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  • 1.
    Aarnio, Mikko
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Appel, Lieuwe
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Fredriksson, Mats
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology. Karolinska Inst, Dept Neurosci, Stockholm, Sweden.
    Gordh, Torsten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Wolf, Olof
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Sörensen, Jens
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Eriksson, Måns
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Peterson, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Linnman, Clas
    Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [(11)C]-D-deprenyl PET/CT.2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, p. 418-424Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND AIMS: Positron emission tomography (PET) with the radioligand [(11)C]-D-deprenyl has shown increased signal at location of pain in patients with rheumatoid arthritis and chronic whiplash injury. The binding site of [(11)C]-D-deprenyl in peripheral tissues is suggested to be mitochondrial monoamine oxidase in cells engaged in post-traumatic inflammation and tissue repair processes. The association between [(11)C]-D-deprenyl uptake and the transition from acute to chronic pain remain unknown. Further imaging studies of musculoskeletal pain at the molecular level would benefit from establishing a clinical model in a common and well-defined injury in otherwise healthy and drug-naïve subjects. The aim of this study was to investigate if [(11)C]-D-deprenyl uptake would be acutely elevated in unilateral ankle sprain and if tracer uptake would be reduced as a function of healing, and correlated with pain localizations and pain experience.

    METHODS: Eight otherwise healthy patients with unilateral ankle sprain were recruited at the emergency department. All underwent [(11)C]-D-deprenyl PET/CT in the acute phase, at one month and 6-14 months after injury.

    RESULTS: Acute [(11)C]-D-deprenyl uptake at the injury site was a factor of 10.7 (range 2.9-37.3) higher than the intact ankle. During healing, [(11)C]-D-deprenyl uptake decreased, but did not normalize until after 11 months. Patients experiencing persistent pain had prolonged [(11)C]-D-deprenyl uptake in painful locations.

    CONCLUSIONS AND IMPLICATIONS: The data provide further support that [(11)C]-D-deprenyl PET can visualize, quantify and follow processes in peripheral tissue that may relate to soft tissue injuries, inflammation and associated nociceptive signaling. Such an objective correlate would represent a progress in pain research, as well as in clinical pain diagnostics and management.

  • 2.
    Borjesson, Susanne
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long term illness. Centrum för klinisk forskning, Falun.
    Nordin, Karin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long term illness.
    Rissanen, Ritva
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long term illness.
    Fjällskog, Marie-Louise
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Endocrin Oncology.
    Peterson, Magnus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Arving, Cecilia
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Lifestyle and rehabilitation in long term illness.
    Colored body images reveal the perceived intensity anddistribution of pain in women with breast cancer treated withadjuvant taxanes: a prospective multi-method study of painexperiences2018In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Scand J Pain, ISSN ISSN 1877-8860, p. 1-11, article id https://doi.org/10.1515/sjpain-2018-0050Article, review/survey (Refereed)
    Abstract [en]

    Abstract

    Background and aims:

    Breast cancer is the most prevalent

    adult cancer worldwide. A broader use of screening for

    early detection and adjuvant systemic therapy with chemotherapy

    has resulted in improved survival rates. Taxanecontaining

    chemotherapy is one of the cornerstones of the

    treatment. However, taxane-containing chemotherapy

    may result in acute chemotherapy-induced nociceptive

    and neuropathic pain. Since this pain may be an additional

    burden for the patient both during and after taxane

    chemotherapy, it is important to rapidly discover and

    treat it. There is yet no gold standard for assessing taxaneinduced

    pain. In the clinic, applying multiple methods

    for collecting information on pain may better describe the

    patients’ pain experiences. The aim was to document the

    pain during and after taxane through the contribution of

    different methods for collecting information on taxaneinduced

    pain. Fifty-three women scheduled for adjuvant

    sequential chemotherapy at doses of

    ≥75 mg/m2 of docetaxel

    and epirubicin were enrolled in the study.

    Methods:

    Prospective pain assessments were done on a

    visual analog scale (VAS) before and during each cycle

    of treatment for about 5 months, and using the European

    Organization for Research and Treatment of Cancer

    Quality of Life Questionnaire’s (EORTC-QLQ-C30) two

    pain questions at baseline, 3 months, and 12 months. Participants

    scoring pain on the VAS

    >30 and undergoing an

    interview also colored their pain on a body image during

    treatment and at 12 months.

    Results:

    Surprisingly widespread, intense pain was

    detected using a multi-method approach. The colored

    body image showed pain being perceived on 51% of the

    body surface area during treatment, and on 18% 12 months

    after inclusion. In general, the pain started and peaked in

    intensity after the first cycle of taxane. After Cycle 3, most

    women reported an increase in pain on the VAS. Some

    women continued to report some pain even during the

    epirubicin cycles. The VAS scores dropped after the last

    chemotherapy cycle, but not to the baseline level. At baseline,

    3 months and 12 months after inclusion, the women

    who estimated VAS

    >30 reported higher levels of pain on

    the pain questions of the EORTC-QLQ-C30.

    Conclusions:

    This study contributes information on how

    different pain assessment tools offer different information

    in the assessment of pain. The colored body image

    brings another dimension to pain diagnostics, providing

    additional information on the involved body areas

    and the pain intensities as experienced by the women.

    A multi-method approach to assessing pain offers many

    advantages. The timing of the assessment is important to

    properly assess pain.

    Implications:

    Pain relief needs to be included in the

    chemotherapy treatment, with individual assessment and

    treatment of pain, in the same way as is done in chemotherapy-

    triggered nausea. There is a time window whereby the

    risk of pain development is at its highest within 24–48 h

    after receiving taxane chemotherapy. Proper attention to

    pain evaluation and treatment should be in focus during this time window.

  • 3.
    Breivik, Harald
    et al.
    Univ Oslo, Fac Med, Oslo, Norway.;Oslo Univ Hosp, Dept Pain Management & Res, Pbox 4956 Nydalen, N-0424 Oslo, Norway.;Oslo Univ Hosp, Dept Anaesthesiol, Oslo, Norway..
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Acad Hosp, Pain Ctr, Uppsala, Sweden.
    Qualitative pain research emphasizes that patients need true information and physicians and nurses need more knowledge of complex regional pain syndrome (CRPS)2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 15, p. 104-105Article in journal (Other academic)
  • 4. Breivik, Harald
    et al.
    Gordh, Torsten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Neuroinflammation explains aspects of chronic pain and opens new avenues for therapeutic interventions2010In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 1, no 2, p. 65-66Article in journal (Refereed)
  • 5. Breivik, Harald
    et al.
    Gordh, Torsten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Kalso, Eija
    Jensen, Troels S.
    Lindal, Eirkur
    A networking and publishing tool for pain researchers and pain clinicians in the Nordic countries2010In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 1, no 1, p. 1-2Article in journal (Refereed)
  • 6.
    Breivik, Harald
    et al.
    Univ Oslo, Fac Med, Oslo, Norway.;Oslo Univ Hosp, Dept Anaesthesiol, Oslo, Norway.;Oslo Univ Hosp, Dept Pain Management & Res, Box 4956, N-0424 Oslo, Norway..
    Stubhaug, Audun
    Univ Oslo, Fac Med, Oslo, Norway.;Oslo Univ Hosp, Dept Pain Management & Res, Box 4956, N-0424 Oslo, Norway..
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Acad Hosp, Ctr Multidisciplinary Pain, Uppsala, Sweden.
    CNS-mechanisms contribute to chronification of pain2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 15, no 1, p. 137-139Article in journal (Other academic)
  • 7.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Acad Hosp Uppsala, Ctr Multidisciplinary Pain, Uppsala, Sweden.;St Olavs Hosp, Natl Ctr Complex Disorders, Trondheim, Norway.
    A glimpse into a neglected population: Emerging adults2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, p. 230-232Article in journal (Other academic)
  • 8.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    An investigation into enlarging and reducing the size of mirror reflections of the hand on experimentally induced cold-pressor pain in healthy volunteers2016In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 10, p. 26-27Article in journal (Other academic)
  • 9.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Acad Hosp, Pain Ctr, Uppsala, Sweden..
    Cortical reorganization of the healthy hand in upper-limb complex regional pain syndrome (CRPS): Is reorganizations of common beliefs about CRPS necessary?2016In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 13, p. 136-137Article in journal (Refereed)
  • 10.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Academic Hospital, Multidisciplinary Pain Center, Uppsala, Sweden.
    Important new insight in pain and pain treatment induced changes in functional connectivity between the Pain Matrix and the Salience, Central Executive, and Sensorimotor networks2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 16, p. 64-65Article in journal (Other academic)
  • 11.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Acad Hosp Uppsala, Ctr Multidisciplinary Pain, Uppsala, Sweden.;St Olavs Hosp, Natl Ctr Complex Disorders, Trondheim, Norway..
    Is there hope for the most complicated chronic pain patients facing back surgery?2016In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 13, p. 130-131Article in journal (Refereed)
  • 12.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Acad Hosp, Pain Ctr, Uppsala, Sweden..
    Patient Reported Outcomes (PROs) are sensitive outcome-variables in patients with chronic pain: Importance of self-efficacy2016In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 13, p. 25-26Article in journal (Refereed)
  • 13.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Acad Hosp Uppsala, Ctr Multidisciplinary Pain, Uppsala, Sweden.;St Olavs Hosp, Natl Ctr Complex Disorders, Trondheim, Norway..
    Relief of phantom limb pain using mirror therapy: A bit more optimism from retrospective analysis of two studies2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 15, p. 96-97Article in journal (Other academic)
  • 14.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Acad Hosp, Ctr Multidisciplinary Pain, Uppsala, Sweden.;St Olavs Hosp, Natl Ctr Complex Disorders, Trondheim, Norway.
    Sleep, widespread pain and restless legs: What is the connection?2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, p. 174-175Article in journal (Other academic)
  • 15.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Acad Hosp Uppsala, Multidisciplinary Pain Ctr, Uppsala, Sweden.;St Olavs Hosp, Natl Ctr Complex Disorders, Trondheim, Norway..
    The meaning and consequences of amputation and mastectomy from the perspective of pain and suffering - Lessons to be learned and relearned2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 14, p. 98-99Article in journal (Refereed)
  • 16.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Acad Hosp, Ctr Multidisciplinary Pain, S-75185 Uppsala, Sweden.
    The triumvirate of co-morbid chronic pain, depression, and cognitive impairment: Attacking this "chicken-and-egg" in novel ways2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 15, p. 148-149Article in journal (Other academic)
  • 17.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine. Acad Hosp, Ctr Multidisciplinary Pain, Uppsala, Sweden.
    The wit and wisdom of Wilbert (Bill) Fordyce (1923 - 2009)2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 16, p. 160-163Article, review/survey (Refereed)
  • 18.
    Butler, Stephen
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Gordh, Torsten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Important knowledge of pain and phantom experiences after breast surgery and leg- or arm-amputation: value of qualitative pain research2010In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 1, no 1, p. 8-8Article in journal (Refereed)
  • 19.
    Gordh, Torsten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Uppsala Univ Hosp, Ctr Pain Management & Res, S-75185 Uppsala, Sweden..
    A possible biomarker of low back pain: 18F-FDeoxyGlucose uptake in PETscan and CT of the spinal cord2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 15, p. 79-80Article in journal (Other academic)
  • 20.
    Gordh, Torsten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Analysis of C-reactive protein (CRP) levels in pain patients - Can biomarker studies lead to better understanding of the pathophysiology of pain?2016In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 11, p. 165-166Article in journal (Other academic)
  • 21.
    Gordh, Torsten
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Lind, Anne-Li
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Bodolea, Constatin
    Hewitt, Ellen
    Larsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Biochemial structure and function.
    Cathepsin S is increased in cerebrospinal fluid from patients with neuropathic pain: A support of the microglia hypothesis in humans2014In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 5, no 3, p. 208-209Article in journal (Refereed)
    Abstract [en]

    Aims: Cathepsin S has been reported to be a biomarker of spinal microglial activation, a process suggested to be involved in the pathophysiology of chronic neuropathic pain. So far this has been shown only in animal experiments. The aim of this study was to investigate the concentrations of cathepsin S in human cerebrospinal fluid (CSF) samples from a well-defined patient cohort suffering from neuropathic pain as compared to controls.

    Methods: CSF samples from patients suffering from chronic neuropathic pain (n = 14) were analyzed for cathepsin S levels using commercial sandwich ELISAs (DY1183, R&D Systems, Minneapolis, MN, USA). Control CSF was sampled from patients undergoing minor urological surgical procedures under spinal anaesthesia (n = 70), having no obvious pain suffering.

    Results: The neuropathic pain group had significantly higher levels of CSF cathepsin S (median 15189 pg/mL, range 3213–40,040), than the control group (median 5911 pg/mL, range 1909–17,188) (p < 0.005, Mann–Whitney U-test).

    Conclusion: The results support the existence of microglial activation in chronic neuropathic pain patients. CSF Cathepsin S may serve as a potential biomarker for this specific mechanism linked to neuropathic pain. In the future, Cathepsin S inhibiting drugs might become a new treatment alternative for neurophatic pain.

  • 22.
    Gordh, Torsten
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Vinnars, Bertil
    Fischer, Håkan
    Blomberg, Hans
    Modig, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Fredrikson, Mats
    Hartvig, Per
    Brain activation due to postoperative pain from the right hand measured with regional cerebral blood flow using positron emission tomography2010In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 1, no 3, p. 115-119Article in journal (Refereed)
  • 23.
    Heddini, Ulrika
    et al.
    Karolinska Institutet, Division of Obstetrics and Gynecology.
    Johannesson, Ulrika
    Karolinska Institutet, Division of Obstetrics and Gynecology.
    Grönbladh, Alfhild
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmaceutical Biosciences.
    Nyberg, Fred
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmaceutical Biosciences.
    Nilsson, Kent W.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.
    Bohm-Starke, Nina
    Karolinska Institutet, Division of Obstetrics and Gynecology.
    A118G polymorphism in the μ-opioid receptor gene and levels of β-endorphin are associated with provoked vestibulodynia and pressure pain sensitivity2014In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 5, no 1, p. 10-16Article in journal (Refereed)
    Abstract [en]

    Background and aims

    Provoked vestibulodynia (PVD) is the most common cause of dyspareunia among young women. The aetiology is largely unknown and treatment is often extensive and longstanding with varying outcomes. Patients display general pain hypersensitivity and there are correlations with other chronic pain syndromes such as fibromyalgia later in life. The A118G polymorphism in the μ-opioid receptor (OPRM1) gene influences endogenous pain regulation and pain sensitivity, but has not been studied in this patient group before. We aimed to investigate a possible association between A118G polymorphism and PVD, with correlation to plasma levels of β-endorphin, and to explore relationships between this polymorphism and pain sensitivity among women with PVD and healthy controls.

    Methods

    This case–control study included 98 women with PVD and 103 controls. Participants filled out study-specific questionnaires and underwent quantitative sensory testing of pressure pain thresholds on the arm, leg and in the vestibular area. Levels of β-endorphin were analyzed by radioimmunoassay using the EURIA-beta-endorphin kit, and the A118G single-nucleotide polymorphism (SNP; rs1799971) in the OPRM1 gene was analyzed using the TaqMan SNP genotyping assay.

    Results

    The 118G allele was more common in controls (44%) than in patients (30%) (p  = 0.042). The odds ratio of having PVD was 1.8 in participants carrying the 118A allele compared to participants hetero- or homozygous for the 118G allele (OR = 1.846, CI: 1.03–3.31, p = 0.039). Pressure pain thresholds on the leg were higher for participants carrying the 118G allele (mean 480 kPa, SD 167.5) than for those carrying the 118A allele (mean 419, SD 150.4, p = 0.008). Levels of β-endorphin were higher in patients (mean 17.9 fmol/ml, SD 4.71) than in controls (mean 15.8 fmol/ml, SD 4.03) (p < 0.001).

    Conclusion

    We found an association between the A118G polymorphism in the OPRM1 gene and an increased risk of PVD and increased pain sensitivity among participants carrying the 118A allele. PVD patients were more sensitive to pressure pain and had higher levels of plasma β-endorphin than controls. The results indicate that differences in endogenous pain modulation involving the opioid system could contribute to the pathophysiology of PVD and the general pain hypersensitivity seen in these women.

    Implications

    The data support the conceptualization of PVD as part of a general pain disorder with a possible genetic predisposition. The age of onset of PVD is usually between 18 and 25 years and already at this age general pain hypersensitivity is present but rarely causing disability. We believe that early recognition and treatment, with the risk of further development of chronic pain taken into consideration, might prevent future aggravated pain problems in this patient group.

  • 24.
    Hysing, Eva-Britt
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Smith, Lena
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Eriksson, Måns
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Karlsten, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Gordh, Torsten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, no 1, p. 178-185Article in journal (Refereed)
    Abstract [en]

    Background and aims: Patients suffering from chronic nonmalignant pain constitute a heterogeneous population in terms of clinical presentation and treatment results. Few data are available about what distinguishes different groups in this huge population of patients with chronic persistent pain (CPP). A subgroup that is poorly studied, consists of the most severely impaired chronic pain patients. At the Uppsala University Hospital Pain Clinic, there is a specialized department accepting the most complex patients for rehabilitation. In the endeavour to improve and evaluate treatment for this subgroup, a better understanding of the complex nature of the illness is essential. This prospective study aimed to describe the characteristics of this subgroup of patients with CPP.

    Methods: Seventy-two consecutive patients enrolled in the Uppsala programme were evaluated. We collected data on demographics, type of pain and experienced symptoms other than pain using a checklist of 41 possible symptoms. Psychiatric comorbidity was assessed by a psychiatrist using a structured clinical interview. Quality of life (QoL), pain rating and medication/drug/alcohol usage were measured by validated questionnaires: SF-36, NRS, DUDIT and AUDIT. Concerning physical functioning and sick leave, a comparison was made with data from the Swedish Quality Register Registry for pain rehabilitation (SQRP).

    Results: The cohort consisted of 61% women and the average age was 45 (range 20-70) years. For this cohort, 74% reported being on sick leave or disability-pension. In the SQRP 59% were on sick leave at the time they entered the rehabilitation programmes [1]. On average, the study-population reported 22 symptoms other than pain, to be at a high rate of severity. Patients treated in conventional pain rehabilitation programmes reported a mean of 10 symptoms in average. Symptoms reported with the highest frequency (>80%), were lethargy, tiredness, headache and difficulties concentrating. Seventysix percent were diagnosed with a psychiatric disorder. Sixty-nine fulfilled the criteria for depression or depression/anxiety disorder despite that most (65%) were treated with psychotropic medication. Alcohol/drug abuse was minimal. Seventy-one percent were on opioids but the doses were moderate (<100 mg) MEq. The pain rating was >= 7 (out of a maximum of 10) for 60% of the patients.

    Conclusion: This study describes what makes the subgroup of pain patients most affected by their pain special according to associated factors and comorbidity We found that they were distinguished by a high degree of psychiatric comorbidity, low physical functioning and extreme levels of symptom preoccupation/hypervigilance. Many severe symptoms additional to pain (e.g. depression/anxiety, tiredness, disturbed sleep, lack of concentration, constipation) were reported. The group seems hypervigilant, overwhelmed with a multitude of different symptoms on a high severity level.

    Implications: When treating this complex group, the expressions of the illness can act as obstacles to achieve successful treatment outcomes. The study provides evidence based information, for a better understanding of the needs concerning these pain patients. Our result indicates that parallel assessment and treatment of psychiatric comorbidities and sleep disorders combined with traditional rehabilitation, i.e. physical activation and cognitive reorganization are imperative for improved outcomes.

  • 25.
    Kalliomäki, Maija-Liisa
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Tampere Univ Hosp, Dept Anaesthesia, POB 2000, Tampere 33521, Finland.
    Sandblom, Gabriel
    CLINTEC, Karolinska Inst, Stockholm, Sweden.
    Hallberg, Mathias
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmaceutical Biosciences.
    Grönbladh, Alfhild
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmaceutical Biosciences.
    Gunarsson, Ulf
    Umea Univ, Dept Surg & Perioperat Sci, S-90187 Umea, Sweden.
    Gordh, Torsten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Univ Uppsala Hosp, Pain Ctr, Uppsala, Sweden.
    Ginya, Harumi
    Precis Syst Sci Co Ltd, Div IVD Syst Dev, Chiba, Japan.
    Nyberg, Fred
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmaceutical Biosciences.
    Genetic susceptibility to postherniotomy pain. The influence of polymorphisms in the Mu opioid receptor, TNF-alpha, GRIK3, GCH1, BDNF and CACNA2D2 genes2016In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 12, p. 1-6Article in journal (Refereed)
    Abstract [en]

    Background and aims: Despite improvements in surgical technique, 5%-8% of patients undergoing herniorrhaphy still suffer from clinically relevant persistent postherniotomy pain. This is a problem at both individual and society levels. The aim of this study was to determine whether or not a single nucleotide polymorphism in a specific gene contributes to the development of persistent pain after surgery. Methods: One hundred individuals with persistent postherniotomy pain, along with 100 without pain matched for age, gender and type of surgery were identified in a previous cohort study on patients operated for groin hernia. All patients underwent a thorough sensory examination and blood samples were collected. DNA was extracted and analysed for single nucleotide polymorphism in the Mu opioid receptor, TNF-alpha, GRIK3, GCH1, BDNF and CACNA2D2 genes. Results: Patients with neuropathic pain were found to have a homozygous single nucleotide polymorph in the TNF-alpha gene significantly more often than pain-free patients (P = 0.036, one-tailed test). Conclusions: SNP in the TNF-alpha gene has a significant impact on the risk for developing PPSP. Implications: The result suggests the involvement of genetic variance in the development of pain and this requires further investigation.

  • 26.
    Karlsson, Bo
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Burell, Gunilla
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences.
    Anderberg, Ulla Maria
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
    Kurt, Svärdsudd
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Cognitive behaviour therapy in women with fibromyalgia: A randomized cllinical trial2015In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 9, p. 11-21Article in journal (Refereed)
    Abstract [en]

    Background and aims

    Stress has been pointed out as an important influential factor in the development and maintaining of the fibromyalgia syndrome (FMS). Since stress may worsen the pain experience, the development of individual strategies for coping with stress is essential to reduce the impact of FMS on daily life. The aim of the study was to investigate whether a group based stress management cognitive behaviour therapy (CBT) programme could influence self-reported stress, wellbeing and life control, as well as self-reported pain behaviour in female FMS patients.

    Methods

    48 female FMS patient were randomized into a cognitive behaviour therapy treatment group (n = 24) and a waitlist control group (n = 24). When the 6 months waitlist period was over the control group received the same CBT programme. This allowed two analytical approaches, one based on the randomized controlled trial design and one based on a before-and-after design to improve the statistical power of the study. Four psychometric instruments were used: The West Haven-Yale Multidimensional Pain Inventory (three parts, MPI-1 to MPI-3), the Maastricht Questionnaire, the Everyday Life Stress, and the Montgomery-Åsberg Depression rating scale – self-reported. Primary outcome was the MPI-1 dimension ‘life control’, secondary outcomes were the MPI-1 dimensions ‘interference’, ‘affective distress’ and ‘support from spouses or significant others’, the various MPI-2 dimensions, the ‘general activity level’ in the MPI-3 dimension, and ‘vital exhaustion’, ‘stress behaviour’, and ‘depression’. The only tertiary outcome was the MPI-1 dimension ‘pain severity’.

    Results

    In the RCT design the West Haven-Yale Multidimensional Pain Inventory dimensions ‘life control’, ‘interference from pain’, ‘affective distress’, ‘support from spouses or significant others’, and ‘distracting responses’ and ratings for depression improved in the treatment group as compared with the control group. In the before-and after design these improvements were maintained and enhanced during 1-year follow-up, and so was the ‘vital exhaustion’ and ‘stress behaviour’. ‘Pain severity’ was rated higher after the intervention.

    Conclusions

    Cognitive behaviour therapy improved the life control in a female population with FMS. Coping behaviour in response to chronic pain was improved at the same time and in spite of higher subjective ratings of pain. Positive effects were seen on depression, vital exhaustion and stress behaviour. The effects of therapy were maintained and enhanced during the follow up period. It appears that women with FMS after the CBT treatment, according to this protocol obtained tools leading to better acceptance of their disorder.

  • 27.
    Karlsten, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, p. 154-155Article in journal (Other academic)
  • 28.
    Miclescu, Adriana
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Butler, Stephen
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Karlsten, Rolf
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    The changing face of acute pain services2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 16, p. 204-210Article in journal (Refereed)
    Abstract [en]

    Background and Aims

    Acute Pain Services have been implemented initially to treat inadequate postoperative pain. This study was undertaken to prospectively review the current challenges of the APS team in an academic hospital assessing the effects of its activity on both surgical and medical pain intensity. It also define the characteristics of the patients and the risk factors influencing the multiple visits from the APS team.

    Method

    This prospective cohort study was conducted at Uppsala University Hospital (a Swedish tertiary and quaternary care hospital) during one year. All the patients referred to the APS team were enrolled. A standardized data collection template of demographic data, medical history, pain diagnosis, associated diseases, duration of treatment, number of visits by the APS team and type of treatment was employed. The primary outcomes were pain scores before, after treatment and the number of follow-ups. The patients were visited by APS at regular intervals and divided by the number of visits by APS team into several groups: group 1 (one visit and up to 2 follow ups); group 2 (3 to 4 follow-ups); group 3 (5 to 9 follow-ups); group 4 (10 to 19 follow-ups); group 5 (>20 followups). The difference between groups were analyzed with ordinal logistic regression analyses.

    Results

    Patients (n = 730) (mean age 56 ± 4, female 58%, men 42%) were distributed by service to medical (41%) and surgical (58%). Of these, 48% of patients reported a pain score of moderate to severe pain and 27% reported severe pain on the first assessment. On the last examination before discharge, they reported 25–30% less pain (P = 0.002). The median NRS (numerical rating scores) decreased significantly from 9.6 (95% confidence interval, 8.7–9.9) to 6.3 (6.1–7.4) for the severe pain (P < 0.0001), from 3.8 (3.2–4.3) to 2.4 (1.8–2.9) for the moderate pain. The odds ratio for frequent follow-ups of the patients between 18 and 85 years (n = 609) was 2.33 (95% CI: 1.35–4.02) if the patient had a history of chronic neuropathic pain, 1.80(1.25–2.60) in case the patient had a history of chronic nociceptive pain, 2.06(1.30–3.26) if he had mental diseases, and 3.35(2.21–5.08) if he had opioid dependency at the time of consultation from APS. Strong predictors of frequent visits included female gender (P = 0.04).

    Conclusions

    Beside the benefits of APS in reducing pain intensity, this study demonstrates that the focus of APS has been shifted from the traditional treatment of acute surgical pain to the clinical challenges of treating hospitalized patients with a high comorbidity of psychiatric diseases, opioid dependency and chronic pain.

  • 29.
    Miclescu, Adriana
    et al.
    Multidisciplinary Pain Center, Uppsala University Hospital, Sweden.
    Schmelz, Martin
    Gordh, Torsten
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Differential analgesic effects of local lidocaine on spontaneous and evoked pain in neuropathic pain: A double blind, randomized controlled study2015In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 8, p. 37-44Article in journal (Refereed)
    Abstract [en]

    Background

    Both peripheral nerve injury and neuroma pain are the result of changes in sodium channel expression. Lidocaine selectively inhibits the spontaneous ectopic activity by binding to sodium channels. Subanesthetics concentrations of lidocaine are able to produce a differential block of the ectopic discharges, but not propagation of impulses, suppressing differentially the associated neuropathic pain symptoms. The aim of this study was to investigate the differences between the analgesic effects of lidocaine 0.5% and a control group of lidocaine 0.1% on several neuroma related pain modalities.

    Methods

    Sixteen patients with neuropathic pain due to painful neuromas caused by nerve injury participated in this randomized, double-blind experiment. The patterns of sensory changes were compared before and after injection of 1 ml lidocaine 0.5% and 0.1% close to the neuroma, the sessions being 1–2 weeks apart. Spontaneous and evoked pains were assessed using a visual analogue scale (VAS), quantitative and qualitative sensory testing. The primary end-point measure was defined as the change in pain score measured from baseline until 60 min after injection. Assessments of spontaneous pain and evoked pain were done post injection at 15 s, 30 s, 1 min, and at 5-min intervals for the first 30-min post injection and then every 10-min to 1 hr post injection. The assessments of pain were performed between the limbs in the following order: spontaneous pain, then assessment of dynamic mechanical allodynia and then hyperalgesia.

    Results

    Lidocaine dose-dependently reduced spontaneous and evoked pain scores by more than 80% with maximum effects between 1 and 5 min for evoked pain and between 3 and 15 min for spontaneous pain. While evoked pain normalized rapidly reaching about 50% of the control level 20 min after the injection, spontaneous pain levels continue to be lower in comparison with baseline values for more than 60 min. When comparing the time course of analgesia between spontaneous and evoked pain, lidocaine-induced a greater reduction of evoked pain, but with shorter duration than spontaneous pain. The differences between evoked pain and spontaneous pain were statistically significant in both groups (lidocaine 0.5% group; p = 0.02 and lidocaine 0.1% group; p = 0.01). Reproducibility was high for all assessed variables. Surprisingly, both lidocaine concentrations produced a sensory loss within the area with hyperalgesia and allodynia: hypoesthesia occurred earlier and lasted longer with lidocaine 0.5% (between 30 s and 5 min) in comparison with lidocaine 0.1% (p = 0.018).

    Conclusion

    Differential analgesic effects of subanesthetic concentrations of local lidocaine on evoked and spontaneous pain in human neuroma suggest that different mechanisms underlie these two key clinical symptoms. Spontaneous pain and evoked pain need an ongoing peripheral drive and any possible CNS amplification change is temporally closely related to this peripheral input.

    Implications

    Painful neuroma represents a clinical model of peripheral neuropathic pain that could lead to a significant step forward in the understanding of pain pathophysiology providing the opportunity to study spontaneous and evoked pain and the underlying mechanisms of neuropathic pain. The proposed model of neuropathic pain allows testing new substances by administration of analgesics directly where the pain is generated.

  • 30.
    Nyström, B.
    et al.
    Lot, Clin Spinal Surg, SE-64594 Strangnas, Sweden; Regementsgatan 20 B, SE-64533 Strangnas, Sweden.
    Svensson, E.
    Univ Orebro, Dept Stat, SE-70182 Orebro, Sweden.
    Larsson, S.
    Karolinska Hosp, Clin Med Rehabil, Stockholm, Sweden; Rehabil Med Simrishamn, SE-27233 Simrishamn, Sweden.
    Schillberg, B.
    Lot, Clin Spinal Surg, SE-64594 Strangnas, Sweden; Regementsgatan 20 B, SE-64533 Strangnas, Sweden.
    Mörk, A.
    Lot, Clin Spinal Surg, SE-64594 Strangnas, Sweden.
    Taube, Adam
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    A small group Whiplash-Associated-Disorders (WAD) patients with central neck pain and movement induced stabbing pain, the painful segment determined by mechanical provocation: Fusion surgery was superior to multimodal rehabilitation in a randomized trial2016In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 12, p. 33-42Article in journal (Refereed)
    Abstract [en]

    Background

    The majority of patients suffering from a whiplash injury will recover, but some will have symptoms (Whiplash Associated Disorders, WAD) for years despite conservative treatment. Some of these patients perceive neck pain that might come from a motion segment, possibly the disc. In comprehensive reviews no evidence has been found that fusion operations have a positive treatment effect on neck pain in WAD patients.

    Purpose

    Our aim was to evaluate the possibility of (a) selecting a subgroup of chronic WAD patients based on specified symptoms possibly indicating segmental pain, and (b) treating said segmental pain through fusion operation based on non-radiological segment localization. The hypothesis was that fusion operation in this selected subgroup of chronic WAD patients could alleviate perceived neck pain.

    Methods

    Eligible patients for the study had a traffic accident as the origin for their neck pain, and no previous neck symptoms. Neck pain should be the predominant symptom and the pain origin reported to be in the midline, being dull, aching in character and at sudden movements combined by a stabbing pain in the same area. Forty-nine patients with these specified symptoms were identified among a large number of chronic WAD patients. Those selected had pronounced symptoms for a median of around 50 months and had previously been investigated and fully treated within the ordinary healthcare system without success.

    No neurological abnormalities were to be found at clinical examination and no specific changes to be seen on X-ray and MRI. The patients were randomized to either cervical fusion operation or multimodal rehabilitation. By using a mechanical provocation test the level/s to be fused were identified. In all but one patient the surgery was performed anteriorly using microsurgical technique and a right-sided Smith-Pedersen approach and plate fixation. The multimodal rehabilitation at the Clinic of Medical Rehabilitation, Karolinska Hospital, Stockholm, included outpatient treatment for four days a week for six weeks and included treatment by physician, physiotherapists, occupational therapist, psychologists, social-service worker and nurses. Perceived change in neck pain was assessed using the Balanced Inventory for Spinal Disorders questionnaire at the 2-year-follow-up.

    Results

    Mean age of the patients was 38 and 40 years (surgery and rehabilitation groups, respectively), the most common type of accident being rear-end collision. At clinical examination muscle tenderness was not an outstanding sign. In most patients the mid-cervical region appeared to be the painful area but one patient localized the pain to C1. At follow-up 67% of the patients in the surgery group and 23% in the rehabilitation group assessed improvements in the ITT analysis. Corresponding proportions in the per protocol analysis were 83% and 12%, respectively.

    Conclusions

    The results support the supposition that among patients with central neck pain for long periods of time following a whiplash injury there are some in whom the neck pain emanates from a motion segment, probably the disc, a situation suitable for fusion surgery.

    Implications

    Thorough individual symptom evaluation in patients with chronic WAD may identify patients who will benefit from cervical fusion surgery.

  • 31.
    Nyström, Bo
    et al.
    Clinic of Spinal Surgery, Strängnäs, Sweden.
    Gregebo, Birgitta
    Clinic of Spinal Surgery, Strängnäs, Sweden.
    Taube, Adam
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Almgren, Stig-Olof
    Clinic of Spinal Surgery, Strängnäs, Sweden.
    Schillberg, Birgitta
    Clinic of Spinal Surgery, Strängnäs, Sweden.
    Zhu, Yingyan
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, p. 22-29Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    It has been reported that in 13-32% of patients with chronic low back pain, the pain may originate in the sacroiliac (SI) joints. When treatment of these patients with analgesics and physiotherapy has failed, a surgical solution may be discussed. Results of such surgery are often based on small series, retrospective analyses or studies using a minimal invasive technique, frequently sponsored by manufacturers.

    PURPOSE:

    To report the clinical outcome concerning pain, function and quality of life following anterior arthrodesis in patients presumed to have SI joint pain using validated questionnaires pre- and post-operatively. An additional aim was to describe the symptoms of the patients included and the preoperative investigations performed.

    MATERIAL AND METHODS:

    Over a 6 year period we treated 55 patients, all women, with a mean age of 45 years (range 28-65) and a mean pelvic pain duration of 9.1 years (range 2-30). The pain started in connection with minor trauma in seven patients, pregnancy in 20 and unspecified in 28. All patients had undergone long periods of treatment including physiotherapy, manipulation, needling, pelvic belt, massage and chiropractic without success, and 15 had been operated for various spinal diagnoses without improvement. The patients underwent thorough neurological investigation, plain X-ray and MRI of the spine and plain X-ray of the pelvis. They were investigated by seven clinical tests aimed at indicating pain from the SI joints. In addition, all patients underwent a percutaneous mechanical provocation test and extra-articular local anaesthetic blocks against the posterior part of the SI joints. Before surgery all patients answered the generic Short-Form-36 (SF-36) questionnaire, the disease specific Balanced Inventory for Spinal Disorders (BIS) questionnaire and rated their level of pelvic and leg pain (VAS, 0-100). At follow-up at a mean of 2 years 49 patients completed the same questionnaires (89%).

    RESULTS:

    At follow-up 26 patients reported a lower level of pelvic pain than before surgery, 16 the same level and six a higher level. Applying Svensson's method RPpelvic pain=0.3976, with 95% CI (0.2211, 0.5740) revealed a statistically significant systematic improvement in pelvic pain. At follow-up 28 patients reported a higher quality of life and 26 reported sleeping better than pre-operatively. In most patients the character of the pelvic pain was dull and aching, often accompanied by a stabbing component in connection with sudden movements. Referred pain down the leg/s even to the feet and toes was noted by half of the patients and 29 experienced frequency of micturition.

    CONCLUSIONS:

    It is apparent that in some patients the SI joints may cause long-term pain that can be treated by arthrodesis. We speculate that continued pain despite a healed arthrodesis may be due to persistent pain from adjacent ligaments. The next step should be a prospective randomized study comparing posterior fusion and ligament resection with non-surgical treatment.

    IMPLICATIONS:

    Anterior arthrodesis can apparently relieve pain in some patients with presumed SI joint pain. The problem is how to identify these patients within the low back pain group.

  • 32.
    Nyström, Bo
    et al.
    Clinic of Spinal Surgery, Strängnäs, Sweden.
    Weber, Hans
    Department of Neurology, Ullevål Hospital, Norway.
    Schillberg, Birgitta
    Clinic of Spinal Surgery, Strängnäs, Sweden.
    Taube, Adam
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Symptoms and signs possibly indicating segmental, discogenic pain: A fusion study with 18 years of follow-up2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 16, p. 213-220Article in journal (Refereed)
    Abstract [en]

    BACKGROUND:

    Only two out of the five existing randomized studies have reported better results from fusion surgery for chronic low back pain (CLBP) compared to conservative treatment. In these studies the back symptoms of the patients were described simply as "chronic low back pain". One possible reason for the modest results of surgery is the lack of a description of specified symptoms that might be related to a painful segment/disc, and patient selection may therefore be more or less a matter of chance. Previous prospective studies including facet joint injections and discography and eventually MRI have failed to identify patients with a painful segment/disc that will benefit from fusion surgery.

    PURPOSE:

    Our purpose was to analyse in detail the pre-operative symptoms and signs presented by patients who showed substantial relief from their back pain following spinal fusion surgery with the aim of possibly finding a pain pattern indicating segmental, discogenic pain.

    METHODS:

    We analysed 40 consecutive patients, mean age 41 years, with a history of disabling low back pain for a mean of 7.7 years. Before surgery the patients completed a detailed questionnaire concerning various aspects of their back pain, and findings at clinical examination were thoroughly noted. Monosegmental posterior lumbar interbody fusion without internal fixation was performed using microsurgical technique. Outcome was assessed at 1, 2 and 4 years after surgery and finally at 18 years, using self-reporting measures and assessment by an independent examiner. Assessment at 18 years applied the Balanced Inventory for Spinal Disorders Questionnaire and the Roland-Morris Disability Questionnaire.

    RESULTS:

    According to the independent observer's assessment at two years 27 of the 40 patients were much improved. Analysis of the pre-operative depiction of the back symptoms of this group revealed a rather uniform pattern, the most important being: dominating back pain originating in the midline of the spine, with a dull, aching character and stabbing pain in the same area provoked by sudden movements. Most patients in this group also had diffuse pain radiation of various extension down one or both legs and often bladder dysfunction with frequency. At clinical examination, localized interspinal tenderness was observed within the spinal area in question and the patient's back pain was provoked by pressure in that area and by tapping a neighbouring spinous process. At 18 years after surgery 19 patients assessed themselves as much improved. At that time 5 of them had pension due to age, 7 early pension, one worked full time and six patients part time. Eleven patients were re-operated due to defect bony healing.

    CONCLUSIONS:

    The results may suggest that the use of a detailed symptom analysis and clinical examination may make it possible to select a subgroup of patients within the CLBP group likely to have better outcome following fusion surgery.

    IMPLICATIONS:

    The next step would be to execute prospective studies and if our findings concerning back pain details and signs among CLPB patients can be confirmed this can provide for more accurate selection of patients suitable for fusion surgery.

  • 33.
    Peterson, Magnus
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine.
    Breivik, Harald
    Even a “simple” pain condition such as “Tennis Elbow” is not only a somatic experience: Body and mind are inseparable entities2013In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 4, no 3, p. 153-154Article in journal (Refereed)
  • 34.
    Stehlik, Romana
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Ulfberg, Jan
    Capio Hlth Ctr, Sleep Disorders Ctr, Örebro, Sweden.
    Zou, Ding
    Univ Gothenburg, Sahlgrenska Acad, Ctr Sleep & Vigilance Disorders, Gothenburg, Sweden.
    Hedner, Jan
    Univ Gothenburg, Sahlgrenska Acad, Ctr Sleep & Vigilance Disorders, Gothenburg, Sweden; Sahlgrens Univ Hosp, Sleep Disorders Ctr, Gothenburg, Sweden.
    Grote, Ludger
    Univ Gothenburg, Sahlgrenska Acad, Ctr Sleep & Vigilance Disorders, Gothenburg, Sweden; Sahlgrens Univ Hosp, Sleep Disorders Ctr, Gothenburg, Sweden.
    Morning cortisol and fasting glucose are elevated in women with chronic widespread pain independent of comorbid restless legs syndrome2018In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 18, no 2, p. 187-194Article in journal (Refereed)
    Abstract [en]

    Background and aims: Chronic widespread pain (CWP) is associated with poor quality of sleep, but the detailed underlying mechanisms are still not fully understood. In this study we investigated the influence of CWP on morning cortisol and fasting glucose concentrations as well as sleep disordered breathing.

    Methods: In this case-control study, subjects with CWP (n=31) and a control group without CWP (n=23) were randomly selected from a population-based cohort of women. Current pain intensity, sleep quality, excessive daytime sleepiness [Epworth sleepiness scale (ESS)], psychiatric comorbidity and occurrence of restless legs syndrome (RLS) were assessed. Overnight polygraphy was applied to quantify sleep apnoea, airflow limitation and attenuations of finger pulse wave amplitude (>50%) as a surrogate marker for increased skin sympathetic activity. Morning cortisol and fasting glucose concentrations were determined. Generalised linear models were used for multivariate analyses.

    Results: CWP was associated with higher cortisol (464±141 vs. 366±111 nmol/L, p=0.011) and fasting glucose (6.0±0.8 vs. 5.4±0.7 mmol/L, p=0.007) compared with controls. The significance remained after adjustment for age, body mass index, RLS and anxiety status (β=122±47 nmol/L and 0.89±0.28 mmol/L, p=0.009 and 0.001, respectively). The duration of flow limitation in sleep was longer (35±22 vs. 21±34 min, p=0.022), and pulse wave attenuation was more frequent (11±8 vs. 6±2 events/h, p=0.048) in CWP subjects compared with controls. RLS was associated with higher ESS independent of CWP (β=3.1±1.3, p=0.018).

    Conclusions: Elevated morning cortisol, impaired fasting glucose concentration and increased skin sympathetic activity during sleep suggested an activated adrenal medullary system in subjects with CWP, which was not influenced by comorbid RLS.

    Implications: CWP is associated with activated stress markers that may deteriorate sleep.

  • 35.
    Stehlik, Romana
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care. Gothenburg Univ, Sahlgrenska Acad, Ctr Sleep & Vigilance Disorders, Gothenburg, Sweden..
    Ulfberg, Jan
    Capio Hlth Ctr, Sleep Disorders Ctr, Orebro, Sweden..
    Zou, Ding
    Gothenburg Univ, Sahlgrenska Acad, Ctr Sleep & Vigilance Disorders, Gothenburg, Sweden..
    Hedner, Jan
    Gothenburg Univ, Sahlgrenska Acad, Ctr Sleep & Vigilance Disorders, Gothenburg, Sweden.;Sahlgrens Univ Hosp, Sleep Disorders Ctr, Gothenburg, Sweden..
    Grote, Ludger
    Gothenburg Univ, Sahlgrenska Acad, Ctr Sleep & Vigilance Disorders, Gothenburg, Sweden.;Sahlgrens Univ Hosp, Sleep Disorders Ctr, Gothenburg, Sweden..
    Perceived sleep deficit is a strong predictor of RLS in multisite pain - A population based study in middle aged females2017In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 17, no 1, p. 1-7Article in journal (Refereed)
    Abstract [en]

    Background: Chronic pain conditions as well as Restless Legs Syndrome (RLS) are known to be associated with subjectively and objectively disturbed sleep. RLS has been recently described as highly prevalent in multisite pain and the role of sleep as a modifying factor in this RLS phenotype is unknown. This study aimed to investigate if perceived sleep deficit and other sleep related parameters predict RLS in subjects with multisite pain.

    Current knowledge/study rationale: We have recently demonstrated a strong association between Restless Legs Syndrome (RLS) and number of pain locations. In the current analysis we hypothesized that impaired sleep predicts RLS in subjects with multisite pain.

    Method: Questionnaire-based data from 2727 randomly selected women aged 18-64 years were used to analyze RLS symptoms, self-reported sleep quality, and the degree of daytime sleepiness (Epworth Sleepiness Scale (ESS)) in relation to type, degree and localization of body pain. Potential confounders including anthropometrics, pain localization, co-morbidities, and medication were adjusted for in the Generalized Linear Models (GLM).

    Results: Perceived sleep deficit >= 90 min (OR 2.4 (1.5-3.8), p < 0.001) and frequent nocturnal awakenings (OR 2.3 (1.4-3.6), p < 0.001) were the strongest sleep related predictors for RLS in subjects with multisite pain. Additional factors include prolonged sleep latency (>= 30 min, OR 1.8 (1.1-2.8), p = 0.01) and daytime symptoms like elevated daytime sleepiness (ESS score = 9, OR 1.8 (1.2-2.7), p = 0.005). Accordingly, RLS diagnosis was associated with impaired sleep quality (TST (Total Sleep Time) -8.2 min, sleep latency + 8.0 min, and number of awakenings from sleep + 0.4, p < 0.01). ESS score increased with RLS diagnosis (+0.74, p < 0.01) and number of pain locations (0.5, 1.7, and 1.8 for 1, 3, and 5 pain areas, p < 0.001). In addition, confounders like pain severity, the history of psychiatric disease, and current smoking were associated with impaired sleep quality in this group of females. Conclusions: Perceived sleep deficit and sleep fragmentation are the strongest sleep related predictors of RLS in multisite pain. Potential implication of our results are that clinical management programmes of RLS in subjects with multisite pain need to consider both sleep quality and sleep quantity for individually tailored treatment regimes. Study impact: RLS, pain, and sleep disorders are highly interrelated. Our study strongly suggests that clinical management of RLS in patients with multisite pain needs to consider sleep quality as an independent risk factor.

  • 36. Stein, Klaus Felix
    et al.
    Miclescu, Adriana
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
    Effectiveness of multidisciplinary rehabilitation treatment for patients with chronic pain in a primary health care unit2013In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 4, no 4, p. 190-197Article in journal (Refereed)
    Abstract [en]

    Background

    In recent years, multidisciplinary rehabilitation (MDR) became an alternative treatment option for chronic non-cancer pain. MDR is mostly available in specialized pain units, usually at rehabilitation centers where the level of knowledge and therapeutically options to treat pain conditions are considered to be high. There is strong evidence that MDR in specialized pain units is affecting pain and improves the quality of life in a sustainable manner. There are few studies about MDR outcome in primary health care, especially in those units situated in rural areas and with a different population than that encountered in specialized hospitals. That, in spite of the fact that the prevalence of pain in the patients treated in primary care practice is about 30%. The aim of this study is to analyze the effectiveness of MDR for chronic non-cancer patients in a primary health care unit.

    Methods

    This study included a total of 51 patients with chronic pain conditions who were admitted and completed the local MDR-program at the primary health care unit in Arvika, Sweden. The major complaint categories were fibromyalgia (53%), pain from neck and shoulder (28%) or low back pain (12%). The inclusion criteria were age between 16 and 67 years and chronic non-cancer pain with at least 3 months duration. The multidisciplinary team consisted of a general practitioner, two physiotherapists, two psychologists and one occupational therapist. The 6-week treatment took place in group sessions with 6–8 members each and included cognitive-behavioral treatment, education on pain physiology, ergonomics, physical exercises and relaxation techniques.

    Primary outcomes included pain intensity, pain severity, anxiety and depression scores, social and physical activity, and secondary outcomes were sick leave, opioid consumption and health care utilization assessed in the beginning of the treatment and at one year follow-up. Data was taken from the Swedish Quality Register for Pain Rehabilitation (SQRP) and the patients’ medical journal.

    Results

    One year after MDR treatment, sick leave decreased from 75.6% to 61.5% (p < 0.05). Utilization of health-care during one year decreased significantly from 27.4 to 20.1 contacts (p = 0.02). There were significant improvements concerning social activity (p = 0.03) and depression (p < 0.05), but not in anxiety (p = 0.1) and physical activity (p = 0.08). Although not statistically significant, some numerical decrease in the mean levels of pain intensity, pain severity and opioid consumption were reported one year after MDR (p > 0.05).

    Conclusions

    The results obtained one year after rehabilitation indicated that patients with chronic non-cancer pain might benefit from MDR in primary health care settings.

    Implications

    This study suggests that MDR in primary care settings as well as MDR at specialized pain units may lead to better coping in chronic non-cancer pain conditions with lower depression scores and higher social activity, leading to lower sick leave. This study demonstrated that there is a place for MDR in primary health care units with the given advantage of local intervention in rural areas allowing the patients to achieve rehabilitation in their home environment.

  • 37.
    Svensson, Elisabeth
    et al.
    Örebro University, Dept Stat, Örebro, Sweden.
    Nyström, Bo
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery. Clin Spinal Surg, Strängnäs, Sweden.
    Goldie, Ian
    Karolinska Univ Hosp, Dept Orthopaed, Stockholm, Sweden.
    Landrø, Nils Inge
    Univ Oslo, Dept Psychol, Ctr Study Human Cognit, Oslo, Norway; Univ Oslo, Dept Psychol, Clin Neurosci Res Grp, Oslo, Norway.
    Sidén, Åke
    Karolinska Univ Hosp, Dept Neurol, Stockholm, Sweden.
    Staff, Peer
    Oslo Univ Hosp, Dept Phys Med & Rehabil, Oslo, Norway; Trakka 1, Oslo, Norway.
    Schillberg, Birgitta
    Clin Spinal Surg, Strängnäs, Sweden.
    Taube, Adam
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Statistics.
    Superior outcomes following cervical fusion vs. multimodal rehabilitation in a subgroup of randomized Whiplash-Associated-Disorders (WAD) patients indicating somatic pain origin. Comparison of outcome assessments made by four examiners from different disciplines.2018In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 18, no 2, p. 175-186Article in journal (Refereed)
    Abstract [en]

    Background and aims: Whiplash-Associated Disorders (WAD) are characterized by great variability in long-term symptoms. Patients with central neck and movement-induced stabbing pain participated in a randomized study comparing cervical fusion and multimodal rehabilitation. As reported in our previous paper, more patients treated by cervical fusion than by rehabilitation experienced pain relief. Although patient reported outcome measures are a core component of outcome evaluation, independent examiner has been recommended. Because of the heterogeneity of WAD complaints the patients in our study were examined at baseline and follow-up by four experts representing neurology, orthopedics, psychology and physical medicine. The aim was to compare the professional assessments of change both regarding the possible impact of the different examiners’ perspectives on individual patient’s outcome, and also on the analysis of possible outcome differences between the treatment groups.

    Methods: WAD patients with long-term neck pain as the predominant symptom after a traffic accident were eligible. The neck pain origin should be in the midline and perceived as dull and aching, with sudden movement inducing midline stabbing pain. Of the 1,052 patients in contact with our team, 49 were eligible. The overall treatment effect was evaluated on a global outcome transitional scale. The criteria for the scale categories were defined by each expert’s professional perspective on change in the whiplash complaints. Statistical methods that take account of the non-metric properties of ordered categorical data were used. Observed inter-expert disagreement was evaluated by the Svensson method that identifies and measures systematic group-related disagreement separately from disagreement caused by individual variation. Possible differences in the distributions of assessments on the expert-specific outcome scales between the treatment groups were analyzed by the Kruskal-Wallis test.

    Results: The per-protocol evaluation showed that a majority of the 18 patients who underwent fusion surgery were assessed as somewhat or much better, ranging from 67% to 78% depending on the expert. Corresponding proportions of improvement in the 17 patients treated by multimodal rehabilitation ranged from 29% to 53%. The statistical analyses confirmed better outcomes in the patients treated by fusion surgery, with p-values ranging from 0.003 to 0.04. The experts’ assessments of intra-patient change disagreed more or less for all patients. The analyses of the paired comparisons confirmed that these disagreements could most probably be explained by the different profession-specific operational definitions of the outcome scales rather than by individual variations in data.

    Conclusions: The multi-dimensional complexity of WAD-related complaints was comprehensively demonstrated by the inter-disciplinary disagreements in assessing intra-patient outcomes. The superiority of positive treatment effects in patients who underwent cervical fusion compared with multimodal rehabilitation was evident to all experts.

    Implications: The results strengthen our previous opinion that neck pain in this subgroup of WAD patients has a somatic origin. More than one examiner is recommended for multi-dimensional outcome assessments.

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