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OBJECTIVES: Chronic pain is a major global public-health issue. In Sweden, 20% adults report moderate to severe chronic pain, with 7% continuously seeking healthcare. Shortcomings in treatment, accessibility, and knowledge in healthcare for chronic pain have previously been reported. A generic treatment structure from primary to specialized care and rehabilitation was missing. This study aims to describe the development process for the creation of a person-centered and coherent care (P3C) pathway for adults with chronic pain in Sweden.

METHODS: A National Action Group with expertise in pain medicine, rehabilitation medicine, psychiatry, anesthesiology, neurosurgery, general medicine, nursing, psychology, physiotherapy, occupational therapy, and patient representation was commissioned to develop the pathway following a stepwise co-designed approach, which included mapping current situation, goals, measures and indicators of the pathway, assessment of consequences and anchoring the process.

RESULTS: Goals were based on challenges identified in the mapping, including improvements in patient's well-being, continuity during and between care contacts, timely self-management, communication between levels of care, and knowledge about pain. Points of pathway entrance and exit were described. Measures focused on areas such as early pain analysis, biopsychosocial approach to assessment and treatment, early rehabilitation plan, teamwork, dialogue and joint plans between levels of care, patient participation, and education on pain and its consequences. Process and outcome indicators, and a report on benefits and risks for patients, ethical aspects, costs, and impacts of the pathway on other areas of healthcare were included.

CONCLUSIONS: The P3C pathway addressed the challenges described by patients and practitioners. By being person-centered and coherent, it can promote patient empowerment and equality in care, with emphasis on early and timely interventions, dialogue between patients and practitioners and between levels of care, self-management of pain instead of prolonged medical intervention, value-driven and coordinated care contacts, and increased knowledge about chronic pain, based on existing evidence and experience.

Lower- extremity constraint-induced movement therapy (LE-CIMT) has proven effective in overcoming physical disabilities. Participating in the LE-CIMT requires some independent walking ability without aids that indicates a higher level of motor function than for the entire stroke population. However, only few studies evaluated health-related quality of life (HRQoL) after LE-CIMT. This study aimed to compare HRQoL of people who had participated in LE-CIMT post-stroke to the general population and evaluate whether descriptive characteristics and clinical result were associated with their HRQoL. An observational survey study with a questionnaire including the Swedish RAND-36 and Saltin–Grimby Physical Activity Level Scale was sent to 162 people. Reference data from the Mid-Health Survey in Sweden was used for norm-based comparisons of RAND-36. Respondents’ result from six-minute walk test post-LE-CIMT were used in the univariate analyse. The response rate was 65% (n=106; 69 males and 37 females with a mean age of 62±12 years). Ninety percent of the respondents could move around indoors and outdoors independently, despite this, 21% considered themselves physically inactive. The respondents had significantly reduced HRQoL compared to the general population in four of eight domains in the RAND-36: physical functioning (p=0.001), role-functioning (physical; p<0.001), general health (p=0.010), and social functioning (p<0.001). Regression analysis showed that longer walking distance significantly was associated with the RAND-36 physical functioning domain (β=6.45, 95% confidence interval=2.03–10.87, p=0.005). People in the chronic phase post-stroke who had previously participated in LE- CIMT had reduced HRQoL compared to the general population regarding physical functioning, role-functioning physical, general health, and social functioning. A longer walking distance was associated with higher HRQoL in physical functioning domain, emphasising the importance of mobility training in post-stroke rehabilitation.

Dysfunction in executive functions is common among patients with chronic pain. However, the relationships between executive functioning and pain management have not been extensively studied. In this study, 189 outpatients (160 women, 29 men; mean age 33.15) with chronic pain underwent an extensive neuropsychological assessment, including several tests of executive functions. In addition, all participants completed self-assessment questionnaires regarding pain and interference of pain in everyday life. After adjusting for effects of age, education, and depression, several aspects of executive functioning were significantly associated with self-assessed everyday interference of pain (rs = 0.13–0.22, all ps < 0.05). This indicates that lower performance on tests of executive functioning was significantly associated with a higher degree of pain interference and a lower degree of life control. Pain characteristics such as pain intensity, pain duration, and pain spreading were not associated with executive functioning. These results suggest that preserved executive functions are related to better coping with pain, but not directly to the pain itself, in patients with chronic pain. Depression was also associated with self-management of pain, indicating that patients with lower executive functioning in combination with depression may need special attention during rehabilitation.

Objectives: Fatigue is common in patients with chronic pain. Still, there is a lack of studies examining objectively measurable cognitive aspects of fatigue: cognitive fatigability (CF). We aimed to investigate the presence of CF in patients with chronic pain and its relation to self-rated fatigue, attention, pain characteristics, sleep disturbance, depression, and anxiety.

Methods: Two hundred patients with chronic pain and a reference group of 36 healthy subjects underwent a comprehensive neuropsychological test battery, including measurement of CF with the Wechsler Adult Intelligence Scale-III Coding subtest, and self-assessment of trait and state fatigue.

Results: The patients with chronic pain did not show more CF as compared to the reference group. There was an association between CF and processing speed on a test of sustained and selective attention in the chronic pain group, while self-rated fatigue measures and pain characteristics were not associated with CF. Self-rated fatigue measures were highly correlated with self-rated pain intensity, spreading of pain, depression, anxiety, and sleep disturbance.

Conclusions: The findings highlight the distinction between objective and subjective aspects of fatigue in chronic pain, and that the underlying causes of these different aspects of fatigue need to be studied further.

Objective: To follow up patients with post-COVID-19 condition (PCC) 6 months after a multidisciplinary team assessment in specialist care regarding symptoms of pain, anxiety, depression, fatigue and cognition, level of activity, physical activity and sick leave.

Methods: A prospective pilot study conducted in a clinical setting of patients (n = 22) with PCC referred from primary healthcare to a specialist clinic for a 2 day-multidisciplinary team assessment followed by a subsequent rehabilitation plan. Data were collected through questionnaires filled in prior to the team assessment and 6 months later.

Results: Fifteen of the initial 22 patients participated in the follow-up. No statistically significant improvements were seen in any of the questionnaires after 6 months. However, 76.9% of the participants perceived the intervention as being helpful. This differed between the genders, where all the women 100% (n = 8) perceived it as being helpful, compared with 40% (n = 2) of the men (p = 0.012).

Conclusions: Based on these findings, the benefit of a multidisciplinary team assessment of PCC is not fully convincing. However, since the participants themselves perceived the intervention as being helpful, the team assessment seems to be of some value. Further studies with larger populations would be of interest.

Objective: To investigate outcomes in patients with chronic pain after participation in an interdisciplinary pain rehabilitation programme with language interpreters, and to investigate the outcomes in women and men separately.

Design: Prospective multi-centre cohort study. Patients: Ninety-five patients in Sweden with chronic pain who have insufficient knowledge of the Swedish language.

Methods: Duration and intensity of pain, anxiety and depression, health-related quality of life and fear of movement were evaluated before and after the pro-gramme. Patients were compared with a reference group comprising Swedish-speaking patients participating in an ordinary interdisciplinary pain rehabilitation programme.

Results: Before the interdisciplinary pain rehabilitation programme with language interpreters, all variables except pain duration differed significantly to the detriment of the studied group. The studied group showed significant improvements after the interdisciplinary pain rehabilitation programme with language interpreters, with regards to pain inten-sity, depression and fear of movement. The reference group improved significantly for all variables. The women in the studied group showed significant improvements for the same variables as the whole group, while the men in the studied group did not improve in any of the variables.

Conclusion: This study indicates that patients with chronic pain, and especially women, who have insufficient knowledge of Swedish seem to benefit from participating in an interdisciplinary pain rehabilitation programme with language interpreters. The result may be of value for the further development of rehabilitation programmes with language interpreters.

Objective: Chronic pain is a common manifestation of Ehlers-Danlos syndrome and hypermobility spectrum disorders; thus it is often suggested that patients undergo generic interdisciplinary pain rehabilitation, despite there being little evidence to support this decision. The aim of this study is to examine the effectiveness of standard rehabilitation programmes for chronic pain on patients with Ehlers-Danlos syndrome and hypermobility spectrum disorders, compared with patients with other chronic pain disorders.

Subjects: Data, collected between 2008 and 2016, were extracted from a Swedish national registry. The patient data comprised of 406 cases with Ehlers-Danlos syndrome or hypermobility spectrum disorders, 784 cases with a whiplash-related diagnosis, 3713 cases with diagnoses relating to spinal pain, and 2880 cases of fibromyalgia.

Methods: The differences between groups on key outcome measures from pre-to 1-year follow-up after interdisciplinary pain rehabilitation were analysed using linear mixed effects models. Sensitivity analysis in the form of pattern-mixture modelling was conducted to discern the impact of missing data.

Results: No significant differences were found in improvements from pre-to 1-year follow-up for patients with Ehlers-Danlos syndrome or hypermobility spectrum disorder compared with other diagnostic groups regarding measures of health-related quality of life, mental health, or fatigue. At follow-up, differences in pain interference (d = –0.34 (95% confidence interval [95% CI] –0.5 to –0.18)), aver-age pain (d = 0.22 (95% CI 0.11–0.62)) and physical functioning (d = 2.19 (95% CI 1.61–2.77)) were detected for the group with spinal-related diagnoses in relation to those with EDS/HSD, largely due to pre-treatment group differences. Sensitivity analysis found little evidence for missing data influencing the results.

Conclusion: This study suggests that patients with Ehlers-Danlos syndrome/hypermobility spectrum disorders may benefit from inclusion in an interdisciplinary pain rehabilitation programme.

Objective: To investigate whether high-intensity lower extremity constraint-induced movement therapy can improve balance, leg strength, and dual-task ability.

Design: A longitudinal cohort study in a real-world outpatient clinic.

Patients: 147 community-dwelling participants in the subacute and chronic poststroke phases.

Methods: Participants received lower extremity constraint-induced movement therapy for 6 hours/day during 2 consecutive weeks, including balance, strength, and functional training. The Berg Balance Scale (BBS), Single-Leg-Stance (SLS) bilaterally, one Repetition Maximum (1RM) in a leg press, symmetry of leg strength (Diff-1RM), Timed Up and Go (TUG), and the TUG Manual test were assessed before, after, and 3 months after lower extremity constraint-induced movement therapy.

Results: Compared with preintervention data, statistically significant improvements after lower extremity constraint-induced movement therapy (p < 0.001) were demonstrated for balance with an absolute value in BBS at 1.9 points (effect size 0.38) and SLS at 2.4 s (effect size 0.24), and for leg strength at 10.2 kg (effect size 0.54) for the affected leg. Diff 1RM decreased significantly at 5.8 kg (effect size 0.39) and improvements on dual-task ability at 2.7 s were significant (effect size 0.14). The effects persisted at the 3-month follow-up.

Conclusions: High-intensity lower extremity constraint-induced movement therapy may be a feasible treatment option for middle-aged stroke patients to affect balance, leg strength, and dual-task ability positively in an out-patient clinical setting.

BACKGROUND: Every year, many people suffer from traumatic brain injuries (TBI) with dramatic consequences for both the victim and their close relatives in the form of remaining lifelong symptoms and functional disabilities as a result.

METHODS: This study evaluates the outcomes of 49 patients after mild TBI (mTBI) at follow-up after 5 years by using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) to assess post-TBI symptoms and the Glasgow Outcome Scale Extended (GOSE) to assess disability. The specific aim was to evaluate post-TBI characteristics concerning age, gender, pre-injury systemic disease, computed tomography (CT) result and additional TBIs.

RESULTS: Almost eighty percent reported RPQ symptoms, the most common for both genders being fatigue (51%) and poor concentration (51%). Seventy-six percent had a good recovery, 18% moderate disability, while 6% reported severe disability. The number of symptoms was significantly correlated to the level of disability. All participants with severe disability had repeated mTBI. Only twenty-one percent reported that they received some form of rehabilitation intervention after their mTBI.

CONCLUSIONS: Five years after suffering mTBI, patients reported high rates of symptoms and disabilities. Our findings suggest that tailored rehabilitation interventions should be designed to identify mTBI patients in need of early rehabilitation. This would result in minimized suffering for the individual and improved cost-effectiveness for society.

Objectives: To explore predictive factors for the development and maintenance of jaw pain over a 2-year period.

Methods: One hundred nineteen cases (73 women) and 104 controls (59 women), mean age 34.9 years (SD 13.9), attended baseline and 2-year follow-up examinations. The whiplash cases visited the emergency department at Umeå University Hospital, Sweden, with neck pain within 72 h following a car accident, and baseline questionnaires were answered within a month after trauma. Controls were recruited via advertising. Inclusion criteria were age 18–70 years, living in Umeå municipality and Swedish speaking. The exclusion criterion was neck fracture for cases and a previous neck trauma for controls. Validated questionnaires recommended in the standardized Research Diagnostic Criteria for temporomandibular disorders were used. Jaw pain was assessed by two validated screening questions answered with “yes” or “no.” A logistic regression analysis was used to predict the outcome variable jaw pain (yes/no) after 2 years.

Results: Whiplash trauma did not increase the odds of development of jaw pain over a 2-year period (OR 1.97, 95% CI 0.53–7.38). However, non-specific physical symptoms (OR 8.56, 95% CI 1.08–67.67) and female gender (OR 4.89, 95% CI 1.09–22.02) did increase the odds for jaw pain after 2 years.

Conclusion: The development and maintenance of jaw pain after whiplash trauma are primarily not related to the trauma itself, but more associated with physical symptoms.

Clinical relevance: The development of jaw pain in connection with a whiplash trauma needs to be seen in a biopsychosocial perspective, and early assessment is recommended.