Monika Löfgren

'A constant struggle' : successful strategies of women in work despite fibromyalgia.

Purpose. This study aimed to explore, and obtain increased knowledge of, the strategies used by working women with fibromyalgia regarding control of pain, fatigue and other symptoms. Method. Qualitative methods with an emergent design were used. The informants were women with fibromyalgia who had participated in rehabilitation 6–8 years earlier, and were still in work. Diaries, focus groups and individual interviews were used for data collection. Content analysis and grounded theory were used for the analyses. Results. A model with three categories emerged. The core category ‘constant struggle’ contains eight sub-categories: enjoying life, taking care of oneself, positive thinking, setting limits, using pain as a guide, creative solutions, learning/being knowledgeable and ‘walking a tightrope’. The category ‘grieving process’ was a prerequisite for managing the struggle and the category ‘social support’ contained what facilitated the struggle. Conclusion. The informants fought a constant struggle against the symptoms and the consequences of their fibromyalgia. Their strategies were action-oriented and evinced a positive spirit. To have grieved and accepted their situation was a prerequisite for managing, and support from the family was a help in the struggle.

PAIN RELIEF IN WOMEN WITH FIBROMYALGIA: A CROSS-OVER STUDY OF SUPERFICIAL WARMTH STIMULATION AND TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION

OBJECTIVE To compare the effects of portable superficial warmth with transcutaneous electrical nerve stimulation on pain in patients with fibromyalgia. METHODS The study had a randomized cross-over design. A total of 32 patients with fibromyalgia were randomly assigned to 2 groups. After instruction, the patients treated themselves using a portable device providing superficial warmth (42 degrees C) or a transcutaneous electrical nerve stimulation apparatus. After 3 weeks the patients switched therapy. The patients rated pain intensity on a 0-100 numerical rating scale before and after each treatment. After 6 weeks, patients were questioned concerning therapy preference. RESULTS There was no difference in level of pain relief when comparing the 2 treatment modes. Median pain intensity in patients using warmth therapy decreased from 77.5 on the numerical rating scale before treatment to 62.5 after treatment and in patients using transcutaneous electrical nerve stimulation from 80 to 62.5. Ten patients reported a reduction of 20 units or more on the numerical rating scale after warmth therapy, as did 10 after transcutaneous electrical nerve stimulation. Seventeen of 32 patients preferred warmth therapy and 10 preferred transcutaneous electrical nerve stimulation. CONCLUSION Sensory stimulation with superficial warmth or transcutaneous electrical nerve stimulation yielded comparable temporary pain reduction in patients with fibromyalgia. Both procedures are self-administered, safe and in-expensive.

Fibromyalgia Is Associated with Decreased Connectivity Between Pain- and Sensorimotor Brain Areas

Fibromyalgia (FM) is a syndrome characterized by chronic pain without known peripheral causes. Previously, we have reported dysfunctional pain inhibitory mechanisms for FM patients during pain administration. In this study we employed a seed correlation analysis, independent component analysis (ICA), and an analysis of fractional amplitude of low frequency fluctuations (fALFF) to study differences between a cohort of female FM patients and an age- and sex-matched healthy control group during a resting-state condition. FM patients showed decreased connectivity between thalamus and premotor areas, between the right insula and primary sensorimotor areas, and between supramarginal and prefrontal areas. Individual sensitivity to painful pressure was associated with increased connectivity between pain-related regions (e.g., insula and thalamus) and midline regions of the default mode network (including posterior cingulate cortex and medial prefrontal cortex) among patients and controls. However, neither ICA nor fALFF revealed any group differences. Our findings suggest that abnormal connectivity patterns between pain-related regions and the remaining brain during rest reflect an impaired central mechanism of pain modulation in FM. Weaker coupling between pain regions and prefrontal- and sensorimotor areas might indicate a less efficient system level control of pain circuits. Moreover, our results show that multiple, complementary analytical approaches are valuable for obtaining a more comprehensive characterization of deviant resting-state activity. In conclusion, our findings show that FM primarily is associated with decreased connectivity, for example, between several pain-related areas and sensorimotor regions, which could reflect a deficiency in pain regulation.

Resistance exercise improves muscle strength, health status and pain intensity in fibromyalgia—a randomized controlled trial

IntroductionFibromyalgia (FM) is characterized by persistent widespread pain, increased pain sensitivity and tenderness. Muscle strength in women with FM is reduced compared to healthy women. The aim of this study was to examine the effects of a progressive resistance exercise program on muscle strength, health status, and current pain intensity in women with FM.MethodsA total of 130 women with FM (age 22–64 years, symptom duration 0–35 years) were included in this assessor-blinded randomized controlled multi-center trial examining the effects of progressive resistance group exercise compared with an active control group. A person-centred model of exercise was used to support the participants’ self-confidence for management of exercise because of known risks of activity-induced pain in FM. The intervention was performed twice a week for 15 weeks and was supervised by experienced physiotherapists. Primary outcome measure was isometric knee-extension force (Steve Strong®), secondary outcome measures were health status (FIQ total score), current pain intensity (VAS), 6MWT, isometric elbow-flexion force, hand-grip force, health related quality of life, pain disability, pain acceptance, fear avoidance beliefs, and patient global impression of change (PGIC). Outcomes were assessed at baseline and immediately after the intervention. Long-term follow up comprised the self-reported questionnaires only and was conducted after 13–18 months. Between-group and within-group differences were calculated using non-parametric statistics.ResultsSignificant improvements were found for isometric knee-extension force (p = 0.010), health status (p = 0.038), current pain intensity (p = 0.033), 6MWT (p = 0.003), isometric elbow flexion force (p = 0.02), pain disability (p = 0.005), and pain acceptance (p = 0.043) in the resistance exercise group (n = 56) when compared to the control group (n = 49). PGIC differed significantly (p = 0.001) in favor of the resistance exercise group at post-treatment examinations. No significant differences between the resistance exercise group and the active control group were found regarding change in self-reported questionnaires from baseline to 13–18 months.ConclusionsPerson-centered progressive resistance exercise was found to be a feasible mode of exercise for women with FM, improving muscle strength, health status, and current pain intensity when assessed immediately after the intervention.Trial registrationClinicalTrials.gov identification number: NCT01226784, Oct 21, 2010.

But I know what works - patients' experience of spinal cord injury neuropathic pain management

Purpose: To explore and obtain increased knowledge about (i) strategies and treatments used by individuals with neuropathic pain following spinal cord injury (SCI) for handling long-term pain, and (ii) their experience, needs and expectations of SCI neuropathic pain management. Methods: Qualitative methods with an emergent research design were used. Eighteen informants who suffered from long-term SCI neuropathic pain participated. Data were collected with diaries and thematized research interviews. Content analysis and constant comparison according to grounded theory were used for the analyses. Results: A model with four categories emerged: “Pain is my main problem” explained the impact of pain in the informants’ everyday life; “Drugs – the health care solution” described the informants’ experience of pain management; “The gap in my meeting with health care” described the discrepancy between what the informants wanted and what health care could offer. “But…this works for me” described treatments and strategies, which the informants found helpful for pain control and pain relief. Conclusion: Neuropathic pain, one of the major problems following SCI, is difficult to treat successfully. To improve treatment outcome, health care needs to listen to, respond to and respect the patient’s knowledge, experience and wishes. Future research needs to address treatments that patients find effective. Implications for Rehabilitation Patients’ experiences, knowledge and preferences need to be taken into account when designing pain management. Complementary treatments (non-pharmacological) ought to be an important part of successful neuropathic pain management.

Holistic group rehabilitation - a short cut to adaptation to the new life after mild acquired brain injury

Purpose. The purpose was to explore and understand what patients with mild acquired brain injury ((mABI)) consider is effective in a holistic therapy group rehabilitation programme and how the programme affects the rehabilitation process. Methods. Thematic interviews were conducted with ten informants with diagnosed mABI. They were recruited through purposive sampling after completing a group rehabilitation programme. The data were analysed using a constant comparative method. Results. The programme provided the informants with awareness of their difficulties in daily life. They were thus motivated to develop compensatory strategies for better function. The core category ‘process of change’ and four sub-categories were defined: ‘the group process’, ‘the individual’, ‘family’ and ‘work’. These describe how the programme supported illness management strategies, e.g. setting and maintaining boundaries, coping with and accepting the hard facts of disability. Body awareness training was important. Work capacity was regarded as a measure of recovery. Social relations concentrated on meaningful exchanges. Conclusion. When meeting patients with mABI it is important to consider that, despite apparently well functioning; they might suffer from disabling symptoms that affect performance of daily life. A holistic group rehabilitation programme with integrated information properly provides a short cut to facilitating awareness and adjustment.

Comparison of the Levels of Pro-Inflammatory Cytokines Released in the Vastus Lateralis Muscle of Patients with Fibromyalgia and Healthy Controls during Contractions of the Quadriceps Muscle – A Microdialysis Study

Objective Fibromyalgia is associated with central hyperexcitability, but it is suggested that peripheral input is important to maintain central hyperexcitability. The primary aim was to investigate the levels of pro-inflammatory cytokines released in the vastus lateralis muscle during repetitive dynamic contractions of the quadriceps muscle in patients with fibromyalgia and healthy controls. Secondarily, to investigate if the levels of pro-inflammatory cytokines were correlated with pain or fatigue during these repetitive dynamic contractions. Material and Methods 32 women with fibromyalgia and 32 healthy women (controls) participated in a 4 hour microdialysis session, to sample IL-1β, IL-6, IL-8, and TNF from the most painful point of the vastus lateralis muscle before, during and after 20 minutes of repeated dynamic contractions. Pain (visual analogue scale; 0–100) and fatigue Borg’s Rating of Perceived Exertion Scale; 6–20) were assessed before and during the entire microdialysis session. Results The repetitive dynamic contractions increased pain in the patients with fibromyalgia (P < .001) and induced fatigue in both groups (P < .001). Perceived fatigue was significantly higher among patients with fibromyalgia than controls (P < .001). The levels of IL-1β did not change during contractions in either group. The levels of TNF did not change during contractions in patients with fibromyalgia, but increased in controls (P < .001) and were significantly higher compared to patients with fibromyalgia (P = .033). The levels of IL-6 and IL-8 increased in both groups alike during and after contractions (P’s < .001). There were no correlations between pain or fatigue and cytokine levels after contractions. Conclusion There were no differences between patients with fibromyalgia and controls in release of pro-inflammatory cytokines, and no correlations between levels of pro-inflammatory cytokines and pain or fatigue. Thus, this study indicates that IL-1β, IL-6, IL-8, and TNF do not seem to play an important role in maintenance of muscle pain in fibromyalgia.

Normalization of aberrant resting state functional connectivity in fibromyalgia patients following a three month physical exercise therapy

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

On parallel tracks: newly home from hospital—people with stroke describe their expectations

Purpose: This study aimed to investigate how stroke survivors describe their expectations regarding life when coming home, and how these expectations were met on discharge from the rehabilitation clinic and during their first 3 months at home.Method: Semistructured interviews were performed repeatedly with five people, two women and three men, during 3 months around their discharge from hospital. Fifteen interviews were performed and analyzed using content analysis.Results: On discharge from the rehabilitation clinic, the informants described experience of being at a dividing line between the safety of the ward and the unknown at home. Expectations for improvement were high. A few weeks later, they described being on parallel tracks in life, waiting for improvement and adjusting to life at home. Three months after discharge, they were still waiting for improvement and had begun to realize that life might never be the same as before the stroke.Conclusions: Patients after stroke may have high, sometimes unrealistic expectations of recovery at discharge. Health care professionals need to support patients in adjusting to real life by balancing high expectations with realistic views on the prognosis, this to enhance the rehabilitation process. Practicing at home or in a home-like environment is one way to highlight capacity and personal resources. Implications for Rehabilitation Expectations on discharge and homecoming are an important issue for discussion between patients with stroke, significant others and health professionals. Patients and significant others would benefit from a realistic prognosis and indications of possible rehabilitation effects in connections with discharge. It is suggested that practicing at home or in a home-like environment before discharge is a natural part of the rehabilitation process.

Fibromyalgia patients had normal distraction related pain inhibition but cognitive impairment reflected in caudate nucleus and hippocampus during the Stroop Color Word Test.

The mechanisms causing cognitive problems in chronic pain patients are not well understood. We used the Stroop color word task (SCWT) to investigate distraction-induced analgesia, cognitive performance, and cerebral activation patterns in 29 fibromyalgia (FM) patients (mean age 49.8 years, range 25–64 years) and 31 healthy controls (HC) (mean age 46.3 years, range 20–63 years). In the first study, SCWT was used to investigate distraction-induced analgesia in FM patients. Two versions of the task were applied, one with only congruent color-word images and one with incongruent images. Pressure pain thresholds were assessed using a pressure algometer before, during, and following SCWT. In the second study, reaction times (RTs) were assessed and functional magnetic resonance imaging (fMRI) was used to investigate cerebral activation patterns in FM patients and HC during the SCWT. An event-related task mixing incongruent and congruent images was used. In study one, we found reduced pressure pain sensitivity during SCWT in both groups alike and no statistically significant differences were seen between the incongruent and congruent conditions. The study two revealed longer RTs during the incongruent compared to the congruent condition in both groups. FM patients had longer RTs than HC in both conditions. Furthermore, we found a significant interaction between group and congruency; that is, the group differences in RTs were more pronounced during the incongruent condition. This was reflected in a reduced activation of the caudate nucleus, lingual gyrus, temporal areas, and the hippocampus in FM patients compared to HC. In conclusion, we found normal pain inhibition during SWTC in FM patients. The cognitive difficulties seen in FM patients, reflected in longer RTs, were related to reduced activation of the caudate nucleus and hippocampus during incongruent SCWT, which most likely affected the mechanisms of cognitive learning in FM patients.