories as their experiences unfold through events in time. These stories are then deconstructed and analysed in order to bring meaning to the lives described. This study found that the communal folklore of pain remains underpinned by dominant ideological forces and discursive practices which sustain the powerlessness of persistent pain sufferers. The sufferer is rendered powerless through medical technologies including the medical interview. Through language the perception of pain is understood and translated in such a way as to cause the sufferer to question the validity of their experience while accepting blame for the persistence of their pain and the need to have it stop. It was postulated that resistance to this process provides the mechanism through which persistent pain sufferers are able to surrender previously held notions of self to alternate identities, which encapsulate the embodied experience of pain. The sufferer can then move to a position where their persistent pain experience is validated. / Doctor of Philosophy (PhD)

The current thesis aims to address the prognosis and management of patients who have injuries necessitating orthopaedic surgery. In Chapter 1 I introduce the thesis, and in Chapter 5 I offer conclusions and summarize the contribution of the work. In Chapter 5, I address the scope, rationale, key findings, limitations and implications. Chapter 2 is a systematic review and meta-analysis investigating the effectiveness of antibiotic prophylaxis in patients with open fracture of the extremities. The results demonstrate moderate quality evidence of an important reduction in the infection rate in patients receiving, versus not receiving, antibiotic prophylaxis. We found no difference in infection rate with longer (3 to 5 days) versus shorter (1 day) duration of antibiotics – this finding warrants only low confidence. Chapter 3 is a systematic survey of current practice and recommendations regarding antibiotic prophylaxis in open fracture management. Authors of publications over the last decade strongly support early systemic antibiotics prophylaxis for patients with open fractures of extremities. In practice, most used systemic antibiotics with both gram-positive and gram-negative coverage, and continued the administration for 2 to 3 days. Most recommendations suggested gram-positive coverage for less severe injuries, and administration duration of no more than 3 days (half suggested 1 day). For more severe injuries, most recommendations suggested broad antimicrobial coverage continued for 2 to 3 days. Chapter 4 is a longitudinal study investigating predictors of persistent post-surgical pain after tibia fracture. We found significant independent associations between resolution of pain and male sex, non-smoking and alcohol consumption. Age, obesity, type of fracture (closed versus open), additional injuries, and post-operative weight-bearing status did not predict resolution of pain. Our findings suggest that clinicians should be particularly alert to the possibility of troublesome post-operative pain in female smokers who do not drink alcohol. Clinicians may consider counselling patients to discontinue smoking, inform them that they are at nearly double the risk of incidence of troublesome post-operative pain (in addition to the long-term adverse health consequences of smoking). / Thesis / Doctor of Philosophy (PhD) / Antibiotic prophylaxis reduces infection with 10% fewer event rate than the group without antibiotic prophylaxis (low to moderate confidence in estimates). The optimal antibiotic regimens and duration remain uncertain. There is a higher risk of persistent post-surgical pain in female smokers who do not use alcohol, following tibia fractures.

Persistent pain conditions are a major health problem throughout the world and are one of the primary reasons that people seek medical treatment (Gureje, Von Korff, Simon, & Gater, 1998; Verhaak, Kerssens, Dekker, Sorbi, & Bensing, 1998). These conditions are characterized by complex interactions between cognitive, emotional, and physiological disturbances and are often associated with comorbid psychological disorders (Gatchel, 2004). Though previous studies have examined the effect of interventions targeting persistent pain, such as physical self-regulation interventions, few studies have examined the complex interaction between such interventions and other variables such as psychological and physiological functioning and presence of social support. The current study was designed to evaluate the effect of a physical self-regulation intervention (i.e. diaphragmatic breathing entrainment) on response to a brief physical stressor (i.e., mild thermal stimulation) as well as to evaluate whether presence or absence of a supportive partner influenced this relationship. Participant response was measured via self-report of pain intensity and unpleasantness and via physiological measures of respiration rate, blood pressure, heart rate, and heart rate variability. The study consisted of 154 female participants who participated in pairs (i.e., 77 pairs). Each participant was randomly assigned to training in diaphragmatic breathing or a control condition as well as being randomly assigned to complete the study with or without their supportive partner present. Analyses revealed that breathing entrainment resulted in significantly slower breathing rate during the thermal stressor task (p < .01). Presence of a supportive partner interacted with breathing entrainment to influence heart rate during the thermal stressor task (p < .05) such that participants who completed the study with a support person present had a lower heart rate when trained in diaphragmatic breathing than when trained in a control protocol and participants who did not have a support person present showed the opposite effect. Presence of a supportive partner also interacted with breathing entrainment to influence ratings of task unpleasantness (p < .05) such that participants who were trained in diaphragmatic breathing rated the task similarly regardless of presence or absence of a supportive partner, whereas participants who were trained in a control protocol rated the task as more unpleasant when accompanied by a supportive partner. In conclusion, the present study demonstrates the impact of training in diaphragmatic breathing and presence of social support on response to thermal stimuli as measured by both self-report (i.e., ratings of task unpleasantness) and physiological (i.e., respiration rate and heart rate) measures. This study highlights the usefulness of implementing a self-regulatory training strategy for treatment of pain and in considering the efficacy of incorporating a supportive partner into such training.

Bakgrund: Långvarig smärta är svår att bota. Smärtan är svår att lindra och kan vara mycket påfrestande för kroppen. Sjuksköterskans bemötande kan påverka patientens smärtupplevelse. Ett gott bemötande kan hjälpa patienten att finna tilltro till vården samt lindra smärtan medans ett dåligt bemötande kan förvärra smärtupplevelsen. Syfte: Syftet är att ta reda på hur patienter med långvarig smärta upplever sin smärta samt hur de upplever sjuksköterskans bemötande i omvårdnaden. Metod: En litteraturstudie har genomförts där tio artiklar rörande långvarig smärta har granskats och analyserats och sammanställts i olika teman. Artiklarna har varit både kvalitativa och kvantitativa. Uppsatsen utgår från Joyce Travelbees omvårdnadsteori men baseras även på andra teorier. Resultat: I resultatet framkommer det att sjuksköterskans bemötande har stor betydelse för patientens upplevelse av vården. Patienter har känt sig förolämpade och nedvärderade och upplevt att de inte blivit trodda på. Patienter menar att dialogen mellan dem och sjuksköterskan är av stor vikt då det kan vara ett sätt att bearbeta oro och rädsla över deras sjukdomstillstånd. Diskussion: Det är viktigt att sjuksköterskan är medveten om patienten och dennes upplevelser. Hur sjuksköterskan bemöter patienten kan påverka dennes upplevelser av vården och kan skapa både en trygghet men också en känsla av osäkerhet hos patienten. Som sjuksköterska är det viktigt att frångå egna värderingar för att kunna se den unika personen som man har framför sig. Nyckelord: Långvarig smärta, omvårdnad, patientens upplevelser, bemötande / Background: Persistent pain is difficult to cure. The pain is difficult to reduce and can be very stressful to the body. The approach by the nurse can affect the patient’s perceived pain. A good approach can help the patient to find trust in public care and to reduce the pain, and a bad approach can make the pain experience worse. Aim: The aim of this study was to find out how patients with persistent pain experience their pain and how they experience the nurses clinical encounter in the care. Method: A literature study has been conducted, where ten articles handling persistent pain have been investigated, analyzed and been compiled into different themes. The articles have been both qualitative and quantitative. The study is based on Joyce Trevelbees nursing theory but includes other theories as well. Results: The result shows that the approach by the nurse is very important for the patient’s perception of the public care. Patients have felt offended, disparaged and disbelieved. Patients mean that the dialogue between the patient and the nurse is of high importance, as this is a way to handle concern and fear related to their illness. Discussion: It is important that the nurse is aware of the patient and the patient’s experiences. The approach by the nurse can affect the patient’s perception of the public care. It can create both a sense of security and of uncertainty for the patient. It is important as a nurse to leave your own values aside to be able to see the unique person in front of you. Keywords: Persistent pain, nursing, patients experiences, clinical encounter

Mindfulness is a way of managing chronic pain and its consequences as it fosters anaccepting approach to pain that can be beneficial in several aspects of life affected bypain. This study sought to examine whether an online mindfulness training programcould reduce the experience of pain, increase acceptance of pain, and increase qualityof life in a group of individuals suffering from chronic pain. The study was arandomized controlled trial with a partly active control group. Initially 52 participantswere randomized to the intervention group and 55 to the control group. The drop outrates were high, 21 participants from the intervention group and 40 participants fromthe control group completed post measurement. Increased levels of mindfulness,reduced pain related distress, and heightened pain acceptance, as well as increasedquality of life, was observed in the intervention group. A strong tendency towards aperceived reduction of pain intensity was also evident in the intervention group. Asthe mindfulness program had positive effects on the overall experience of pain it mayserve as a cost‐effective and useful method of dealing with chronic pain. / Mindfulness är ett sätt att hantera kronisk smärta och dess konsekvenser då det lär uten accepterande inställning till smärta som kan vara till hjälp i flera aspekter av livetpåverkade av smärta. Denna studie undersökte huruvida ett online‐baseratmindfulnessprogram kunde minska upplevelsen av smärta, öka acceptans av smärtaoch öka livskvaliteten hos en grupp individer med kronisk smärta. Studien varrandomiserad och kontrollerad med en delvis aktiv kontrollgrupp. Initialtrandomiserades 52 deltagare till experimentgruppen och 55 deltagare tillkontrollgruppen. Bortfallet var högt, 21 deltagare från experimentgruppen och 40deltagare från kontrollgruppen fullgjorde eftermätningarna. Ökade nivåer avmindfulness, reducerat smärtrelaterat lidande, ökad acceptans av smärta såväl somökad livskvalitet återfanns i experimentgruppen. En stark tendens till minskadupplevd smärtintensitet var också tydlig hos experimentgruppen. Dåmindfulnessprogrammet hade positiva effekter på den övergripande upplevelsen avsmärta kan det fungera som en kostnadseffektiv och användbar metod att hanterakronisk smärta.

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Bakgrund  Långvarig smärta är ett folkhälsoproblem som skapar lidande för den drabbade. Farmakologisk behandling ger inte alltid optimal effekt vilket kan leda till att personer med långvarig smärta söker sig till andra behandlingsmetoder. Därför behövs vidare forskning i de icke-farmakologiska behandlingsmetoderna för att få kunskap och information om den drabbades upplevelser av icke-farmakologisk behandling.  Syfte  Syftet var att belysa personers upplevelser av icke-farmakologisk behandling vid långvarig smärta.  Metod  En litteraturöversikt gjordes baserad på 15 vetenskapliga artiklar. Sökningen av litteratur genomfördes i två databaser CINAHL och PubMed. En kvalitetsgranskning av artiklarna utfördes med hjälp av Sophiahemmets bedömningsunderlag. Därefter gjordes en integrerad dataanalys där resultat från artiklarna analyserades och sammanställdes.  Resultat  Två huvudkategorier, Upplevd smärta och välbefinnande, samt sju subkategorier sammanställdes i resultatet. Resultat visade att icke-farmakologiska behandlingar ger en förbättring på smärtintensitet och ett ökat välmående inom både psykiska och fysiska funktioner.  Slutsats  Icke-farmakologiska behandlingsmetoder visades ha måttlig till god effekt på smärtintensitet. Smärtan försvann inte helt men en minskning i smärtintensitet gav plats för annat i personens liv, vilket ledde till en ökning i personens välmående som kan appliceras i sjuksköterskans arbete i omvårdnad av personer med långvarig smärta. / Background Persistent pain is a public health problem that creates suffering for the affected. Pharmacological treatment does not always give an optimal effect, which can lead to people with persistent pain seeking other treatment methods. Therefore, further research into the non-pharmacological treatment methods is needed in order to obtain knowledge and information about the experiences of those affected. Aim The aim was to shed light on people's experiences of non-pharmacological treatment in persistent pain. Method A literature review was made based on 15 scientific articles. The search for literature was conducted in two databases CINAHL and PubMed. A quality review of the articles was made with the help of Sophiahemmet's assessment basis. An integrated data analysis was then performed where results from the articles were analyzed and compiled. Results Two main categories, experienced pain and well-being, and seven sub-categories were compiled in the result. Results showed that non-pharmacological treatments provide an improvement in pain intensity and increased well-being in both mental and physical functions. Conclusions Non-pharmacological treatment methods have been shown to have a moderate to good effect on pain intensity. The pain did not disappear completely, but a decrease in pain intensity gave way to other things in the person's life, which led to an increase in the person's well-being that can apply in the nurse's work in caring for people with persistent pain.

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Le syndrome de fragilité est devenu le concept le plus étudié ces dix dernières années par les gériatres, de par le vieillissement rapide de la population Française et mondiale et pour l'intérêt en terme de prévention globale que ce syndrome pourrait représenter. L’ intérêt qu’ apporte ce nouveau concept de plus en plus consensuel est en effet sa capacité à définir une personne âgée comme étant une entité fonctionnelle et multidimensionnelle (cognitive, thymique et sociale) pouvant être réversible. A partir de la, l’élaboration d'une stratégie par les médecins, afin de dépister les patients les plus fragiles pourrait permettre d’éviter les stades irréversibles de la perte d’autonomie, l’institutionnalisation et la surmortalité. Cela aurait probablement des conséquence s possibles en matière de santé publique. Un des facteurs de risque possible de la fragilité est la douleur chronique qui a toujours été considérée à tord comme un simple symptôme prévalent chez les personnes âgées et non pas comme une maladie soit une entité clinico - pathologique complexe pouvant interagir avec la fragilité. Dans ce travail, nous avons étudié les mécanismes physiopathologiques communs qui lient le syndrome de fragilité à la douleur chronique , leur interaction et l’ intérêt que peut susciter l’optimisation du dépistage de la douleur chronique chez les personnes âgées dans l’évaluation des personnes les plus fragiles. Nous proposons à travers de nouveaux projets de recherche clinique prospectifs , de démontrer au - delà d e la relation possible entre la fragilité et la douleur persistante, le rôle que pourrait jouer les médicaments essentiellement analgésiques dans la réversibilité de ce syndrome / The frailty concept has become the most studied one over the past decade , by the rapid aging of French and the world population and for the interest in terms of overall prevention that this syndrome could represent. The advantage brought by this ne w concept increasingly consensual relies on its ability to define elderly as a m ultidimensional functional entity (cognitive, social and mood) being reversible. Caregivers have to start before to tailor a care plan by screening for the frailest patients in order to avoid irreversible stages of frailty, ( institutionalization and mortal ity ) . This probably would have possible consequences for public health. One of the possible risk factors for fragility is persistent pain which has always been wrongly considered as a mere prevalent symptom in o lder people and not as a clinical and patholo gical entity that can interact with the complex fragility syndrome. In this work, we studied the common pathophysiological mechanisms that link frailty to pain, their interaction and the interest that may lead to optimize screening of pain in older adults within frailty evaluation. We offer through new clinical research projects looking to demonstrate beyond the possible relationship between fragility and persistent pain, the potential role of analgesic drugs mainly in the reversibility of this syndrome

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