Search

Introduction Persons with dementia experience time-related problems, but there is a lack of instruments evaluating their time processing ability and daily time management. This study aimed to evaluate the psychometric properties of the instruments KaTid (R)-Senior measuring time processing ability, and Time-S (c) Senior and Time-Proxy (c) measuring daily time management for persons with dementia. Methods Persons with dementia (n = 53) and their significant others (n = 49) participated in the study. Rasch analyses were used to evaluate the instruments' rating scale functioning; internal scale validity; person-response validity; unidimensionality; person-separation reliability; and internal consistency. Versions excluding items with poor fit to the Rasch model were also evaluated. Results Overall, the Rasch analyses showed acceptable psychometric properties. All instruments met the criteria for unidimensionality and the reliability was good. More challenging items should be added in KaTid-Senior for better targeting of persons with mild dementia. Person-response validity issues in Time-S Senior need to be addressed. Conclusion The instruments can validly and reliably be used to assess time processing ability and daily time management in persons with dementia in clinical research and healthcare settings. In turn, this can contribute to the development of methods to compensate for impaired time processing ability and daily time management. The assessments can also increase the possibility of early detection of impaired time processing ability and daily time management, thereby facilitating adequate timing of interventions and enhanced occupational performance.

Frida Svanholm,1 Mathilda Björk,1 Monika Löfgren,2,3 Björn Gerdle,1 Henrik Hedevik,4 Peter Molander1,5 1Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; 2Department of Clinical Sciences, Karolinska Institutet, Stockholm, Sweden; 3Department of Rehabilitation Medicine, Danderyd Hospital, Stockholm, Sweden; 4Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; 5Department of Behavioural Sciences and Learning, Linköping University, Linköping, SwedenCorrespondence: Frida Svanholm, Pain and Rehabilitation Centre, County Council of Östergötland, Brigadgatan 22, Linköping, S-58185, Sweden, Tel +46 730-447785, Email frida.svanholm@liu.seBackground: Interdisciplinary pain rehabilitation programs (IPRPs) help people with chronic pain improve their health and manage their work; however, the way IPRPs address sick leave could be improved. Although work interventions can be a part of IPRP, it is not well known how and to what extent.Aim: This study explores the frequency of work interventions and the characteristics of patients who participate in work interventions as part of IPRP at specialist pain rehabilitation departments in Sweden. In addition, this study explores the association between participation in work interventions and change in patients’ self-rated work ability after IPRP.Methods: Data from the Swedish quality registry for pain rehabilitation (SQRP), which includes 3809 patients between 2016 and 2018, were analysed with descriptive statistics and regression analyses.Results: The results indicate a high participation rate in work interventions (90%). Some differences were evident concerning characteristics of patients who participated in different work interventions. The return-to-work (RTW) plan, the most frequently used work intervention, had the strongest association with change in self-rated work ability after IPRP. However, the effect sizes were small, and the initial score best explained the change. Furthermore, there were differences between employed and unemployed patients and employment had a positive association with change in self-rated work ability.Conclusion: More research is needed to understand IPRP’s mechanisms and work interventions to support patients with chronic pain, reduce sick leave, and manage work. Employment status needs to be considered and interventions should be tailored to match the individual needs.Keywords: chronic pain, work interventions, rehabilitation

IntroductionChronic pain (CP) is one of the most frequently presenting conditions in health care and many patients with CP report mental fatigue and a decline in cognitive functioning. However, the underlying mechanisms are still unknown.Methods and analysisThis study protocol describes a cross-sectional study aimed at investigating the presence of self-rated mental fatigue, objectively measured cognitive fatigability and executive functions and their relation to other cognitive functions, inflammatory biomarkers and brain connectivity in patients with CP. We will control for pain-related factors such as pain intensity and secondary factors such as sleep disturbances and psychological well-being. Two hundred patients 18–50 years with CP will be recruited for a neuropsychological investigation at two outpatient study centres in Sweden. The patients are compared with 36 healthy controls. Of these, 36 patients and 36 controls will undergo blood sampling for inflammatory markers, and of these, 24 female patients and 22 female controls, between 18 and 45 years, will undergo an functional MRI investigation. Primary outcomes are cognitive fatigability, executive inhibition, imaging and inflammatory markers. Secondary outcomes include self-rated fatigue, verbal fluency and working memory. The study provides an approach to study fatigue and cognitive functions in CP with objective measurements and may demonstrate new models of fatigue and cognition in CP.Ethics and disseminationThe study has been approved by the Swedish Ethics Review Board (Dnr 2018/424-31; 2018/1235–32; 2018/2395–32; 2019–66148; 2022-02838-02). All patients gave written informed consent to participate in the study. The study findings will be disseminated through publications in journals within the fields of pain, neuropsychology and rehabilitation. Results will be spread at relevant national and international conferences, meetings and expert forums. The results will be shared with user organisations and their members as well as relevant policymakers.Trial registration numberNCT05452915.

Interdisciplinary pain rehabilitation (IPR) is a recommended treatment for people with chronic pain. An inadequate description of the content of IPR programs makes it difficult to draw conclusions regarding their effects. The purpose of this study was to describe the perceptions and attitudes of healthcare professionals toward a content description of IPR programs for patients with chronic pain. Individual interviews with healthcare professionals (n = 11) working in IPR teams in Sweden were conducted between February and May 2019. Analysis of the interviews resulted in a theme: interdisciplinary pain rehabilitation is a complex intervention, with three categories: limitations in the description of IPR programs; lack of knowledge about IPR and chronic pain; and facilitating and hindering factors for using the content description of IPR programs. Conclusion: Healthcare professionals perceived that IPR programs could be described through a general content description. A general content description could enhance the quality of IPR programs through a better understanding of their content and a comparison of different IPR programs. Healthcare professionals also expressed the importance of a content description being a guide rather than a steering document.

To reduce the individual, societal, and economic burden of the high sick leave rates due to chronic pain, it is essential to find effective strategies for increasing return to work (RTW). Although multimodal rehabilitation programs (MMRPs) may have positive effects on RTW, the results are inconsistent. This study explores the factors that contribute to decreasing sick leave and increasing RTW in patients with chronic pain who completed a MMRP.Four focus groups and three individual interviews were conducted. In total, 18 patients were interviewed. All patients had chronic pain and had completed a MMRP. They were either employed or unemployed, either working to some degree or fully on sick leave. The data were analysed using qualitative content analysis.Three main categories were identified: Knowledge and understanding-prerequisites for tailored solutions; Individual adaptations-necessary but difficult to implement; and Stakeholder collaboration-needs improvement.The participants described a variety of facilitating and limiting factors that created complex prerequisites for RTW. This finding makes it clear that these patients need tailored interventions and strong collaboration among all stakeholders throughout the rehabilitation process. Tailored interventions and collaborations could improve the effectiveness of MMRPs.IMPLICATIONS FOR REHABILITATIONPatients with chronic pain need tailored solutions and adaptations based on their individual needs in the RTW rehabilitation process.To return to work, patients with chronic pain needs support to strengthen their selfconfidence and to be prepared with knowledge and strategies about their abilities and their rights and obligations in relation to the labour market.A well-designed and communicated RTW rehabilitation plan supports the patient in the RTW rehabilitation process.To improve the possibility for employees and employers to create a sustainable work situation, stakeholder reconciliation meetings should be held routinely over time to strengthen the transfer of knowledge and collaboration.

Chronic pain is a major reason for sick leave worldwide. Interdisciplinary pain rehabilitation programs (IPRPs), workplace interventions, and stakeholder collaboration may support patients in their return to work (RTW). Few studies have examined stakeholders' experiences of important components in the RTW rehabilitation process for patients with chronic pain, especially in the context of IPRP. This study explores and describes stakeholders' experiences with stakeholder collaboration and factors related to RTW for patients with chronic pain who have participated in IPRP.Six focus groups, three pair and four individual interviews were conducted with a total of 28 stakeholder representatives from three societal and three health care stakeholders. Data were analyzed using qualitative content analysis.The participants revealed that stakeholder collaboration and a tailored RTW rehabilitation plan were important strategies although they noted that these strategies were not working sufficiently efficient as presently implemented. The different stakeholders' paradigms and organizational prerequisites were described as hindrances of such strategies and that the degree of tailoring depended on individual attitudes.More knowledge transfer and flexibility, clearer responsibilities, and better coordination throughout the RTW rehabilitation process may increase the efficiency of stakeholder collaboration and support for patients.Implications for rehabilitationStakeholders need to have a close dialogue initiated before IPRP to be able to reach consensus and shared decision making in the RTW rehabilitation plan throughout the RTW rehabilitation process.Individually tailored solutions based on a thorough assessment of each patient's work ability and context are identified during IPRP and shall be included in the shared RTW rehabilitation plan.The responsibilities of the stakeholders need to be clarified and documented in the RTW rehabilitation plan.The role of RCs should be developed to improve the coordination throughout the patients' RTW rehabilitation process.

Purpose: There is a lack of knowledge about interprofessional rehabilitation for culturally diverse patients with chronic pain. This study explores experiences of healthcare professionals developing and working with rehabilitation with patients in need of an interpreter and their experience of working with interpreters. Methods: Twelve healthcare professionals at two Swedish specialist rehabilitation centres were interviewed. Grounded theory principles were used for the data collection and analysis. Results: The main category "Demanding and Meaningful Work" represents three concurrently interacting categories: “Frustration” includes the informants’ doubts regarding the benefits of the rehabilitation, lack of care for patients and cultural dissonance between professionals and patients. "Challenges" describes problems in the rehabilitation work due to the need for interpreted mediated communication, the complexity in health status and social aspects among the patients. "Solutions" represents practical working methods and personal approaches developed by the informants for managing frustrations and challenges. Conclusions: The informants’ frustration and challenges when working with a new group of patients, vulnerable and different in their preconceptions, led to new solutions in working methods and approaches. When starting a pain rehabilitation programme for culturally diverse patients, it is important to consider the rehabilitation team’s need for additional time and support. IMPLICATIONS FOR REHABILITATION Healthcare professionals who encounter immigrants with chronic pain need resources to develop their own skills in order to handle complex ethical questions as the patients represent a vulnerable patient group with many low status identities In order to adapt rehabilitation programmes to patient groups with different languages and pre-understandings of chronic pain, there is a need for a team with specific qualities, i.e., close cooperation, an innovative atmosphere, time and also support from experts For appropriate language interpretation it is important to have a professional interpreter and a healthcare professional who are aware of and adopt the rules, possibilities and restrictions of interpretation The rehabilitation of patients in need of language interpretation needs more time and organisation compared to the rehabilitation of patients who speak the national language.

IntroductionAbout 20% of the adult population have chronic pain, often associated with psychological distress, sick leave and poor health. There are large variations in the clinical picture. A biopsychosocial approach is used in investigation and treatment. The concept of personalised medicine, that is, optimising medication types and dosages for individual patients based on biomarkers and other patient-related factors, has received increasing attention in different diseases but used less in chronic pain. This cooperative project from all Swedish University Hospitals will investigate whether there are changes in inflammation and metabolism patterns in saliva and blood in chronic pain patients and whether the changes correlate with clinical characteristics and rehabilitation outcomes.Methods and analysisPatients at multidisciplinary pain centres at University Hospitals in Sweden who have chosen to participate in the Swedish Quality Registry for Pain Rehabilitation and healthy sex-matched and age-matched individuals will be included in the study. Saliva and blood samples will be collected in addition to questionnaire data obtained from the register. From the samples, proteins, lipids, metabolites and micro-RNA will be analysed in relation to, for example, diagnosis, pain characteristics, psychological distress, body weight, pharmacological treatment and clinical rehabilitation results using advanced multivariate data analysis and bioinformatics.Ethics and disseminationThe study is approved by the Swedish Ethical Review Authority (Dnr 2021-04929) and will be conducted in accordance with the declaration of Helsinki.The results will be published in open access scientific journals and in popular scientific relevant journals such as those from patient organisations. Data will be also presented in scientific meetings, meeting with healthcare organisations and disseminated in different lecturers at the clinics and universities. Funding Agencies|Petrus and Augusta Hedlunds Foundation; Gun and Bertil Stohnes Foundation; Loo and Hans Osterman Foundation; Demens foundation; Brain foundation [FO2018-0315]; Senil demens Sarfond foundation Region Orebro; Gamla Tjanarinnor foundation; Swedish Research Council [2018-02470]; Research-ALF region Ostergotland [RO-834951]

Objective Interdisciplinary pain rehabilitation (IPR) usually employs a cognitive–behavioural therapeutic (CBT) approach. However, there is growing support for chronic pain treatments based on acceptance and commitment therapy (ACT). Most studies of ACT and CBT for chronic pain have evaluated their effects after psychological interventions, not after IPR. We compared the results of an ACT-based IPR programme with two CBT-based IPR programmes. Methods We used a retrospective multicentre pretest–posttest design with matched patient groups at three centres. Data were collected from the Swedish Quality Registry for Pain Rehabilitation before and after IPR participation. Participants completed the EQ-5D health-related quality of life questionnaire, the Chronic Pain Acceptance Questionnaire, (CPAQ) and the Hospital Anxiety and Depression Scale (HADS). Analyses were performed to compare the effects of the different interventions. Results Neither EQ-5D nor HADS depression scores were affected by the psychological approach used. The score changes on both CPAQ subscales (activity engagement and pain willingness) indicated significant improvements between admission and discharge at all centres. Conclusions These findings indicate the effectiveness of using psychological approaches to manage chronic pain. Both CBT and ACT had a beneficial effect on most of the assessed health-related parameters.

The current study used functional magnetic resonance imaging to directly compare disease-relevant cerebral pain processing in well-characterized patient cohorts of fibromyalgia (FM, nociplastic pain) and rheumatoid arthritis (RA, nociceptive pain). Secondary aims were to identify pain-related cerebral alterations related to the severity of clinical symptoms such as pain intensity, depression, and anxiety. Twenty-six patients with FM (without RA-comorbidity) and 31 patients with RA (without FM-comorbidity) underwent functional magnetic resonance imaging while stimulated with subjectively calibrated painful pressures corresponding to a pain sensation of 50 mm on a 100-mm visual analogue scale. Stimulation sites were at the most inflamed proximal interphalangeal joint in the left hand in patients with RA and the left thumbnail in patients with FM, 2 sites that have previously been shown to yield the same brain activation in healthy controls. The current results revealed disease-distinct differences during pain modulation in RA and FM. Specifically, in response to painful stimulation, patients with FM compared to patients with RA exhibited increased brain activation in bilateral inferior parietal lobe (IPL), left inferior frontal gyrus (IFG)/ventrolateral prefrontal cortex (vlPFC) encapsulating left dorsolateral prefrontal cortex, and right IFG/vlPFC. However, patients with RA compared to patients with FM exhibited increased functional connectivity (during painful stimulation) between right and left IPL and sensorimotor network and between left IPL and frontoparietal network. Within the FM group only, anxiety scores positively correlated with pain-related brain activation in left dorsolateral prefrontal cortex and right IFG/vlPFC, which further highlights the complex interaction between affective (ie, anxiety scores) and sensory (ie, cerebral pain processing) dimensions in this patient group.

Long-term symptoms after whiplash injury often comprise neck pain, headache, anxiety, depression, functional impairment and low quality of life. In an observational cohort study, we examined physical and mental health effects in patients with subacute to chronic whiplash-associated disorders (WAD) after participation in a multimodal rehabilitation (MMR) program. MMR is a team-based multi-professional method based on a bio-psycho-social model with a cognitive focus to reach an individualized and common goal for the team and patient together. Standardized self-report questionnaires were filled in three times: before MMR, after MMR, and one year after MMR. A total of 322 participants completed the program, 161 of whom responded in full and were further analyzed. At one-year follow-up after MMR, a significant improvement was seen in the evaluation of the primary outcomes (physical and mental health) and secondary outcomes (anxiety, depression, pain intensity and interference with life). Women improved on all outcomes while men did not improve on the psychological measures (mental health, depression and anxiety). This study indicates that a MMR program could be beneficial for patients with subacute to chronic WAD, at least for women, since the outcomes at one-year follow-up were positive.

Although chronic pain is common in patients with Ehlers–Danlos syndrome (EDS) and hypermobility syndromes (HMS), little is known about the clinical characteristics of these groups. The main aim was to compare EDS/HMS with common local and generalized pain conditions with respect to Patient Reported Outcome Measures (PROMs). Data from the Swedish Quality Register for Chronic Pain (SQRP) from 2007 to 2016 (n = 40,518) were used, including patients with EDS/HMS (n = 795), fibromyalgia (n = 5791), spinal pain (n = 6693), and whiplash associated disorders (WAD) (n = 1229). No important differences in the PROMs were found between EDS and HMS. Women were represented in > 90% of EDS/HMS cases and fibromyalgia cases, and in about 64% of the other groups. The EDS/HMS group was significantly younger than the others but had a longer pain duration. The pain intensity in EDS/HMS was like those found in spinal pain and WAD; fibromyalgia had the highest pain intensity. Depressive and anxiety symptoms were very similar in the four groups. Vitality—a proxy for fatigue—was low both in EDS/HMS and fibromyalgia. The physical health was lower in EDS/HMS and fibromyalgia than in the two other groups. Patients with EDS/HMS were younger, more often female, and suffered from pain for the longest time compared with patients who had localized/regional pain conditions. Health-care clinicians must be aware of these issues related to EDS/HMS both when assessing the clinical presentations and planning treatment and rehabilitation interventions.

Background: There is lack of knowledge on how occupational therapists (OTs) assess daily time management (DTM) for persons with dementia (PwDs) and on which aspects affect prescription of time assistive technology (AT). Aim: To explore OTs' experiences of assessing the need for and prescribing time AT for PwDs. Material and methods: Focus group interviews with OTs that prescribe time AT for PwDs analyzed via qualitative content analysis. Results: A main category and four categories were identified. The categories illustrated a complex and time-consuming prescription process, which was facilitated if the PwD was supported by a significant other (SO). Support from a SO was especially important during implementation and follow-up. OTs had to take individual responsibility for staying informed about time AT. Organizational limitations and time constraints were barriers for OTs striving to work according to national prescription guidelines. Conclusions and significance: High demands are made on SO's participation during the prescription process. PwDs with no support from SOs are at risk not receiving or fully benefitting from time AT. To avoid inequalities, specific forms of support need to be developed and targeted at PwDs without SOs to ensure that they have sufficient opportunities to access and use time AT.

The study sought to examine women's experience of painful endometriosis including long-term aspects, social consequences, impact of treatment and development of own coping strategies.This qualitative study was based on 16 individual interviews analyzed according to grounded theory. The thirteen women (age 24-48) were recruited at a pain clinic in Stockholm, Sweden.A theory illustrating women's experience of living with painful endometriosis was developed with three categories and one core category. Bidirectional interactions between the categories and with the core category were found. Endometriosis influenced the women's sensations, feelings and reactions, creating a sense of difference from other women (category: Woman with painful endometriosis). The condition led to either helpful or harmful encounters with health care and significant others (category: Dependence). It also had overall physical, social and existential consequences (category: A ruined life). To cope, the women had to struggle for coherence by searching for understanding, coping and meaning (core category: Living with painful endometriosis).Living with severe painful endometriosis signified a struggle for coherence. The women needed to deal with feelings of difference, dependence and a ruined life and thus struggled for understanding, coping and meaning. Health-care providers should promote the struggle for coherence by explaining the feeling of difference, minimizing dependence and supporting the process of disease-related grief.

Studies have shown that pain acceptance strategies related to psychological flexibility are important in the presence of chronic musculoskeletal pain. However, the predictors of these strategies have not been studied extensively in patients with whiplash-associated disorders (WAD).The purpose of this study was to predict chronic pain acceptance and engagement in activities at 1-year follow-up with pain intensity, fear of movement, perceived responses from significant others, outcome expectancies, and demographic variables in patients with WAD before and after multimodal rehabilitation (MMR).The design of this investigation was a cohort study with 1-year postrehabilitation follow-up.The subjects participated in MMR at a Swedish rehabilitation clinic during 2009-2015.The patients had experienced a whiplash trauma (WAD grade I-II) and were suffering from pain and reduced functionality. A total of 386 participants were included: 297 fulfilled the postrehabilitation measures, and 177 were followed up at 1 year after MMR.Demographic variables, pain intensity, fear of movement, perceived responses from significant others, and outcome expectations were measured at the start and after MMR. Chronic pain acceptance and engagement in activities were measured at follow-up.The data were obtained from a Swedish Quality Registry for Pain Rehabilitation (SQRPR).Outcome expectancies of recovery, supporting and distracting responses of significant others, and fear of (re)injury and movement before MMR were significant predictors of engagement in activities at follow-up. Pain intensity and fear of (re)injury and movement after MMR significantly predicted engagement in activities at follow-up. Supporting responses of significant others and fear of (re)injury and movement before MMR were significant predictors of pain acceptance at the 1-year follow-up. Solicitous responses of significant others and fear of (re)injury and movement at postrehabilitation significantly predicted pain acceptance at follow-up.For engagement in activities and pain acceptance, the fear of movement appears to emerge as the strongest predictor, but patients' perceived reactions from their spouses need to be considered in planning the management of WAD.

The evaluation of intensive cognitive training is usually based on neuropsychological tests and questionnaires. A study of the subjective experience of cognitive training would provide another type of valuable information concerning the effects of rehabilitation. We used grounded theory methods to explore the experience and management of attention dysfunction in daily life two-four years after brain injury. Data were collected by in-depth interviews of 14 adults with moderate-to-mild attention dysfunction after stroke or traumatic brain injury, and working part time or full time at the time of the interviews. The group received 20 hours of attention process training within the context of multidisciplinary rehabilitation early after brain injury. Data were analysed by open coding with constant comparison. The management of attention dysfunction was described by the informants as a dynamic process where strategies are continuously refined and flexibly adjusted as awareness and metacognitive knowledge increases. This process is regulated by situation-dependent factors. Attention process training might provide a suitable starting point for the identification of problem areas, improved specific goalsetting and stimulated self-training. The model describes the dynamic nature of the process, the ongoing struggle, self-training and search for feedback.

Background: Health and physical capacity are commonly associated with disease, age, and socioeconomic factors. The primary objective of this study was to investigate the degree to which physical capacity, defined as muscle strength and walking ability, is decreased in women with fibromyalgia (FM), as compared to healthy women, who are matched for age and level of education. The secondary aim was to investigate whether muscle strength and walking ability are associated with age, symptom duration, activity limitations and, Body Mass Index (BMI) in women with FM and control subjects. Methods: This controlled, cross-sectional, multi-center study comprised 118 women with FM and 93 age-and education-level-matched healthy women. The outcome measures were isometric knee-extension force, isometric elbow-flexion force, isometric hand-grip force, and walking ability. Differences between the groups were calculated, and for the women with FM analyses of correlations between the measures of physical capacity and variables were performed. Results: The women with FM showed 20% (p amp;lt; 0.001) lower isometric knee-extension force, 36% (p amp;lt; 0.001) lower isometric elbow-flexion force, 34% (p amp;lt; 0.001) lower isometric hand-grip force, and 16% lower walking ability (p amp;lt; 0.001), as compared to the healthy controls. All measures of muscle strength in women with FM showed significant weak to moderate relationship to symptom duration (r(s) = -0.23-0.32) and walking ability (r(s) = 0.25-0.36). Isometric knee-extension force correlated with activity limitations, as measured using the SF-36 Physical function subscale (r(s)= 0.23, p = 0.011). Conclusions: Physical capacity was considerably decreased in the women with FM, as compared to the age-and education-level-matched control group. All measures of physical capacity showed a significant association with symptom duration. Knee-extension force and walking ability were significantly associated with activity limitations, age, and BMI. It seems important to address this problem and to target interventions to prevent decline in muscle strength. Assessments of muscle strength and walking ability are easy to administer and should be routinely carried out in the clinical setting for women with FM. Funding Agencies|Swedish Rheumatism Association; Swedish Research Council [K2009-52P-20943-03-2, K2011-69X-21874-01-6, K2009-69P-21300-04-4, K2013-52X-22199-01-3, K2015-99x-21874-05-04]; Health and Medical Care Executive Board of Vastra Gotaland Region; ALF-LUA at Sahlgrenska University Hospital; Gothenburg Center for Person Centered Care (GPCC); AFA Insurance [140341]; Stockholm County Council (ALF); Karolinska Institutet Foundation

Background We aimed to explore pressure pain sensitivity and the function of segmental and plurisegmental exercise-induced hypoalgesia (EIH) in persons with rheumatoid arthritis (RA) compared with healthy control subjects (HC). Methods Forty-six participants with RA (43 female, 3 male) and 20 HC (16 female, 4 male) participated in the study. Pressure pain thresholds, suprathreshold pressure pain at rest, and segmental and plurisegmental EIH during standardised submaximal contractions were assessed by algometry. Assessments of EIH were made by performing algometry alternately at the contracting (30% of the individual maximum) right m. quadriceps and the resting left m. deltoideus. Results Participants with RA had higher sensitivity to pressure pain (RA, 318 kPa; HC, 487 kPa; p 0.05). Conclusions Our results indicate a generally increased pain sensitivity but normal function of EIH among persons with RA and offer one possible explanation for pain reduction observed in this group of patients following clinical exercise programmes. Trial registration ISRCTN registry, ISRCTN25539102. Retrospectively registered on 4 March 2011.

Chronic pain is associated with dysfunctional endogenous pain modulation, involving both central opioid and serotonergic (5-HT) signaling. Fibromyalgia (FM) is a chronic pain syndrome, characterized by widespread musculoskeletal pain and reduced exercise-induced hypoalgesia (EIH). In this study, we assessed the effects of 3 functional genetic polymorphisms on EIH in 130 patients with FM and 132 healthy controls. Subjects were genotyped regarding the mu-opioid receptor (OPRM1) gene (rs1799971), the serotonin transporter (5-HTT) gene (5-HTTLPR/rs25531), and the serotonin-1a receptor (5-HT1a) gene (rs6296). The patients with FM had increased pain sensitivity and reduced EIH compared with healthy controls. None of the polymorphisms had an effect on EIH on their own. We found significant gene-to-gene interactions between OPRM1 x 5-HTT and OPRM1 x 5-HT1a regarding activation of EIH, with no statistically significant difference between groups. Better EIH was found in individuals with genetically inferred strong endogenous opioid signaling (OPRM1 G) in combination with weak 5-HT tone (5-HTT low/5-HT1a G), compared with strong 5-HT tone (5-HTT high/5-HT1a CC). Based on the proposed mechanisms of these genetic variants, the findings indicate antagonistic interactions between opioid and serotonergic mechanisms during EIH. Moreover, despite different baseline pain level, similar results were detected in FM and controls, not supporting an altered interaction between opioid and 5-HT mechanisms as the basis for dysfunction of EIH in patients with FM. In summary, our results suggest that, by genetic association, the mu-opioid receptor interacts with 2 major serotonergic structures involved in 5-HT reuptake and release, to modulate EIH.

Background It has been described that bedside reporting can contribute to patient safety and increase patient involvement in healthcare. To our knowledge, however, there is no existing research on bedside handover during labour. Aim The aim of this study was to examine the patient’s experiences of bedside handover during labour. Method A qualitative design was used. Nineteen couples were interviewed after childbirth regarding their experiences of bedside handover during delivery. Twelve of those had experienced bedside handover and were, thereby, included in the study. The interviews were performed in a delivery ward in Stockholm during January 2018. The material was analysed according to content analysis. Results Four main categories emerged from the data: non-verbal communication, verbal communication, concerns, and birth experience. In general, bedside handover was perceived to be positive, the participants felt they were treated professionally, and that they had been involved during the handover. One advantage with the handover was the possibility for parents to confirm the sharing of information during the handover, which made them feel secure. Moreover, most of the parents reported they received good treatment and had a good labour experience. Parents’ experiences of bedside handover and midwives’ support were summarised as follows: midwives used common words and avoided using medical terminology, and they kept eye contact with the woman and her partner. Conclusion Bedside handover was experienced by both parents as a way of being positively included in the care of their newborn. The caregivers were described as being attentive, respectful, and were good listeners.

Background Both temporomandibular disorders myalgia (TMDM) and fibromyalgia (FM) have been linked to central and peripheral changes in serotonin availability. The precursor of serotonin, tryptophan (TRP), is mainly catabolised via another pathway to produce kynurenine (KYN), but whether changes of this pathway are present in TMDM and FM are still unclear. Objective The aim was to explore blood plasma concentrations of TRP and KYN in TMDM and FM in an attempt to identify novel associations for future research. Methods Plasma of 113 female participants (17 TMDM, 40 FM and 56 healthy pain-free controls) were analysed for TRP and KYN concentrations. The degradation of TRP via the KYN pathway was indicated by the KYN to TRP ratio (KYN/TRP). Pain intensities were assessed with the Graded Chronic Pain Scale (GCPS) and Visual Analogue Scale (VAS). Psychological symptoms were evaluated using the Hospital Anxiety and Depression Scale (HADS), Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder scale (GAD-7). Results In TMDM there was a negative correlation between TRP and pain intensity (rs = -0.55 P = .023) and positive correlations between KYN/TRP and pain intensity (rs = 0.59 P = .013). In FM, KYN/TRP was negatively correlated with anxiety symptoms (rs = -0.36 P = .022) and a trend towards significantly lower TRP levels was found compared to controls (P = .05). Conclusion The association between KYN/TRP and pain intensity as well as anxiety ratings in this small exploratory study may indicate that KYN/TRP could be a relevant indicator for symptom severity in TMDM and FM. Further investigations of the KYN pathway in chronic myalgia are warranted.

Objectives: To investigate: (i) changes in sick-leave benefits from 1 year prior to multimodal rehabilitation to 1 and 2 years after rehabilitation; (ii) sex differences in sick leave; and (iii) the impact of policy changes on sick leave. Methods: All patients undergoing multimodal rehabilitation registered in a national pain database for 2007-11 (n = 7,297) were linked to the Swedish Social Insurance Agency database. Sick leave was analysed in 3-month periods: T0: 1 year before rehabilitation; T1: before start; T2: 1 year after; and T3: 2 years after rehabilitation. Four sick-leave benefit categories were constructed: no sick leave, part-time sick leave, full-time sick leave, and full-time permanent sick leave. The individual change in sick-leave category at each time-period was analysed. Results: Sick-leave benefits increased from T0 to T1 (p < 0.001) and decreased from T1 to T3 (p < 0.001). Reductions were significant for both men and women from T1 to T3, but men had less sick-leave benefits at T2 and T3. Positive changes in sick-leave benefits at T2 and T3 were found both prior to and after policy changes, with less sick-leave benefits after policy changes at all time-points. Conclusion: Multimodal rehabilitation may positively influence sick-leave benefits for patients with chronic pain, regardless of their sick-leave situation, sex or policy changes.

Objectives: To investigate: (i) changes in sick-leave benefits from 1 year prior to multimodal rehabilitation to 1 and 2 years after rehabilitation; (ii) sex differences in sick leave; and (iii) the impact of policy changes on sick leave. Methods: All patients undergoing multimodal rehabilitation registered in a national pain database for 2007–11 (n?=?7,297) were linked to the Swedish Social Insurance Agency database. Sick leave was analysed in 3-month periods: T0: 1 year before rehabilitation; T1: before start; T2: 1 year after; and T3: 2 years after rehabilitation. Four sick-leave benefit categories were constructed: no sick leave, part-time sick leave, full-time sick leave, and full-time permanent sick leave. The individual change in sick-leave category at each time-period was analysed. Results: Sick-leave benefits increased from T0 to T1 (p?

Background Giving birth is a transformative event. Memories of the birth often remain in a woman’s mind for the rest of her life. Key aspects of a mother's overall birth experience include concerns about the safety and health of the baby, and the first contact the mother has with her child. To the best of our knowledge, research has not yet been published relating to the ways in which women undergoing caesarean sections in the 1970s and 1980s experienced the birth of their baby and whether or not their mode of delivery has affected their reproductive health and their relationship to their child. Objective To describe women’s experience of undergoing a caesarean section in the 1970s and 1980s in Sweden. Design A qualitative method using semi-structured questions and content analysis. Participants Twenty-two women were interviewed who underwent caesarean section during the 1970s and 1980s in Sweden. Results The overarching theme surrounding women’s experience of having undergone a caesarean section 30–40 years ago is that it is described as “undesired life event”. Four categories were established: vaginal birth as the norm; a total loss of control; acceptance and contact with the child. Conclusion Undergoing a caesarean section during the 1970s and 1980s was considered to be an undesired life events. The interlocuters who participated in this study had little knowledge about operative childbirth and were poorly prepared for a complicated birth and postpartum care. The women did not suffer any long-term physiological harm yet were harmed psychologically until they came to terms with their negative experience and reached acceptance of it.

The purpose was to explore interview data from young adults with long-standing pain about their experience of contacts with caregivers in a primary care setting, in order to synthesize and qualitat ...

Background and aims Multimodal rehabilitation (MMR) programmes, including, physical training, educational and psychological interventions by an interdisciplinary team are found to be more successful for patients with disabling chronic pain compared with less comprehensive treatments. MMR programmes are based on the biopsychosocial model and the goal is usually to improve function, quality of life and facilitate and enable return to work. As pain clinics traditionally offer conventional medical pain treatment, there is limited knowledge about MMR given in this context. The aim of our study was to describe characteristics of patients with chronic pain, treated with a MMR programme at a conventional pain clinic, to evaluate patient-reported outcome measures (PROM) from start to one year after, and to study possibly associated factors for the improvement of health-related quality of life after one year. Methods A prospective, observational study with a one-year follow-up was performed. Subjects A total of 42 individuals (38 females, age 44.0 ± 12.3 years and 4 men age 40 ± 8.5 years) with different pain diagnoses were included. After a team assessment, the patients began a programme that lasted about three months. The MMR programme contained coordinated, individually adapted treatments administered individually or in groups, and was based on cognitive behavioural principles. Questionnaires regarding health-related quality of life (HRQoL) (EQ-5D), insomnia (ISI), mental health (HADS), painrelated disability (PDI), kinesiophobia (TSK), current pain intensity (VAS) and sense of coherence (SOC) were used at the start of the MMR and at follow-up. Demographic data were collected from the patient records. Results The PROM at baseline showed substantial pain problems with low HRQoL (EQ-5D index of 0.1 ± 0.282, and EQ VAS of 32.67 ± 20.1), moderate insomnia (ISI 18.95 ± 6.7), doubtful cases of depression and anxiety (HADS-depression 9.35 ± 4.1 and HADS-anxiety 9.78 ± 3.95), presence of pain-related disability (PDI 39.48 ±12.64), kinesiophobia (TSK 40.8 ± 9.8), as well as moderate current pain (VAS 61.31 ± 20.4). The sense of coherence was weak (SOC of 51.37 ± 14). At one-year follow-up, significant (p ≥ 0.05) improvement occurred on the EQ-5D index, EQ VAS, ISI, PDI and TSK. In the logistic regression analysis, no significant associations could be identified. Conclusions MMR for patients with complex pain problems can be a successful treatment alternative at conventional pain clinics. Implications Since access to rehabilitation clinics in Sweden may be limited, the availability of MMR can increase by providing this type of intervention in pain clinics. Increased knowledge of MMR in different settings can also contribute to increased understanding and collaboration between pain clinics and rehabilitation units.

OBJECTIVE: To describe the organization, content and dosage of interdisciplinary pain rehabilitation, and the differences in degree of severity of problems of patients admitted to clinical units reporting to a Swedish national quality pain registry, grouped according to unit size and possible affiliation with a university hospital. METHODS: Reports from 31 out of 39 clinical units in Sweden, on inclusion processes, organization, content and dosage of interdisciplinary pain rehabilitation, and patient-reported data from a Swedish national quality pain registry at assessment for interdisciplinary pain rehabilitation were analysed. RESULTS: the number of patients treated annually at each unit ranged from 3 to 340. In 17 units, teams comprised 5 professionals. Dosage of interdisciplinary pain rehabilitation ranged from 20-180 h per patient in total. Patients at the university-hospital units scored the highest levels of symptoms and lowest levels of health-related quality of life. Units used similar sets of inclusion criteria, and several treatments, such as education, self-training and psychological interventions, were used by most units. CONCLUSION: When interpreting outcome data from registries, aspects other than rehabilitation outcomes must be considered. The interpretation of outcomes from quality registries would be facilitated if data, in addition to assessments and patient-reported outcomes, also includes standardized descriptions of the reporting clinical units. (Less)

Background We aimed to evaluate the 1-year and 2-year outcome of a health-enhancing physical activity (HEPA) support program on global pain, pressure pain sensitivity, and exercise-induced segmental and plurisegmental hypoalgesia (EIH) in persons with rheumatoid arthritis (RA). Methods Thirty participants (27 women and 3 men) were recruited from a larger intervention cohort that engaged in strength training and moderate-intensity aerobic activity. Assessments were performed before the HEPA intervention and at 1-year and 2-year follow-ups. Global pain was assessed on a visual analogue scale (0–100). Pressure pain thresholds (PPTs) and suprathreshold pressure pain at rest corresponding to 4/10 (medium pain) (SP4) and 7/10 (strong pain) (SP7) on Borg CR 10 scale were assessed by algometry. In a subsample (n = 21), segmental and plurisegmental EIH were assessed during standardized submaximal static contraction (30% of the individual maximum), by algometry, alternately at the contracting right M. quadriceps and the resting left M. deltoideus. Results Global pain decreased from before the intervention to 2-year follow-up (median 11 to median 6, P = 0.040). PPTs and SP4 pressure pain at rest did not change from before the intervention to 2-year follow-up, while SP7 decreased from mean 647 kPa to mean 560 kPa (P = 0.006). Segmental EIH during static muscle contraction increased from the assessment before the intervention (from mean 1.02 to mean 1.42, P = 0.001), as did plurisegmental EIH (from mean 0.87 to mean 1.41, P

The aims of this study were to compare circulating cytokines between FM and healthy controls and to investigate the effect on cytokine levels by 15 weeks of progressive resistance exercise or relaxation therapy in FM. Baseline plasma cytokine levels and clinical data were analyzed in 125 women with FM and 130 age-matched healthy women. The FM women were then randomized to progressive resistance exercise (n=49) or relaxation (n=43). Baseline IL-2, IL-6, TNF-α, IP-10, and eotaxin were higher in FM than in healthy controls (P<0.041), whereas IL-1βwas lower (P<0.001). There were weak correlations between cytokine levels and clinical variables. After both interventions, IL-1ra had increased (P=0.004), while IL-1βhad increased in the relaxation group (P=0.002). Changes of IFN-γ, IL-2, IL-4, IL-6, IL-8, and IL-17A were weakly correlated with changes of PPT, but there were no significant correlations between changes of cytokine and changes in other clinical variables. The elevated plasma levels of several cytokines supports the hypothesis that chronic systemic inflammation may underlie the pathophysiology of FM even if the relation to clinical variables was weak. However, 15 weeks of resistance exercise, as performed in this study, did not show any anti-inflammatory effect on neither FM symptoms nor clinical and functional variables. This trial is registered withClinicalTrials.govNCT01226784, registered October 21, 2010. The first patient was recruited October 28, 2010.

When suffering a spinal cord injury (SCI), the patient and family face numerous challenges regardless of socio-economic level. The stigmatisation of persons with disabilities has been reported, however, reports from Southern Africa are largely lacking.To explore the experiences of living with a traumatic SCI in Botswana concerning perceived attitudes, obstacles and challenges.A qualitative approach with semi-structured interviews was conducted. Thirteen community-dwelling persons who have lived with an SCI for at least two years participated.A theoretical model was formed that illustrate the associations between the core category, Self, and the categories Relationships and Society. The model illustrates that personal resources, including a strong identity and a positive attitude, are crucial to the experience of inclusion in the community. A supportive family, a source of income, and faith were strong facilitators, while inaccessibility and devaluing attitudes were barriers. Having a disability led to increased risk of poverty and social exclusion.This study emphasised the importance of personal resources, family support, and improved accessibility to facilitate inclusion in the society. Informants requested legislation to advocate for the rights of persons with disabilities to be respected, with the aim of moving towards an equal accessible society. Implications for Rehabilitation Reclaiming or restructuring one's identity after a SCI is crucial for the person's ability to move on and develop beneficial coping strategies. Support from family and friends, staff and peer support are crucial parts in that process. Spirituality, values, needs and coping strategies vary profoundly among persons sustaining disabling injuries. In striving to optimise care, rehabilitation staff needs to be attentive to the personal resources and preferences to be able to individualise care, encounter, and facilitate transition back to the community. Family members play a crucial part in rehabilitation. It is essential for the patients' well-being and care that they get explicit descriptions of the patient's abilities. Living in a well-adapted home will facilitate well-being, independence, and return to work. Rehabilitation staff needs to focus their efforts on making this successful prior to discharge from hospital.

The present purpose was to explore patients' and involved physicians' needs and requests for improving their management of neuropathic pain following spinal cord injury (SCI).Sixteen patients with SCI and neuropathic pain, and nine physicians, were interviewed in focus-groups or individual interviews. An emergent design was used and the interviews and analyses were carried out in parallel, making it possible to use and deepen new emerging knowledge. The interviews were transcribed verbatim and processed according to content analysis.A final model with four themes described the results. Three themes covered the current situation: limitations in structure, lack of knowledge and competence, and frustrations. A fourth theme, needs and requests, described suggestions by patients and physicians for future improvements. Suggestions included increased participation, increased patient involvement in the pain rehabilitation process, support in the process of learning to live with pain, implementation of multi-modal pain rehabilitation, and the use of complementary treatments for neuropathic pain.Neuropathic pain following SCI needs to be assessed and treated using a structured, inter-disciplinary, multi-modal rehabilitation approach involving patients in planning and decision-making.For improving SCI neuropathic pain management, there is a great need for individually-tailored management, planned in a dialogue on equal terms between health care and the patient. Patients desire continuity and regularity and the possibility of receiving complementary treatments for SCI neuropathic pain. Access to structured pain rehabilitation is needed. Support and tools need to be provided in the learning-to-live with pain process.

Physical exercise is one of the most efficient interventions to mitigate chronic pain symptoms in fibromyalgia (FM). However, little is known about the neurophysiological mechanisms mediating these effects. In this study we investigated resting-state connectivity using functional magnetic resonance imaging (fMRI) before and after a 15 week standardized exercise program supervised by physical therapists. Our aim was to gain an understanding of how physical exercise influences previously shown aberrant patterns of intrinsic brain activity in FM. Fourteen FM patients and eleven healthy controls successfully completed the physical exercise treatment. We investigated post- versus pre-treatment changes of brain connectivity, as well as changes in clinical symptoms in the patient group. FM patients reported improvements in symptom severity. Although several brain regions showed a treatment-related change in connectivity, only the connectivity between the right anterior insula and the left primary sensorimotor area was significantly more affected by the physical exercise among the fibromyalgia patients compared to healthy controls. Our results suggest that previously observed aberrant intrinsic brain connectivity patterns in FM are partly normalized by the physical exercise therapy. However, none of the observed normalizations in intrinsic brain connectivity were significantly correlated with symptom changes. Further studies conducted in larger cohorts are warranted to investigate the precise relationship between improvements in fibromyalgia symptoms and changes in intrinsic brain activity., Highlights • Physical exercise reduced the impact of fibromyalgia (FM) in everyday life. • Longitudinal changes included restored insular-sensory functional connectivity. • The links between connectivity and symptom improvements require further studies.

Objectives: Resistance exercise results in health benefits in fibromyalgia. The aim of this study was to determine the factors that mediate change in muscle strength in women with fibromyalgia as a result of resistance exercise. Methods: Sixty-seven women with fibromyalgia (age range 25-64 years) were included. Tests of muscle strength and questionnaires related to pain, fear avoidance and physical activity were carried out. Multivariable stepwise regression was used to analyse explanatory factors for change and predictors for final values of knee-extension force, elbow-flexion force and hand-grip force. Results: Change in knee-extension force was explained by fear avoidance beliefs about physical activity at baseline, together with change in pain intensity, knee-extension force at baseline, age and body mass index (BMI) (R-2= 0.40, p = 0.013). Change in elbow-flexion force was explained by pain intensity at baseline, together with baseline fear avoidance beliefs about physical activity, BMI and elbow-flexion force at baseline (R-2 = 0.32, p = 0.043). Change in hand-grip force was explained by hand-grip force at baseline, change in pain intensity and baseline fear avoidance (R-2 = 0.37, p = 0.009). Final muscle strength was predicted by the same variables as change, except pain. Conclusion: Pain and fear avoidance are important factors to consider in rehabilitation using resistance exercise for women with fibromyalgia. Funding Agencies|Swedish Rheumatism Association; Swedish Research Council [K2009-52P-20943-03-2, K2011-69X-21874-01-6, K2015-99X-21874-05-05, K2009-69P-21300-04-4, K2013-52X-22199-01-3, K2015-99x-21874-05-4, 2011-4807]; Health and Medical Care Executive Board of Vastra Gotaland Region; ALF-LUA at Sahlgrenska University Hospital; Stockholm County Council (ALF); Gothenburg Center for Person Centered Care (GPCC); Karolinska Institutet Foundation; AFA Insurance [140341]

Monika Löfgren,1,2 Jan Ekholm,2 Lisbet Broman,3 Philipe Njoo,1 Marie-Louise Schult1–3 1Department of Rehabilitation Medicine Stockholm, Danderyd University Hospital, Sweden; 2Karolinska Institutet, Division of Rehabilitation Medicine, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden; 3Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Stockholm, Sweden Aim: To describe the use of a “workable” visual profile of function and disability, based on a modified Brief International Classification of Functioning, Disability and Health (ICF) Core Set for chronic widespread pain, for initial assessments in a clinical setting of interdisciplinary pain rehabilitation teams. Method: The Brief ICF Core Set was slightly adapted to meet the needs of an interdisciplinary rehabilitation medicine team working in a university outpatient clinic and admitting patients referred from primary care. The Core Set categories were made measurable by means of eg, assessment instruments and clinical investigations. The resulting profile was given a workable shape to facilitate rapid understanding of the initial assessment outcome. Results: Individual patients showed different profiles of problems and resources, which facilitated individual rehabilitation planning. At the level of the study group, the profiles for the Core Set component Body Functions showed that most patients had severe impairment in the sensation of pain and exercise tolerance categories of function, but most had resources in the motivation and memory categories of function. Likewise, for the component Activities, most patients had limitations in lifting and carrying objects and remunerative employment, but most had resources in intimate relationships and family relationships. At first, the use of the modified Brief ICF Core Set in the team conference was rather time consuming, but after a couple of months of experience, the team assessment took approximately 30 minutes to complete per patient. Conclusion: The profile of the modified Brief ICF Core Set for chronic widespread pain served as a common platform, facilitating cooperation between the rehabilitation team members and providing a uniform language, which helped in structuring the clinical work. The profile also provided an easily accessible, overall view of the patient’s problems and resources, which helped in understanding the functioning situation of the patient. Keywords: ICF, interdisciplinary teamwork, chronic widespread pain, assessment