Patients with chronic pain : quantitative and qualitative studies of treatment or rehabilitation at a pain clinic

Background and aim: Chronic pain is a major problem, often with comorbidity of insomnia, mental disorders and limitations in function, activity and participation, all leading to poor quality of life. Patients describe their pain as unpredictable and ‘invisible’ thus influencing being and communication. Patients with chronic pain are treated in primary care, pain clinics and rehabilitation units. Pain-clinic patients represent a wide range of diagnoses and knowledge of these settings is limited. The overall aim of the work presented in this thesis was to explore aspects of living with chronic pain among patients attending a pain clinic.

Methods and results: Three studies resulting in four papers were performed at a pain clinic where patient-adapted treatment alternatives included conventional, mainly pharmacological, pain treatment (CPT) and a team-based multimodal rehabilitation programme (MMR).

In Study I, interviews with 14 informants (13 female, age 23-77) who had participated in MMR one year earlier were analysed using content analysis. The core theme “Change is possible” and the themes “A life ruled by pain” (the situation before rehabilitation), “The penny’s dropped” (experience during rehabilitation) and “Live a life, not only survive” (the situation at the time of the interviews) emerged from the data. The process describes how the informants could integrate earlier disabling symptoms into a well-functioning lifestyle (Paper I).

Study II was a longitudinal, observational study of patients assessed and treated. Patientreported outcome measures (PROM) of health-related quality of life (EQ-5D), pain (VAS), anxiety and depression (HADS), insomnia (ISI), pain related disability (PDI), kinesiophobia (TSK) and sense of coherence (SOC) were collected at the first visit and one year later. Data were analysed according to the treatment alternatives: MMR-group (n= 42) (Paper II) and CPT-group (n=271) as well as patients assessed and referred (AOgroup, n=47) (Paper III). The baseline showed substantial problems in PROM with the worst state in the MMR-group. Significant improvements (p <0.05) were found in the follow-up of both treatment groups in EQ-5D, ISI, PDI and TSK in the MMR-group. The CPT-group improved also in VAS, while the AO-group did not change.

Study III: In this qualitative study 13 women with painful endometriosis, treated with CPT, were included. Sixteen interviews were analysed according to grounded theory. The theory as developed describes the experience of endometriosis and its treatment in the core category. “Surviving painful endometriosis, struggle for coherence”, formed from the categories “Woman with painful endometriosis”, “Dependence” and “A ruined life”.

Conclusions: The analysis of interviews and questionnaires of patients with chronic pain at a pain clinic showed congruent findings: complex suffering, with significant influence of the pain condition on living and health. In the follow-up of minor or comprehensive interventions, improvement was found in several outcomes and patients described a change to a well-functioning life. However, ongoing problems remained, pointing to the chronicity of the condition. To live a good life with chronic pain requires the sufferer to understand her or his situation, to use functional coping strategies and to find support in significant others and health care, thus integrating the chronic condition.

List of scientific papers

I. Hållstam, A., Stålnacke, BM., Svensén, C., Löfgren, M. (2015). 'Change is possible': Patients' experience of a multimodal chronic pain rehabilitation programme. Journal of Rehabilitation Medicine. 47:242-248.
https://doi.org/10.2340/16501977-1926

II. Hållstam, A., Löfgren, M., Svensén, C., Stålnacke, BM. (2016). Patients with chronic pain: One-year follow-up of a multimodal rehabilitation programme at a pain clinic. Scandinavian Journal of Pain. 10:36-42.
https://doi.org/10.1016/j.sjpain.2015.08.008

III. Hållstam, A., Löfgren, M., Benson, L., Svensén, C., Stålnacke, BM. Assessment and treatment at a pain clinic: One- year follow-up of patients with chronic pain. Scandinavian Journal of Pain. Epub ahead of print 9-Sep-2016.
https://doi.org/10.1016/j.sjpain.2016.08.004

IV. Hållstam, A., Stålnacke, BM., Svensén, C., Löfgren, M. 'Tears included' – women's experience of painful endometriosis and its treatment. [Manuscript]