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- Karlsson, Linn, 1974-
(författare)
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Chronic Pain and Exercise : Studies on pain intensity, biochemistry, adherence and attitudes
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Chronic pain is common in western countries and entails considerable consequences for the afflicted individuals as well as for the society. Furthermore, chronic pain is complex including an advanced interplay between biological-, psychological- and social aspects. Treatment of chronic pain attempts to decrease pain intensity and increase physical-, psychological- and social functioning. However, the treatment of chronic pain is still not optimized. Different types of physical activity and exercise (PA&E) are commonly applied as non-pharmacological treatment strategies for chronic pain, but the most efficient type and dose of PA&E are unclear. In addition, adherence to prescribed PA&E is often troublesome, which further complicates the application of PA&E as treatment for chronic pain.The aim of this thesis is to increase the knowledge about PA&E as treatment for chronic pain regarding pain intensity, biochemical substances, adherence and attitudes.The findings of this thesis were that a long-term, home-based PA&E intervention comprising strength exercises as well as stretch exercises decreased pain intensity and increased function in women with chronic neck- and shoulder pain. Using microdialysis technique, differences in pain modulatory biochemical substances were found, before the intervention, in painful trapezius muscle compared to pain-free trapezius muscle. In addition, alterations in pain modulatory substances in painful trapezius muscle after the intervention were found, which possibly could imply peripheral physiological effects of PA&E. Furthermore, psychological factors could be associated to the effects of and adherence to the PA&E intervention. An intention to be physically active were expressed by patients with chronic pain, but a discordance between the intention and PA&E-behaviour were evident, even though the PA&E were experienced as valuable.In conclusion, this thesis strengthens the importance of PA&E as treatment for chronic pain. Especially, this thesis increases the knowledge about; possible peripheral pain inhibitory effects after long-term exercise; how psychological factors might affect the results of PA&E; and also about important behavioural aspects that might affect adherence to prescribed PA&E. This thesis highlights the need of more research on physiological pain inhibitory effects of long-term PA&E in chronic pain. Furthermore, improved methods for ensured adherence to prescribed PA&E are necessary in order to optimize the effect of PA&E as treatment for chronic pain.
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| 2. |
- Lundgren, Johan, 1977-
(författare)
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Behind the Screen : -Internet-Based Cognitive Behavioural Therapy to Treat Depressive Symptoms in Persons with Heart Failure
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- IntroductionThe prevalence of depressive symptoms in persons with heart failure is higher than in age- and gender-matched populations not suffering from heart failure. Heart failure in itself is associated with an unpredictable trajectory of symptoms, a poor prognosis, high mortality and morbidity, and low health-related quality of life (HrQoL). With the addition of depressive symptoms to heart failure the negative health effects increase further. Though the negative consequences of depressive symptoms in heart failure are well known, there is a knowledge gap about the course of depressive symptoms in heart failure and about how to effectively manage these symptoms. Pharmacological treatment with serotonin reuptake inhibitors has not been able to demonstrate efficacy in persons with heart failure. In a few studies, cognitive behavioural therapy (CBT) delivered face-to-face, has demonstrated effects on depressive symptoms in persons with heart failure. However, currently there are barriers in delivering face-to-face CBT as there is a lack of therapists with the required training. As a solution to this, the use of Internet-based CBT (ICBT) has been proposed. ICBT has been shown to be effective in treatment of mild and moderate depression but has not been evaluated in persons with heart failure.AimThe overall aim of this thesis was to describe depressive symptoms over time and to develop and evaluate an ICBT intervention to treat depressive symptoms in persons with heart failure.Design and MethodsThe studies in this thesis employ both quantitative (Studies I, II and III) and qualitative (Studies II and IV) research methods. The sample in Study I (n=611) were recruited in the Netherlands. The participants (n=7) in Study II were recruited via advertisements in Swedish newspapers. Studies III and IV used the same cohort of participants (Study III n=50, Study IV n=13). These participants were recruited via an invitation letter sent to all persons who had made contact with healthcare services in relation to heart failure during the previous year, at the clinics of cardiology or medicine in four hospitals in southeast Sweden.Study I had a quantitative longitudinal design. Data on depressive symptoms was collected at baseline (discharge from hospital) and after 18 months. Data on mortality and hospitalisation was collected at 18 and 36 months after discharge from hospital. Study II employed three differentBehind the Screen2patterns of design, as follows: I) The development and context adaptation of the ICBT program was based on research, literature and clinical experience and performed within a multi-professional team. II) The feasibility of the program from the perspective of limited efficacy and function was investigated with a quantitative pre-post design. III) Participants’ experience of the ICBT program was investigated with a qualitative content analysis. Data on depressive symptoms was collected pre and post intervention. The time used for support and feedback was logged during the intervention, and qualitative interviews were performed with the participants after the end of the intervention. Study III was designed as a randomised controlled trial. A nine-week ICBT program adapted to persons with heart failure and depressive symptoms was tested against an online moderated discussion forum. Data on depressive symptoms, HrQoL and cardiac anxiety was collected at baseline (before the intervention started) and after the end of the intervention (approximately 10 weeks after the start of the intervention). Study IV had a qualitative design to explore and describe participants’ experiences of ICBT. The participants were recruited from within the sample in Study III and all had experience of ICBT. Data collection occurred after the ICBT program ended and was carried out using qualitative interviews by telephone.ResultsThe mean age of the samples used in this thesis varied between 62 and 69 years of age. Concerning the symptom severity of heart failure, most persons reported New York Heart Association (NYHA) class II (40-57%) followed by NYHA class III (36-41%). Ischaemic heart disease was the most common comorbidity (36-43%). The vast majority had pharmacological treatment for their heart failure. Six percent of the persons in Study I used pharmacological antidepressants. In Studies II and III, the corresponding numbers were 43% and 18% respectively.Among persons hospitalised due to heart failure symptoms, 38% reported depressive symptoms. After 18 months, 26% reported depressive symptoms. Four different courses of depressive symptoms were identified: 1) Non-depressed 2) Remitted depressive symptoms. 3) Ongoing depressive symptoms. 4) New depressive symptoms. The highest risk for readmission to hospital and mortality was found among persons in the groups with ongoing and new depressive symptoms.A nine-week ICBT program consisting of seven modules including homework assignments on depressive symptoms for persons with heart failure was developed and tested. The RCT study (Study III) showed no significant difference in depressive symptoms between ICBT and a moderated discussion forum. Within-group analysis of depressive symptoms demonstrated a significant decrease of depressive symptoms in the ICBT group but not in the discussion forum group.The participants’ experience of ICBT was described in one theme: ICBT- an effective, but also challenging tool for self-management of health problems. This theme was constructed based on six categories: Something other than usual healthcare; Relevance and recognition; Flexible, understandable and safe; Technical problems; Improvements by live contact; Managing my life better.ConclusionAfter discharge from hospital, depressive symptoms decrease spontaneously among a large proportion of persons with heart failure, though depressive symptoms are still common in persons with heart failure that are community dwelling. Depressive symptoms in persons with heart failure are associated with increased risk of death and hospitalisation. The highest risks are found among persons with long-term ongoing depressive symptoms and those developing depressive symptoms while not hospitalised.ICBT for depressive symptoms in heart failure is feasible. An intervention with a nine-week guided self-help program with emphasis on behavioural activation and problem-solving skills appears to contribute to a decrease in depressive symptoms and improvement of HrQoL.When ICBT is delivered to persons with heart failure and depressive symptoms the participants requests that the ICBT is contextually adapted to health problems related to both heart failure and depressive symptoms. ICBT is experienced as a useful tool for self-care and something other than usual healthcare. ICBT also requires active participation by the persons receiving the intervention, something that was sometimes experienced as challenging.
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| 3. |
- Zarenoe, Reza, 1969-
(författare)
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Tinnitus in Patients with Sensorineural Hearing Loss : Management, Quality of Life and Treatment Strategies
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Approximately 15% of Swedish people experience tinnitus, but only 2.4% experience severe problems. Treatment modalities for tinnitus vary, but the most common treatment is counseling. The majority of patients with tinnitus report some degree of hearing loss, and hearing aids have been used for many years in patients who suffer from both tinnitus and hearing impairment. The aim of the present thesis was to investigate disease management, determine quality of life and identify treatment strategies for patients with tinnitus and sensorineural hearing loss.The first two studies described here are retrospective, descriptive studies of patients who sought care for tinnitus and hearing loss at two Ear-Nose-Throat (ENT) clinics in Östergötland County, Sweden, during the years 2004 - 2007. Study I showed that 70% of the cohort had tinnitus; however, many did not initially receive a diagnosis of tinnitus. Information about vertigo, heredity for hearing loss and tinnitus, diabetes history, cardiovascular disease history and other factors related to health was often missing from the patients’ medical records. The results could show that the overall scores using the Tinnitus Handicap Inventory (THI) were higher in female patients than in male patients. Although it is likely that hearing aids would be beneficial for the majority of these patients, 314 (44%) of the 714 total patients had hearing aids. Furthermore, the outcomes from study II demonstrated that a majority of the patients (61%) who were dissatisfied with the care they had obtained had no hearing aids. This finding may indicate that the fitting of hearing aids is an important treatment for patients with both tinnitus and hearing loss.Studies III and IV were prospective studies. Data collection was based on patients who sought care for tinnitus and/or hearing loss at the ENT clinic in Linköping during 2012-2013. In study III, 92 patients were divided into two groups: one group contained individuals with both tinnitus and hearing loss, and the other group contained patients with only hearing loss. The patients were assessed using the Reading Span test, the Hearing in Noise Test (HINT) and three questionnaires (the THI, the Hearing Handicap Inventory for Elderly and the Pittsburg Sleep Quality Index) at baseline and follow-up. The results from the age-matched subgroups (n=30+30) generated from the full clinical groups (46+46) showed significantly improved Reading Span test performance and sleep quality in patients with both tinnitus and hearing loss. Similar results were observed in our full clinical population (n=46+46). However, the interpretation of this finding is difficult due to age differences between the groups. In conclusion, hearing aid fitting had a significantly positive impact on working memory capacity and sleep quality in patients with both tinnitus and hearing loss compared with patients with only hearing loss.In study IV, a brief Motivational Interviewing (MI) guide was integrated into the hearing rehabilitation process for 23 patients with both tinnitus and hearing loss, and they were compared against a control group (n=23) of patients with both tinnitus and hearing loss who underwent traditional hearing rehabilitation. The results showed that the patients who received the brief MI guide required fewer visits to complete their hearing rehabilitation compared with the patients in the control group. In addition, there was a significant difference in THI scores between the groups, which indicated that the intervention reduced tinnitus annoyance more in the MI group. Furthermore, both groups showed higher scores at follow-up compared with baseline on the International Outcome Inventory for Hearing Aids (IOI-HA) scale, which indicated that both approaches showed a positive effect on hearing aid satisfaction.Study V was a retrospective, descriptive study that focused on a part of a Stepped Care model and included patients who participated in half-day tinnitus information meetings from 2004 to 2011 in the audiology clinic at Linköping University Hospital. A total of 426 tinnitus patients with complete questionnaires (the THI and the Hospital Anxiety and Depression Scale, HADS) were included in the study. The results showed significant decreases in scores on the THI and the anxiety module of the HADS before and after the information session. However, there were no statistically significant changes in the depression module of the HADS.In conclusion, this thesis underscores the importance of hearing impairment, cognitive variables and motivational procedures in the management of tinnitus. Multidisciplinary group information needs to be further validated.
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