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- Gunnarsson, Stina, 1980-
(author)
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What makes a patient satisfied with intrathecal baclofen treatment for spasticity : Expectations and experiences
- 2022
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Doctoral thesis (other academic/artistic)abstract
- Patients often report reduced spasticity and/or pain, improved function and comfort, and a high level of satisfaction after treatment with intrathecal baclofen (ITB). However, dissatisfaction, complications and unmet goals are also reported. The overall aim of the thesis was to identify, describe, and analyse what makes a patient satisfied with the effect of ITB treatment for spasticity, by considering patient expectations, experience, outcome, as well as satisfaction with treatment. Four studies are included, all focusing on patients undergoing ITB treatment or about to start treatment. Study I, a qualitative interview study, describes the experiences of 14 patients on ITB from one university hospital. Study II, a cross-sectional study, includes 6 of the 7 main hospitals in Sweden working with ITB treatment. Through questionnaires and medical records, data were collected from 83 patients, on general expectations/optimism, satisfaction with treatment and reports on complications. Study III is based on data from study II on baclofen doses for 81 patients to analyse the development of dose patterns. Study IV, a prospective longitudinal study, includes 29 patients from 2 university hospitals. Data collection focused on pre-expectations, effect at 1-year follow-up and satisfaction with treatment. The results of the thesis are summarized in 3 topics: (1) variables of interest for formulation of patients’ pre-expectations; (2) pre-expectations of outcome and ongoing ITB treatment; (3) outcomes and satisfaction with ITB treatment. Together, those topics describe what makes a patient satisfied with ITB treatment. Patients reported improvements in symptoms and reduced consequences from spasticity, however improvements were not always as good as expected. Reported satisfaction with ITB treatment varied in the 4 studies, but mostly a high level of satisfaction was reported. Variables of importance for satisfaction were improved occupational performance, pre-expectations met and initial status regarding occupational performance. In conclusion, results from this thesis emphasize the need for a dialogue between the patient and health care professionals to enable the formulation of realistic individual pre-expectations and goals. In addition, unmet pre-expectations, complications and frequent hospital visits should be included in the discussion about the benefits of ITB treatment versus the disadvantages.
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| 2. |
- Wiklund, Tobias, 1986-
(author)
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Insomnia Symptoms in Chronic Pain : Clinical presentation, risk and treatment
- 2021
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Doctoral thesis (other academic/artistic)abstract
- In recent years, chronic and recurrent pain have gained interest as distinct conditions interacting both with peripheral and central parts of the nervous system as well as with the immune system. The risk of getting affected by abnormal pain modulation i.e., chronic pain is not equally distributed in the population and the search for risk factors is therefore of interest. One potential risk factor for chronic pain is insomnia symptoms i.e., difficulties falling asleep or maintaining sleep. In turn, insomnia symptoms are overrepresented in persons with chronic pain. Common current pain treatments lead to limited improvement of insomnia symptoms calling for treatments specifically directed to improve sleep. The overall aim of this thesis is therefore to investigate the distribution of insomnia severity in patients seeking specialized care for chronic pain, to investigate the role of insomnia severity as a risk factor for spreading of pre-existing pain, and to evaluate potential treatments for insomnia symptoms comorbid to chronic pain.Study I highlighted the high prevalence rates of insomnia symptoms in patients with chronic pain conditions. Roughly, insomnia was six times more common in our sample compared to the general population. We also showed that there were weak connections between insomnia symptoms and other variables (primarily psychological symptoms and pain intensity). In Study II physical exercise was more efficacious than Acceptance and Commitment Therapy-based stress management and the active control group in reducing insomnia symptoms and pain intensity short term. Improvements in physical exercise were largely maintained after twelve months but pain intensity had then also declined in the control group. No improvements in the Acceptance and Commitment Therapy-based stress management remain significant when an intention to treat principles were applied. In Study III, a dose-dependent increase in risk for spreading of pain was confirmed in subjects reporting moderate and severe insomnia symptoms. Though, there was no increase in the risk of pain spreading in subjects reporting sub-threshold insomnia symptoms (according to Insomnia Severity Index). In Study IV patients in the Internet-delivered Cognitive Behavioural Therapy for insomnia group, showed a more rapid improvement in insomnia symptoms than patients in the internet-delivered applied relaxation. The effect of Cognitive Behavioural Therapy for insomnia had declined slightly after six months and the Applied Relaxation group had continued to improve, leading to a comparable outcome on the Insomnia Severity Index at six-month follow-up.In conclusion, insomnia symptoms are common in patients seeking specialized pain care. High levels of insomnia symptoms increase the risk of spreading of pre-existing pain and this in a dose-dependent manner. Physical exercise has significant, but not clinically meaningful effects on pain intensity and insomnia symptoms. Internet-delivered Cognitive Behavioral Therapy for insomnia leads to a more rapid reduction of insomnia symptoms compared to applied relaxation, although long-term effects are uncertain
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| 3. |
- Bendelin, Nina, 1980-
(author)
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Internet-Delivered Acceptance and Commitment Therapy for Chronic Pain : Feasibility, patients’ experiences and implementation process
- 2023
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Doctoral thesis (other academic/artistic)abstract
- Chronic pain represents a major burden for individuals and society. Internet-delivered psychological interventions are evidence-based treatments that enable patients to access qualified care at a time and place convenient for them. Internet-delivered Acceptance and commitment therapy (IACT) has shown promising treatment effects for chronic pain patients on pain-related outcomes such as disability, pain intensity, and interference, and on psychological outcomes such as catastrophizing, fear-avoidance and acceptance. Interdisciplinary pain rehabilitation programs (IPRP) are multimodal interventions given by synchronized teams of health care professionals from different disciplines. With moderate treatment effects on many outcomes, IPRP is the best evidence treatment for chronic pain to date. IACT may add to IPRP’s effectiveness by providing individual psychological treatment via the internet. However, IACT has not yet been implemented in routine care in a larger scale. In this thesis, the aim was to study if IACT may be acceptable for chronic pain patients and if it is feasible and effective as an addition to IPRP. Three methodological approaches were used: qualitative analysis, implementation science and a controlled trial of effectiveness in a clinical context. Study I showed that an internet-delivered aftercare intervention enabled chronic pain patients to change their perception of their body and pain and their attitude about their future and self. Furthermore, self-motivating goals and acceptance strategies appeared to influence autonomy. The results gave promise to the feasibility of IACT as aftercare following IPRP. Study II showed that chronic pain patients’ experiences of IACT vary, with respect to being in treatment and the consequences of treatment. Specifically, e-therapist feedback and deadlines for homework may have an impact on autonomy and change. Patients’ expectations, motivations, and restraints could explain treatment engagement and experiences. In Study III, IACT added during IPRP enhanced the treatment effects on pain acceptance and affective distress. Furthermore, IACT added as aftercare strengthened the long-term effect of IPRP on psychological flexibility and self-efficacy. However, unsatisfactory completion rates complicated the interpretation of the findings. Study IV showed that implementing IACT in an IPRP setting may be facilitated by contextual alinement and modifications based on patients’ needs. Thorough testing of the application and matching the intervention’s aim with the host’s needs are important not to challenge the process. An implementation framework may ease planning and evaluation of implementation processes. In conclusion, IACT could be feasible as an addition to IPRP. IACT can help chronic pain patients self-manage their pain and improve pain acceptance and self-efficacy. However, chronic pain patients’ varying experiences may need to be considered to improve treatment engagement and help patients benefit from treatment. In addition, implementation of IACT in IPRP settings is likely to depend on both flexibility to changing host needs and continuity of known pivotal components in IACT.
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