Patient expectations for a multimodal pain rehabilitation programme: active participation and coping skills. A qualitative study.

PURPOSE: To describe what patients with chronic pain expect from a multimodal pain rehabilitation programme. MATERIAL AND METHOD: Qualitative interviews were used to uncover expectations about a multimodal rehabilitation programme offered at the Pain and Rehabilitations Centre, The University Hospital; Linköping, Sweden. Sixteen women and two men (mean age 37 years; standard deviation 10 years) with chronic benign pain participated. The interviews were analysed using qualitative content analyses. RESULTS: To participate actively in the multimodal pain rehabilitation programme and to learn adequate coping strategies to improve daily life emerged as a main category. It was based on the following four categories comprising expectations about: participating actively in the programme, interacting with the professionals and fellow patients, cognitive effects of the programme and tools for coping, and explicit effects from the programme. CONCLUSIONS: Many patients expressed expectations which may reflect that the information before the programme had started rehabilitation process at the time point for this study. The results could be applied in rehabilitation programmes by acknowledging expectations to interact with professional team members and fellow patients, by early addressing of positive and negative expectations about the future pain and by incorporating and strengthen expectations of learning to cope with pain. Implications for Rehabilitation Patients' expectations to interact with professional team members and fellow patients by participating actively in the pain rehabilitation programme should be acknowledged in each rehabilitation situation. Patients expressed both positive and negative expectations about their future pain situation and these expectations should be addressed as early as possible in the rehabilitation screening process. Patients' expectations of learning to cope with pain should be incorporated and strengthened in multimodal pain rehabilitation programmes.

Tortured refugees' expectations of a multidisciplinary pain rehabilitation programme: an explorative qualitative study.

BACKGROUND: Refugees have often been exposed to torture in their countries of origin. Rehabilitation of tortured refugees living in Denmark is offered by the specialized Rehabilitation and Research Centre for Torture Victims in Copenhagen. After an interdisciplinary assessment eligible patients are recommended rehabilitation. OBJECTIVE: To explore tortured refugees' expectations of the multidisciplinary pain rehabilitation programme offered at our centre. DESIGN: Explorative qualitative interview study. PATIENTS: Fifteen consecutive Arabic-speaking men, waiting for rehabilitation after having been assessed by a physician, a psychologist, a physiotherapist and a social worker, were interviewed. METHODS: Individual qualitative interviews were performed by an Arabic-speaking psychologist, and analysed with content analyses. RESULTS: One theme: different expectations of multidisciplinary pain rehabilitation and 4 categories emerged: general expectations of the rehabilitation programme; specific expectations of professional treatment; expectations of mutual participation and communication; and expected rehabilitation outcomes. CONCLUSION: The tortured refugees had different, mostly positive, expectations of the multidisciplinary pain rehabilitation programme. General expectations of the rehabilitation content, as well as specific expectations of the professionals' treatment, were expressed. Mutual and active participation and communication between patients and therapists were important expectations. In addition, positive outcomes, such as improved health, improved coping ability and decreased pain, were expected.

Sensory functions in the foot soles in victims of generalized torture, in victims also beaten under the feet (falanga) and in healthy controls - A blinded study using quantitative sensory testing.

BACKGROUND: Falanga torture (beatings on the foot soles) produces local chronic pain and severe walking difficulties. We have previously reported signs of neuropathic pain in the feet of falanga victims. The objective here was to clarify underlying pain mechanisms by quantifying sensory impairments in the feet of torture victims who had experienced both generalized torture and those who had been exposed to falanga in addition. An ethnically matched control group was available. METHODS: We employed quantitative sensory testing (QST) by investigators blinded to whether the patients, 32 male torture victims from the Middle East, had (n=15), or had not (n=17) been exposed to falanga. Pain intensity, area and stimulus dependence were used to characterize the pain as were interview data on sensory symptoms. QST included thresholds for touch, cold, warmth, cold-pain, heat-pain, deep pressure pain and wind-up to cutaneous noxious stimuli in the foot soles. Clinical data on anxiety and depression were retrieved. RESULTS: Almost all falanga victims had moderate or strong pain in their feet and in twice as large an area of their foot soles as other torture victims. One-third of the latter had no pain in their feet and many reported slight pain; in spite of this, there were no differences in foot sole QST data between the tortured groups. A comparison with normal data indicated that both tortured groups had hypoesthesia for all cutaneous sensory fibre groups except those transmitting cold and heat pain, in addition to deep mechano-nociceptive hyperalgesia. CONCLUSION: A comparison of the QST data between victims having been exposed to generalized torture and victims who in addition had been exposed to falanga, showed no differences on the group level. The sensory disturbances in relation to our control group are compatible with central sensitization and de-sensitization, pointing to a core role of central mechanisms. A further analysis to create individual sensory profiles from our measurements is in progress.

Pain when walking: individual sensory profiles in the foot soles of torture victims - a controlled study using quantitative sensory testing.

BACKGROUND: With quantitative sensory testing (QST) we recently found no differences in sensory function of the foot soles between groups of torture victims with or without exposure to falanga (beatings under the feet). Compared to matched controls the torture victims had hyperalgesia to deep mechano-nociceptive stimuli and hypoesthesia to non-noxious cutaneous stimuli. The purpose of the present paper was to extend the group analysis into individual sensory profiles of victims' feet to explore possible relations between external violence (torture), reported pain, sensory symptoms and QST data to help clarify the underlying mechanisms. METHODS: We employed interviews and assessments of the pain and sensory symptoms and QST by investigators blinded to whether the patients, 32 male torture victims from the Middle East, had (n=15), or had not (n=17) been exposed to falanga. Pain intensity, area and stimulus dependence were used to characterize the pain. QST included thresholds for touch, cold, warmth, cold-pain, heat-pain, deep pressure pain and wind-up to cutaneous noxious stimuli. An ethnically matched control group was available.The normality criterion, from our control group data, was set as the mean +/- 1.28SD, thus including 80% of all values.QST data were transformed into three categories in relation to our normality range; hypoesthesia, normoesthesia or hyperesthesia/hyperalgesia. RESULTS: Most patients, irrespective of having been exposed to falanga or not, reported severe pain when walking. This was often associated with hyperalgesia to deep mechanical pressure. Hypoesthesia to mechanical stimuli co-occurred with numbness, burning and with deep mechanical hyperalgesia more often than not, but otherwise, a hypoesthesia to cutaneous sensory modalities did not co-occur systematically to falanga, pain or sensory symptoms. CONCLUSION: In torture victims, there seem to be overriding mechanisms, manifested by hyperalgesia to pressure pain, which is usually considered a sign of centralization. In addition there was cutaneous hypoesthesia, but since there was no obvious correlation to the localization of trauma, these findings may indicate centrally evoked disturbances in sensory transmission, that is, central inhibition. We interpret these findings as a sign of changes in central sensory processing as the unifying pathological mechanism of chronic pain in these persons.

An increased response to experimental muscle pain is related to psychological status in women with chronic non-traumatic neck-shoulder pain.

BACKGROUND: Neck-shoulder pain conditions, e.g., chronic trapezius myalgia, have been associated with sensory disturbances such as increased sensitivity to experimentally induced pain. This study investigated pain sensitivity in terms of bilateral pressure pain thresholds over the trapezius and tibialis anterior muscles and pain responses after a unilateral hypertonic saline infusion into the right legs tibialis anterior muscle and related those parameters to intensity and area size of the clinical pain and to psychological factors (sleeping problems, depression, anxiety, catastrophizing and fear-avoidance). METHODS: Nineteen women with chronic non-traumatic neck-shoulder pain but without simultaneous anatomically widespread clinical pain (NSP) and 30 age-matched pain-free female control subjects (CON) participated in the study. RESULTS: NSP had lower pressure pain thresholds over the trapezius and over the tibialis anterior muscles and experienced hypertonic saline-evoked pain in the tibialis anterior muscle to be significantly more intense and locally more widespread than CON. More intense symptoms of anxiety and depression together with a higher disability level were associated with increased pain responses to experimental pain induction and a larger area size of the clinical neck-shoulder pain at its worst. CONCLUSION: These results indicate that central mechanisms e.g., central sensitization and altered descending control, are involved in chronic neck-shoulder pain since sensory hypersensitivity was found in areas distant to the site of clinical pain. Psychological status was found to interact with the perception, intensity, duration and distribution of induced pain (hypertonic saline) together with the spreading of clinical pain. The duration and intensity of pain correlated negatively with pressure pain thresholds.

Computer-aided surface estimation of pain drawings - intra- and inter-rater reliability.

Pain drawings are often utilized in the documentation of pain conditions. The aim here was to investigate intra- and inter-rater reliability of area measurements performed on pain drawings consecutively, using the computer program Quantify One. Forty-eight patients with chronic nonmalignant pain had shaded in their experienced pain on the front and back views of a pain drawing. The templates were scanned and displayed on a 17-inch computer screen. Two independent examiners systematically encircled the shaded-in areas of the pain drawings with help of a computer mouse, twice each on two separate days, respectively. With this method it is possible to encircle each marked area and to obtain immediate details of its size. The total surface area (mm(2)) was calculated for each pain drawing measurement. Each examiner measured about 2400 areas, and as a whole, the number of areas measured varied only by 3%. The intra-rater reliability was high with intraclass correlation coefficients 0.992 in Examiner A and 0.998 in Examiner B. The intra-individual absolute differences were small within patients within one examiner as well as between the two examiners. The inter-rater reliability was also high. Still, significant differences in the absolute mean areas (13%) were seen between the two examiners in the second to fourth measurement sessions, indicating that one of the examiners measured systematically less. The measurement error was ≤10%, indicating that use of the program would be advantageous both in clinical practice and in research, but if repeated, preferably with the same examiner. Since pain drawings with this method are digitized, high quality data without loss of information is possible to store in electronic medical records for later analysis, both regarding precise location and size of pain area. We conclude that the computer program Quantify One is a reliable method to calculate the areas of pain drawings.

Using data from Multidimensional Pain Inventory subscales to assess functioning in pain rehabilitation.

The aim of this study was to examine whether Multidimensional Pain Inventory (MPI) subscale score changes can be used for monitoring interdisciplinary cognitive behavioural pain rehabilitation programmes, using the Psychological General Well-Being (PGWB) index as an independent variable of rehabilitation outcome. Data from 434 consecutively referred patients disabled by chronic pain were analysed. The intervention was a 4-week interdisciplinary pain rehabilitation group programme (5 h/day), based on biopsychosocial and cognitive behavioural principles. Mean PGWB total scores improved after rehabilitation (P<0.0001) with clinically relevant effect sizes for patients with 'dysfunctional' and 'interpersonally distressed' MPI profiles. Substantial correlations (r=0.7-0.3; P<0.001) were found between the changes in PGWB total scores and four of the MPI subscale scores. These were combined into a composite variable ['pain severity', 'interference', 'life control' (given reversed scores) and 'affective distress'], and were labelled as the Pain Rehabilitation Index. The subscales, 'support' and 'general activity level', were omitted, as changes were ambiguous with respect to functioning. 'Dysfunctional' and 'interpersonally distressed' profile patients showed a marked improvement in Pain Rehabilitation Index after rehabilitation (effect sizes of 0.77 and 0.43; P<0.0001, respectively). Conversely, the 'adaptive copers' may have deteriorated somewhat (effect size -0.28; P=0.036). We propose that scores from four MPI subscales are integrated and the difference pre-post rehabilitation is used to indicate composite rehabilitation outcomes, making it possible to interpret all included MPI subscales in the same direction. Psychometric evaluation of the index is warranted.

Self-reported activity in tortured refugees with long-term sequelae including pain and the impact of foot pain from falanga--a cross-sectional study.

PURPOSE: To describe activity limitations in tortured refugees referred for rehabilitation, particularly the impact of neuropathic pain resulting from falanga (beatings under the feet). METHODS: Physiotherapists assessed 103 consecutively referred torture victims with a long history of sequelae, among them pain and mobility problems. All had been subjected to various forms of physical and psychological torture and 71 victims had also suffered falanga. Main outcome measures used were: the Disability Rating Index (DRI; 12 items) to assess self-reported capacity to carry out daily activities; for falanga victims, a specific foot assessment of sensory function in the feet. RESULTS: All patients perceived clear activity limitations according to the DRI. The falanga victims' feet were categorised according to the type of foot pain: stimulus-independent pain; stimulus-evoked pain; no pain. The two groups with foot pain displayed sensory dysfunction and suffered more extensive activity limitations. After correction for confounding factors, these two groups reported significantly more activity limitations in 7 out of 12 DRI items than those who were not exposed to falanga. CONCLUSION: In this group of victims who had chronic pain for at least 5 years after torture, all perceived activity limitations, but pain from falanga had a greater overall impact on disability assessed in terms of daily activities.

Validity of electrical stimulus magnitude matching in chronic pain.

OBJECTIVE: To examine the validity of the PainMatcher in chronic pain. DESIGN: Comparison of parallel pain estimates from visual analogue scales with electrical stimulus magnitude matching. PATIENTS: Thirty-one patients with chronic musculoskeletal pain. METHODS: Twice a day ongoing pain was rated on a standard 100-mm visual analogue scale, and thereafter magnitude matching was performed using a PainMatcher. The sensory threshold to electrical stimulation was tested twice on separate occasions. RESULTS: In 438 observations visual analogue scale ranged from 3 to 95 (median 41) mm, and PainMatcher magnitudes from 2.67 to 27.67 (median 6.67; mean 7.78) steps. There was little correlation between visual analogue scale and magnitude data (r = 0.29; p < 0.0001). The mean sensory threshold was 3.67 steps, indicating that the PainMatcher, on average, stimulated at 2.1 times the perception threshold at matching point. CONCLUSION: Electrical magnitude matching of chronic pain intensity elicited limited activation of nerve fibres at 2.0-2.2 times sensory threshold, indicating that the induced pain was evoked by coarse nociceptive Adelta fibres. While the visual analogue scale estimates covered the whole range of the instrument, the PainMatcher readings utilized only a small part of the instrument range and, importantly, had little or no relation to the visual analogue scale estimates. The validity of the PainMatcher procedure is doubtful.

Rehabilitating torture survivors.

Refugees have often been exposed to torture in their countries of origin. A core issue is the resulting multifaceted presentation of somatic, psychological and social problems in the same individual, leading to severe activity limitations and participation restrictions. An international conference, "Rehabilitating Torture Survivors", was organized by the Rehabilitation and Research Centre for Torture Victims (a rehabilitation clinic and global knowledge and research centre with government support) in collaboration with the Centre for Transcultural Psychiatry at Rigshospitalet in Copenhagen, Denmark, in December 2008. The main topics were: the context of torture; mental problems including psychotherapy; internet-based therapy and pharmaco-therapy; chronic pain; social integration and family; and functioning and rehabilitation. Available evidence highlights the importance of an interdisciplinary approach to rehabilitation, but scientifically rigorous studies of comprehensive rehabilitation programmes for torture survivors are lacking. Therefore, effect studies are urgently warranted. Nevertheless, by combining expertise from different scientific and professional areas, important elements in the problems of torture survivors can be addressed from an evidence base generated both from traumatized and non-traumatized patient populations. Thus, trauma-focused cognitive behavioural therapy and/or eye movement desensitization and reprocessing, as well as interdisciplinary pain rehabilitation, should be components of a successful rehabilitation process, and great attention should be paid to contextual components.

Clinical findings in men with chronic pain after falanga torture.

OBJECTIVES: To explore clinical findings in men with chronic pain after falanga torture as compared with controls, and to try to understand the nature of the pain mechanisms responsible. METHODS: Eleven male torture victims from the Middle East with chronic pain after falanga, and 11 age, sex, and ethnically matched controls with no history of torture were recruited. All participants were interviewed regarding pain characteristics in the feet and lower legs at rest and when walking. Structural changes and motor and sensory function were clinically assessed according to a standardized protocol. The walking pattern was observed for compensatory gait patterns. RESULTS: The torture victims had pain in their feet and lower legs and a compensated gait pattern, usually with severe pain during walking. Reduced light touch and thermal sensation, tactile dysesthesia, allodynia, and tenderness on palpation were common findings. Structural changes in the feet were found in more than half of the victims, but did not correlate with pain reports. These clinical findings were nonexistent or seen only rarely in controls. DISCUSSION: We found clear clinical signs of nerve injury in the feet. The sensory findings indicated 2 neuropathic pain mechanisms, one dominated by a peripheral pain generator and other by irritative phenomena (dysesthesia, allodynia), indicating central sensitization. It is reasonable to assume that these changes are due to the falanga exposure. A nociceptive contribution cannot be excluded. It is important to perform an individual diagnostic analysis to facilitate adequate treatment.

Are auricular maps reliable for chronic musculoskeletal pain disorders? A double-blind evaluation.

AIM: To examine the proposed somatotopic relation between the regions in which patients report musculoskeletal pain and tender points located on the external ears according to a map based on commonly used auricular acupuncture maps. METHODS: Twenty-five patients (16 women) from a chronic pain clinic were included. Patients were asked, before examination of the external ears, if they had past or present musculoskeletal pain in any of 11 body regions. An ear map, collapsed into 11 zones representing the musculoskeletal system, was used. The ear examiner was blinded to the patients' pain conditions, medical history and ongoing treatment. Patients communicated with the examiner only to express if tenderness was present in the external ear on palpation using a spring-loaded pressure stylus commonly used for auricular acupuncture. The degree of tenderness was registered on a 5-point scale and dichotomised (no tenderness or tenderness). Agreements between the patients' painful body regions and tenderness in the external ear zones were presented as percentage, kappa values, sensitivity and specificity. RESULTS: The 25 patients reported 116 past or present musculoskeletal pain regions and had 110 tender ear zones. No statistically significant agreements were found between the painful body regions and the corresponding tender ear zones. CONCLUSIONS: Our results did not show agreements between patients' reported musculoskeletal pain regions and tender zones in the external ears assessed according to commonly used maps in auricular acupuncture using a pressure stylus. However, very tender points occur on the external ear in a population with chronic musculoskeletal pain.

Intra- and inter-rater reliability of the Sollerman hand function test in patients with chronic stroke.

PURPOSE: To examine whether the Sollerman hand function test is reliable in a test-retest situation in patients with chronic stroke. METHOD: Three independent examiners observed each patient at three experimental sessions; two days in week 1 (short-term test-retest) and one day in week 4 (long-term test-retest). A total of 24 patients with chronic stroke (mean age; 59.7 years, mean time since stroke onset 29.6 months) participated. The examiners simultaneously assessed the patients' ability to perform 20 subtests. Both ordinal data (generalized kappa) and total sum scores (Spearman's rank correlation coefficient (Spearman's rho), intra class correlation coefficient (ICC2, 1) and mean differences) were used in the statistical analysis. RESULTS: There was agreement (kappa >or= 0.4) between the examiners for 15 out of the 20 subtests. Using total sum scores, the agreement within the examiners, both short- and long-term, was higher than 0.96 (for Spearman's rho and ICC, respectively). The mean differences were 0.29 - 1.0/80 points within each examiner. Agreement between the examiners at each session was higher than 0.96 (Spearman's rho) and 0.92 (ICC), respectively. Systematic differences (p < 0.05) were, however, found between examiners A and B/C for all sessions. CONCLUSIONS: The Sollerman hand function test seems to be a reliable test in patients with chronic stroke, but we recommend that the same examiner evaluates a patient's hand function pre- and post-treatment.

Pressure pain threshold changes after repeated mechano-nociceptive stimulation of the trapezius muscle: possible influence of previous pain experience.

UNLABELLED: We examined the relation between repeated noxious pressure over the trapezius muscle and changes in pressure pain thresholds (PPTs) in a before-after trial design. A conditioning series of 30 mechano-nociceptive stimuli was applied manually with a handheld algometer probe, and PPTs were measured over 1 trapezius muscle (skin anaesthetized) in 27 healthy women before and after the intervention. With a mean stimulation rate of 0.40 Hz and a mean nociceptive stimulation intensity of 1.78 x Threshold, subjects were found to systematically react with a change in PPT, either a decrease or an increase. Normalized data, transformed into mean unidirectional PPT differences, showed statistically highly significant changes after intervention. The relative risk of reacting with lowered PPTs on noxious stimulation was 3.7 times higher for subjects who had not given birth to children than for subjects who had given birth to 1 or several children (P<.046). When 11 subjects were tested at a second session, a clear correlation of PPT reactions (r=0.527; P<.001) was found. In summary, repetitive mechano-nociceptive stimulation of the trapezius muscle in healthy females evokes moderate and temporary changes in PPT that last for at least 35 minutes after cessation of stimulation. PERSPECTIVE: A possible development of the response with transiently decreased PPTs into a model for human muscle pain is an intriguing possibility, since other models usually involve the introduction of chemical or thermal agents in the muscle, but this must await further research.

Tender or not tender: test-retest repeatability of pressure pain thresholds in the trapezius and deltoid muscles of healthy women.

OBJECTIVE: To examine the test-retest repeatability of pressure pain thresholds in the shoulder muscles of healthy women. DESIGN: Four experimental sessions (days 1, 3, 28, 30), each including 4 consecutive pressure pain threshold measurements at 10-minute intervals. SUBJECTS: Twenty-four healthy female volunteers, mean age 42 years. METHODS: Two examiners measured pressure pain thresholds bilaterally over the trapezius and deltoid muscles with an electronic algometer. Student's paired t-test, intraclass correlation coefficient, ANOVA repeated measures, 95% confidence interval and mean maximal absolute measurement error, were used for statistics. RESULTS: Reliability for each point in all sessions was high; ICC range 0.70-0.94, mean maximal differences; 53-102 kPa (all 4 muscles), and between points in each muscle: ICC right trapezius 0.59-0.77, left 0.67-0.84, right deltoid 0.66-0.83, left 0.70-0.90. Mean maximal differences were 69-101 kPa and 65-111 kPa for the trapezius and deltoid muscles, respectively. The inter-individual variation was 5-fold (trapezius 88-574 kPa; deltoid 91-529 kPa). At the group level, the variation was limited when the first measurement was excluded. Inter-rater and intra-rater repeatability was high without significant differences. Only small side-to-side differences were seen. CONCLUSION: Repeated measurements show stable intra-individual values. The method can be recommended when used by trained and experienced examiners.

Increases in local pressure pain thresholds after muscle exertion in women with chronic shoulder pain.

OBJECTIVE: To examine the relation between muscular tenderness and local muscular fatigue. DESIGN: Before-after trial, measuring pressure pain thresholds and signs of local muscular fatigue by using surface electromyography before, after, 10 minutes after, and 20 minutes after intervention. SETTING: University rehabilitation department in Sweden. PARTICIPANTS: Nineteen female hospital cleaners with unilateral chronic shoulder pain for 1 year. No previous trauma, surgery, or signs of systemic or neurologic disease. INTERVENTION: Static abduction endurance test with submaximal unilateral activation of the trapezius and deltoid muscles. MAIN OUTCOME MEASURES: Pressure pain thresholds and electromyographic fatigue parameters (root mean square [RMS]; mean power frequency [MPF]). RESULTS: Mean normalized pressure pain threshold values increased significantly (95% confidence interval [CI]) and lasted for 20 minutes: in the trapezius, threshold values increased to 115% to 120% (95% CI, 100%-140%; P=.04-.05); and in the deltoid, the threshold increased to 112% to 115% (95% CI, 100%-130%; P=.02-.05). Development of significant electromyographically defined fatigue was seen: in the trapezius, the RMS increased to 130% (95% CI, 119%-141%), and in the deltoid, the MPF decreased to 78% (95% CI, 74%-82%), but normalized within 15 seconds to 10 minutes. CONCLUSION: Lasting bilateral increases in pressure pain thresholds but transient local muscular fatigue were seen after a unilateral static endurance test. The sensitivity of the sensory nervous system may change during a static muscle contraction and sometimes contributes to a localized sensation of numbness.