The meanings of pain: an exploration of women's descriptions of symptoms

Gendered Worlds of Pain: Women, Marginalization, and Chronic Pain

The importance of gender is undertheorized in chronic pain research, meaning extant research cannot sufficiently shed light on how chronic pain experience and treatment are connected to institutions and societal structures. Much literature on gender and pain is not critical in orientation, making it difficult to translate data into recommendations for improved treatment and care. Our study takes a critical approach informed by social theory to understand chronic pain among women who experience socioeconomic marginalization. Drawing on a gender-based subanalysis of interview data collected in Canada as part of an institutional ethnography of chronic pain among people who are socioeconomically marginalized, from women's narratives, we identified 4 themes that speak to gender, chronic pain, and marginalization. These are 1) gendered minimization of women's health concerns, 2) managing intergenerational poverty, 3) living with violence and trauma, and 4) gendered organization of family care. Together, these themes highlight how women's experiences of chronic pain and marginalization amplify gendered vulnerabilities in health care, social services, and society in general. Our findings depict a deeply gendered experience of chronic pain that is inseparable from the daily struggle of managing one's life with pain with heavy responsibilities, the baggage of past trauma, and responsibility for others with few resources. We emphasize the importance of chronic pain care and health and social services that are both gender- and trauma-informed. PERSPECTIVE: This article draws on an institutional ethnography (a holistic qualitative methodology) of chronic pain and socioeconomic marginalization to demonstrate the importance of chronic pain care and health and social services that are both gender- and trauma-informed.

Different logics of pain: the gendered dimension of chronic pain in a relational setting

This study aims to increase our understanding of the gendered dimension of living with chronic pain within a relational context. The empirical setting for this study is Sweden, a country widely recognised for its long history of gender equality. Interview responses from 21 women and 12 men were analysed using the feminist notion of the marriage contract, outlining the terms for women and men living together in a relationship. The result shows how living with chronic pain leads to processes of grief and altered priorities. Respondents emphasize the importance of equality. However, men and women apply different logics when deciding which tasks to prioritise. Although there is no distinct pattern regarding whether or not couples share housework equally, the allocation of responsibilities appears to follow a particular pattern: men tend to prioritise their rehabilitation to become good fathers, women are grateful and prioritise the family before her own well-being. The study indicates that while attitudes and the allocation of household chores may have changed in the past few decades, the marriage contract still restricts women from employment and rehabilitation.

Clinical encounters may not be responding to patients' search for meaning and control over non-specific chronic low back pain - an interpretative phenomenological analysis

PURPOSE

Considering the need to study the experiences of individuals with musculoskeletal problems in contexts that have not yet been investigated as well as the relevance of fostering a research agenda towards person-centred care, this study aimed to explore the experiences of non-specific chronic low back pain from the perspective of Portuguese individuals living with it.

MATERIAL AND METHODS

An interpretative phenomenological analysis was employed to explore the experiences of eight participants, who were recruited purposefully from two primary care centres and one clinic. Semi-structured one-to-one interviews were carried out, audio-recorded and transcribed verbatim.

RESULTS

Three themes were generated as interrelated parts of an extended account that explored the participants' meaning making of their experience: "Non-specific chronic low back pain as a disruptive experience"; "Searching for the meaning of non-specific chronic low back pain"; and, "Clinical encounters that perpetuate the lack of understanding about non-specific chronic low back pain."

CONCLUSIONS

This study offers insight into the Portuguese individuals' experiences of non-specific chronic low back pain. Particularly, it suggests that clinical encounters may not be aligned with patients' needs and expectations. These findings may help clinicians in transferring this knowledge to therapeutic approaches to individuals with similar experiences/contexts.IMPLICATIONS FOR REHABILITATIONPatients with NSCLBP need to understand their pain and to retain a sense of control over their lives.Encounters with health professionals may perpetuate the lack of understanding about pain and strategies to control it, as patients consider themselves unable to have an active role in the decision-making and are disempowered to deal with their pain.Health professionals should involve patients and promote the co-construction of an explanation that integrates both health professionals' knowledge and patients' narratives.There is a need to align both the patients' and health professionals' perspectives regarding health care in order to implement patient-centred and individually tailored treatment.

Measurement of Pain and Related Symptoms in Irritable Bowel Syndrome: The Use of Validated Pain Measurement Tools

This paper reviews the tools available to assess outcomes of treatment in irritable bowel syndrome, especially the effect on abdominal pain. Tools were identified through a wide-ranging scrutiny of PubMed and Google Scholar, together with a review of further references quoted in those publications. It critically considers their development, relevance and reliability. The Irritable Bowel Severity Scoring System (IBS-SSS) was the first simple method of monitoring the progress of the disease and its treatment. It led on to other instruments, such as The Irritable Bowel Syndrome Quality of Life (IBS-QOL). It is easier to read and faster to complete than the IBS-SSS., However, these and other tools were developed for English speaking populations. This review considers the impact of ethnicity and gender, together with the lack of information on the effect of age on the potential validity of these tools in other populations. Issues with the adequacy and appropriateness of translations of such tools are discussed. The overall conclusion is that there are few tools which meet the criteria necessary to place confidence in their validity as appropriate measures of patient outcomes.

"Because the country, it seems though, has turned their back on me": Experiences of institutional betrayal among veterans living with Gulf War Illness

People living with medically unexplained symptoms (MUS) often have poor quality of life and health outcomes. Many struggle to engage with and trust in healthcare systems. This qualitative study examined how experiences with institutions influence perceptions of medical care for MUS by applying the theoretical framework of institutional betrayal to narratives of U.S. military Veterans living with Gulf War Illness (GWI). Institutional betrayal refers to situations in which the institutions people depend upon for safety and well-being cause them harm. Experiences of institutional betrayal both during active military service and when first seeking treatment appeared to shape perceptions of healthcare in this sample. Veterans expressed the belief that the military failed to protect them from environmental exposures. Veterans' concerns regarding subsequent quality of healthcare were intrinsically linked to a belief that, despite official documentation to the contrary, the predominant paradigm of both the U.S. Department of Defense and the U.S. Department of Veterans Affairs (VA) is that GWI does not exist. Veterans reported that providers are not adequately trained on treatment of GWI and do not believe Veterans' descriptions of their illness. Veterans reported taking up self-advocacy, doing their own research on their condition, and resigning themselves to decrease engagement with VA healthcare or seek non-VA care. The study's findings suggest institutional level factors have a profound impact on perceptions of care and the patient-provider relationship. Future research and policy aimed at improving healthcare for people living with MUS should consider the concept of institutional betrayal.

The gender context of pain

Pain is a major source of global suffering, with women bearing the greatest burden. Alongside biology, psychological and social factors, including gender, help explain these differences. However, there has been no direct attempt to develop a unified social psychological model of men and women's pain. By drawing on approaches to both gender and pain, a gender context model of pain is presented. It proposes that pain is partly influenced by the gender context in which it occurs, which operates at both individual and interpersonal levels. The model is used to structure an appraisal of the existing evidence around gender and pain, and explore whether the model helps explain why such variation occurs. It is argued that despite evidence for an association between gender and pain, there are empirical gaps that need to be addressed. Implications and directions for future investigations into sex, gender and pain are considered.

"You have Endometriosis": Making Menstruation-Related Pain Legitimate in a Biomedical World

In this essay, the author reflects on how biomedical and gendered perceptions of reproductive health can impact an illness experience. Using a narrative lens, she relays the frustration of attempting to have her excessive menstrual pain legitimated and treated when loved ones and medical professionals trivialized it and refused to let her take on the sick role. She recounts incidents that demonstrate the embedded and limiting persistence of gendered perceptions of pain. In the end, she argues that only through strong patient self-advocacy and knowledge can one rewrite the social scripts assigned to how women cope with menstrual pain.

"It Was Not Me That Was Sick, It Was the Building": Rhetorical Identity Management Strategies in the Context of Observed or Suspected Indoor Air Problems in Workplaces

Suffering from a contested illness poses a serious threat to one's identity. We analyzed the rhetorical identity management strategies respondents used when depicting their health problems and lives in the context of observed or suspected indoor air (IA) problems in the workplace. The data consisted of essays collected by the Finnish Literature Society. We used discourse-oriented methods to interpret a variety of language uses in the construction of identity strategies. Six strategies were identified: respondents described themselves as normal and good citizens with strong characters, and as IA sufferers who received acknowledge from others, offered positive meanings to their in-group, and demanded recognition. These identity strategies located on two continua: (a) individual- and collective-level strategies and (b) dissolved and emphasized (sub)category boundaries. The practical conclusion is that professionals should be aware of these complex coping strategies when aiming to interact effectively with people suffering from contested illnesses.

The experience of living with patellofemoral pain-loss, confusion and fear-avoidance: a UK qualitative study

OBJECTIVES

To investigate the experience of living with patellofemoral pain (PFP).

DESIGN

Qualitative study design using semistructured interviews and analysed thematically using the guidelines set out by Braun and Clarke.

SETTING

A National Health Service physiotherapy clinic within a large UK teaching hospital.

PARTICIPANTS

A convenience sample of 10 participants, aged between 18 and 40 years, with a diagnosis of PFP and on a physiotherapy waiting list, prior to starting physiotherapy.

RESULTS

Participants offered rich and detailed accounts of the impact and lived experience of PFP, including loss of physical and functional ability; loss of self-identity; pain-related confusion and difficulty making sense of their pain; pain-related fear, including fear-avoidance and 'damage' beliefs; inappropriate coping strategies and fear of the future. The five major themes that emerged from the data were: (1) impact on self; (2) uncertainty, confusion and sense making; (3) exercise and activity beliefs; (4) behavioural coping strategies and (5) expectations of the future.

CONCLUSIONS

These findings offer an insight into the lived experience of individuals with PFP. Previous literature has focused on pain and biomechanics, rather than the individual experience, attached meanings and any wider context within a sociocultural perspective. Our findings suggest that future research is warranted into biopsychosocial targeted interventions aimed at the beliefs and pain-related fear for people with PFP. The current consensus that best-evidence treatments consisting of hip and knee strengthening may not be adequate to address the fears and beliefs identified in the current study. Further qualitative research may be warranted on the impact and interpretation of medical terminology commonly used with this patient group, for example, 'weakness' and 'patellar mal-tracking' and its impact and interpretation by patients.

TRIAL REGISTRATION NUMBER

ISRCTN35272486; Pre-results.

Improving GP communication in consultations on medically unexplained symptoms: a qualitative interview study with patients in primary care

BACKGROUND

Many GPs find the care of patients with medically unexplained symptoms (MUS) challenging. Patients themselves are often not satisfied with the care they receive.

AIM

To explore the problems patients with MUS experience in communication during consultations, with the aim of improving such consultations DESIGN AND SETTING: A qualitative analysis of semi-structured interviews.

METHOD

GP consultations were videorecorded and the GPs were asked immediately afterwards whether MUS were presented. Patients in these MUS consultations were asked to reflect on the consultation in a semi-structured interview while watching a recording of their own consultation.

RESULTS

Of the 393 videorecorded consultations, 43 contained MUS. Patients who did identified six categories of problems. First, they reported a mismatch between the GP's and their own agenda. Second, patients indicated that the GP evoked an uncomfortable feeling in them during the consultation. Third, they found that GPs did not provide a specific management plan for their symptoms. Fourth, patients indicated that the GP was not well prepared for the consultation. Fifth, they perceived prejudices in the GP during the consultation. Finally, one patient found that the GP did not acknowledge a limited understanding of the origin of the symptoms.

CONCLUSION

According to patients, GPs can improve their consultations on MUS by making genuine contact with their patients, by paying more attention to the patient's agenda, and by avoiding evoking uncomfortable feelings and displaying prejudices. They should prepare their consultations and focus on the issues that matter to patients, for example, symptom management. GPs should be honest to patients when they do not understand the origin of symptoms.

"Struggle to obtain redress": Women's experiences of living with symptoms attributed to dental restorative materials and/or electromagnetic fields

The aim of this study was to explore the experiences of illness and the encounters with health care professionals among women who attributed their symptoms and illness to either dental restorative materials and/or electromagnetic fields, despite the fact that research on health effects from dental fillings or electricity has failed to substantiate the reported symptoms. Thirteen women (aged 37-63 years) were invited to the study and a qualitative approach was chosen as the study design, and data were collected using semi-structured interviews. The analysis was conducted with a constant comparative method, according to Grounded Theory. The analysis of the results can be described with the core category, "Struggle to obtain redress," the two categories, "Stricken with illness" and "A blot in the protocol," and five subcategories. The core category represents the women's fight for approval and arose in the conflict between their experience of developing a severe illness and the doctors' or dentists' rejection of the symptoms as a disease, which made the women feel like malingerers. The informants experienced better support and confirmation from alternative medicine practitioners. However, sick-leave certificates from alternative medicine practitioners were not approved and this led to a continuous cycle of visits in the health care system. To avoid conflicting encounters, it is important for caregivers to listen to the patient's explanatory models and experience of illness, even if a medical answer cannot be given.

A synthesis of qualitative research exploring the barriers to staying in work with chronic musculoskeletal pain

PURPOSE

Qualitative research can help to advance our understanding, management and prevention of work disability. Our aim was to integrate qualitative research findings in order to increase our understanding of barriers to stay in work with chronic pain.

METHODS

We searched five electronic bibliographic databases until September 2012, supplemented by citation tracking and hand-searching. We used meta-ethnography to synthesis our findings. Central to meta-ethnography is identifying “concepts” and developing a conceptual model. Concepts were compared and organised into categories.

RESULTS

The following categories can have an impact on the decision to remain in work: struggling to affirm myself as a good worker; balancing life and work in the face of unpredictable symptoms; my work colleagues don't believe me; the system does not facilitate return to work; the battle for legitimacy.

CONCLUSIONS

Our innovation is to present an internationally relevant model based on a conceptual synthesis. This model highlights the adversarial work experience of people with chronic. The papers span 15 years of qualitative research. A significant finding is that these themes continue to pervade the current work environment for those in pain, and this has clear implications for education, social care and policy.

IMPLICATIONS FOR REHABILITATION

People with chronic pain face an adversarial struggle to maintain their credibility at work. Strategies to maintain personal credibility can have an adverse effect on working lives. Changes at a systems level are needed to facilitate continuance and return to work. Cultural changes in the way that we view people with pain would help to keep people in work.

Establishing the (extra)ordinary in chronic widespread pain

Sufferers of chronic illness face delegitimation of their condition and threats to their identities. One way of establishing the legitimacy of their position is for sufferers of chronic illness to emphasize the ‘ordinary’ in their accounts. Sufferers of conditions which are chronic, invisible and contested, such as chronic widespread pain, have the same, and possibly greater, need to legitimize their condition and refute allegations of ‘malingering’ or psychological instability. The article uses interviews with women with chronic widespread pain to illustrate the ways in which the invisible, subjective and everyday nature of chronic pain leads to sufferers experiencing delegitimation of their condition. It suggests that the accounts of women suffering from chronic widespread pain are constructed to portray a positive identity in the face of this experience, particularly through the emphasis on the ‘extraordinary’.

Severe and moderate haemophilia A and B in US females

Haemophilia A and B are rare X-lined hemorrhagic disorders that typically affect men. Women are usually asymptomatic carriers, but may be symptomatic and, rarely, also express severe (factor VIII (FVIII) or factor IX (FIX) <0.01 U mL(-1)) or moderately severe (FVIII/FIX 0.01-0.05 U mL(-1)) phenotypes. However, data on clinical manifestations, genotype and the psychosocial ramifications of illness in severely affected females remain anecdotal. A national multi-centre retrospective study was conducted to collect a comprehensive data set on affected US girls and women, and to compare clinical observations to previously published information on haemophilic males of comparable severity and mildly affected haemophilic females. Twenty-two severe/moderate haemophilia A/B subjects were characterized with respect to clinical manifestations and disease complications; genetic determinants of phenotypic severity; and health-related quality of life (HR-QoL). Clinical data were compared as previously indicated. Female patients were older than male patients at diagnosis, but similarly experienced joint haemorrhage, disease- and treatment-related complications and access to treatment. Gynaecological and obstetrical bleeding was unexpectedly infrequent. F8 or F9 mutations, accompanied by extremely skewed X-chromosome inactivation pattern (XIP), were primary determinants of severity. HR-QoL was diminished by arthropathy and viral infection. Using systematic case verification of participants in a national surveillance registry, this study elucidated the genetics, clinical phenotype and quality of life issues in female patients with severe/moderate haemophilia. An ongoing international case-controlled study will further evaluate these observations. Novel mechanistic questions are raised about the relationship between XIP and both age and tissue-specific FVIII and FIX expression.

"We all talk about it as though we're thinking about the same thing." Healthcare professionals' goals in the management of pain due to advanced cancer: a qualitative study

PURPOSE

Unfortunately, several barriers impede successful management of cancer pain including those relating to the assessment and measurement of pain. There is currently no consensus as to what constitutes good pain control or what healthcare professionals are aiming to achieve in the management of pain for patients with advanced cancer. This study aimed to explore healthcare professionals' views and experiences to elicit what they are aiming to achieve in managing pain for patients with advanced cancer.

METHODS

Healthcare professionals involved in the management of cancer pain were sampled purposively and interviewed using a semi-structured interview technique until saturation of data. Data were analysed using the constant comparison approach.

RESULTS

Sixteen interviews took place and four main themes emerged: aims of pain management, assessing response to pain management, managing expectations, and building relationships. Healthcare professionals found assessing patients' pain challenging and reported that patients had difficulty using numerical rating scales. Healthcare professionals used different terms when talking about managing pain, such as 'pain control' but found it difficult to define these terms. Maintaining patients' function and managing their expectations were described as important. However, it was not always clear whether the patient goals mentioned were voiced explicitly by the patient or assumed by the healthcare professional.

CONCLUSION

Healthcare professionals described what they deemed important in the management of pain. The goals they mentioned almost exclusively related to function as opposed to pain scores, but patients' goals and expectations were often not elicited specifically.

What do patients with advanced incurable cancer want from the management of their pain? A qualitative study

BACKGROUND

Pain is one of the most frequent symptoms among patients with metastatic cancer, yet little is known about what patients with advanced cancer want from the management of their pain. Measuring the effectiveness of the management of pain is challenging as it is a subjective phenomenon and a multifaceted process. Determining how we currently define whether a patient with pain due to advanced cancer has controlled pain (or not) is important, particularly from the patient's perspective.

AIM

To explore how patients with advanced cancer describe the control of pain and what they want from management of this pain.

DESIGN

Qualitative study using face-to-face interviews. Data were analysed using a constant comparison approach.

SETTING/PARTICIPANTS

Purposive sample of patients with advanced cancer known to palliative care services.

RESULTS

Twelve interviews took place until saturation of data was achieved. Four themes emerged: maintaining role, self and independence; compromising/modifying expectations; role of healthcare professionals; and meaning of pain in context of advanced cancer.

CONCLUSION

Patients determined whether their pain was 'controlled' by whether or not they were able to perform activities or tasks and maintain relationships with family or friends, which determined themselves as individuals. Numerical rating scales did not appear to be useful for patients in measuring whether they are able to perform these activities or maintain a sense of control and independence. Individualised goal/task/role/activity setting for patients with advanced cancer pain may be useful to allow patients themselves to determine what they want from the 'management' of their pain.

Patients' experiences of chronic non-malignant musculoskeletal pain: a qualitative systematic review

BACKGROUND

Musculoskeletal (MSK) pain is one of the most predominant types of pain and accounts for a large portion of the primary care workload.

AIM

To systematically review and integrate the findings of qualitative research to increase understanding of patients' experiences of chronic non-malignant MSK pain.

DESIGN AND SETTING

Synthesis of qualitative research using meta-ethnography using six electronic databases up until February 2012 (Medline, Embase, Cinahl, Psychinfo, Amed and HMIC).

METHOD

Databases were searched from their inception until February 2012, supplemented by hand-searching contents lists of specific journals for 2001-2011 and citation tracking. Full published reports of qualitative studies exploring adults' own experience of chronic non-malignant MSK pain were eligible for inclusion.

RESULTS

Out of 24 992 titles, 676 abstracts, and 321 full texts were screened, 77 papers reporting 60 individual studies were included. A new concept of pain as an adversarial struggle emerged. This adversarial struggle was to: 1) affirm self; 2) reconstruct self in time; 3) construct an explanation for suffering; 4) negotiate the healthcare system; and 5) prove legitimacy. However, despite this struggle there is also a sense for some patients of 6) moving forward alongside pain.

CONCLUSIONS

This review provides a theoretical underpinning for improving patient experience and facilitating a therapeutic collaborative partnership. A conceptual model is presented, which offers opportunities for improvement by involving patients, showing them their pain is understood, and forming the basis to help patients move forward alongside their pain.

A meta-ethnography of patients’ experience of chronic non-malignant musculoskeletal pain

Background

The alleviation of pain is a key aim of health care yet pain can often remain a puzzle as it is not always explained by a specific pathology. Musculoskeletal (MSK) pain is one of the most predominant kinds of chronic pain and its prevalence is increasing. One of the aims of qualitative research in health care is to understand the experience of illness, and make sense of the complex processes involved. However, the proliferation of qualitative studies can make it difficult to use this knowledge. There has been no attempt to systematically review and integrate the findings of qualitative research in order to increase our understanding of chronic MSK pain. A synthesis of qualitative research would help us to understand what it is like to have chronic MSK pain. Specifically, it would help us understand peoples' experience of health care with the aim of improving it.

Aim

The aim of this study was to increase our understanding of patients’ experience of chronic non-malignant MSK pain; utilise existing research knowledge to improve understanding and, thus, best practice in patient care; and contribute to the development of methods for qualitative research synthesis.

Methods

We used the methods of meta-ethnography, which aim to develop concepts that help us to understand a particular experience, by synthesising research findings. We searched six electronic bibliographic databases (including MEDLINE, EMBASE and PsycINFO) and included studies up until the final search in February 2012. We also hand-searched particular journals known to report qualitative studies and searched reference lists of all relevant qualitative studies for further potential studies. We appraised each study to decide whether or not to include it. The full texts of 321 potentially relevant studies were screened, of which 77 qualitative studies that explored adults’ experience of chronic non-malignant MSK pain were included. Twenty-eight of these studies explored the experience of fibromyalgia.

Results

Our findings revealed the new concept of an adversarial struggle that explains the experience of people with chronic MSK pain. This included the struggle to affirm self and construct self over time; find an explanation for pain; negotiate the health-care system while feeling compelled to stay in it; be valued and believed; and find the right balance between sick/well and hiding/showing pain. In spite of this struggle, our model showed that some people were able to move forward alongside their pain by listening to their body rather than fighting it; letting go of the old self and finding a new self; becoming part of a community and not feeling like the only one; telling others about pain and redefining relationships; realising that pain is here to stay rather than focusing on diagnosis and cure; and becoming the expert and making choices. We offer unique methodological innovations for meta-ethnography, which allowed us to develop a conceptual model that is grounded in 77 original studies. In particular, we describe a collaborative approach to interpreting the primary studies.

Conclusion

Our model helps us to understand the experience of people with chronic MSK pain as a constant adversarial struggle. This may distinguish it from other types of pain. This study opens up possibilities for therapies that aim to help a person to move forward alongside pain. Our findings call on us to challenge some of the cultural notions about illness, in particular the expectation of achieving a diagnosis and cure. Cultural expectations are deep-rooted and can deeply affect the experience of pain. We therefore should incorporate cultural categories into our understanding of pain. Not feeling believed can have an impact on a person’s participation in everyday life. The qualitative studies in this meta-ethnography revealed that people with chronic MSK pain still do not feel believed. This has clear implications for clinical practice. Our model suggests that central to the relationship between patient and practitioner is the recognition of the patient as a person whose life has been deeply changed by pain. Listening to a person’s narratives can help us to understand the impact of pain. Our model suggests that feeling valued is not simply an adjunct to the therapy, but central to it. Further conceptual syntheses would help us make qualitative research accessible to a wider relevant audience. Further primary qualitative research focusing on reconciling acceptance with moving forward with pain might help us to further understand the experience of pain. Our study highlights the need for research to explore educational strategies aimed at improving patients’ and clinicians’ experience of care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

"They ask whether this is real or fake": a qualitative norwegian study of pregnancy complaints and access to social benefits

Women increasingly combine paid work and childbearing, but working full time throughout pregnancy is commonly experienced as overtaxing. We explored access to sick leave or medical care as experienced by Norwegian women suffering from pelvic girdle pain during pregnancy. Through a grounded theory approach we compared results from qualitative interviews and open Internet discussions, and found that women struggled with credibility and that their claims for sick leave or medical care were commonly disregarded. Support from peers was seen as instrumental in regaining control over their health and was a vehicle in developing critical health literacy.

Inviting pain? Pain, dualism and embodiment in narratives of self-injury

The role of pain in the practice of self-injury is not straightforward. Existing accounts suggest that self-injury does not cause 'physical' pain, however self-injury is also said to alleviate 'emotional' pain by inflicting 'physical' pain. This article explores these tensions using sociological theories regarding the socio-cultural and subjective nature of pain. Analysis derives from in-depth, life-story interviews carried out in the UK with people who had self-injured. Findings contribute to on-going debates within social science regarding the nature of pain. Participants' narratives about pain and self-injury both drew on and challenged dualistic models of embodiment. I suggest that self-injury offers a unique case on which to extend existing theoretical work, which has tended to focus on pain as an unwanted and uninvited entity. In contrast, accounts of self-injury can feature pain as a central aspect of the practice, voluntarily invited into lived experience.

Primary health-care patients' reasons for complaint-related worry and relief

AIM

Primary care patients are commonly worried about their complaints when consulting their doctor. Knowing the reasons behind patients' worries would enhance consultation practices. The aim of this study was to find out the reasons patients themselves give for their worries before a consultation and for possible relief or persistent worry after the consultation.

BACKGROUND

Our previous study using quantitative methods suggested that worried patients were uncertain about what was wrong with them and they perceived their complaints as serious. These results left some aspects unanswered; for instance, why did the patients consider their complaints severe.

METHODS

We conducted semi-structured interviews of patients, aged 18-39 years, with somatic complaints other than a common cold (n = 40), both before and after a consultation, and the patients described their reasons for worry in their own words. These qualitative data were analysed using thematic content analysis.

FINDINGS

The patients gave as reasons for their worries uncertainty, consequences of their complaints (eg, inability to work), insufficient control (eg, inadequate treatment) and prognosis. The patients were relieved when their uncertainty was diminished by getting an explanation for their complaint or when they achieved more control by getting treatment for their complaint. After a consultation, their reasons for worry, except for concern about the ability to function, tended to be replaced by other reasons. Psychological consequences and mistrust in health care also played a role in persistent worry. Our findings offer support to the patient-centred clinical method in primary care. To address the patients' worries properly, the GP should bring them up for discussion. Special attention should be given to worries about the ability to function, as they tend to persist even after a consultation.

Qualitative pain classification in hospice and pain therapy unit

In this study, we investigated patient's meaning attribution to pain in hospice and pain therapy unit, using a qualitative approach: narrative-based medicine. The data presented here were related to patients (n = 17) hospitalized in Rimini Hospice (Italy). These data were compared to those of patients (n = 21) with noncancer pain (control sample). The interviews were then analyzed according to the technique of thematic narrative analysis. The results of our research identified a differential process in pain processing in relationship to the meaning that the patient attributed to pain. The thematic analysis of the interviews allowed the inductive construction of a specific network of pain dimensions, which were summarized in "the pain chronogram."

Conflicting representations of pain: a qualitative analysis of health care professionals' discourse

INTRODUCTION

Studies regarding health care professionals' representations of pain indicate that doctors and nurses tend to concentrate on the organic origin of pain, and to view pain as subordinate to diagnosis and treatment of the disease; they also tend to underestimate the psychological and psychosocial components of pain, which means that they generally view the patient's subjective experience as secondary. This leads to an underestimation of pain.

OBJECTIVE

The objective of this study was to analyze the representations of pain held by doctors, head nurses, and nurses in two Italian hospitals, focusing on how these representations are shaped according to the local culture in which they are constructed and negotiated.

METHODS

Our study is based on a socio-constructionist approach, drawing on semi-structured, in-depth interviews with 26 health care professionals.

RESULTS

The results show similarities and differences in how health care professionals construct their representations of pain. Three main issues emerged. First, the contents of these representations are strictly related to participants' job position and professional training; second, the representation of pain is significantly influenced by the values and meanings associated with the different professions; and third, there are two conflicting representations of pain, focusing on the objectivity vs the subjectivity of pain, respectively.

CONCLUSIONS

To promote significant change regarding pain management within hospital organizations, it is essential to construct shared representations of the problem and its implications, particularly as regards relations with the patient. This change should take place at the educational as well as the socio-organizational level, and it should take into account ideas and proposals from the subjects involved.

A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation?

PURPOSE

The purpose of this critical review is to describe the available theoretical models for understanding the gender issues in prolonged work disability related to persistent musculoskeletal (MSK) pain.

METHOD

A critical literature review was conducted in medicine, health sciences, and social sciences databases (MEDLINE, CINHAL, PsychINFO and SOCINDEX) using specific keywords. After screening titles and abstracts, followed by methodological quality assessment, a total of 55 references were retained for content analysis.

RESULTS

Gender issues in disability related to persistent MSK pain show that men and women may experience pain and rehabilitation process in different ways. Three main themes were exftracted and further described: (1) the experience of distrust; (2) the self-identity process; and (3) the domestic strain. Each of these themes has a specific and potentially different impact on men and women, and we report that experiential differences may strongly impact the rehabilitation process and outcomes such as return to work.

CONCLUSIONS

This critical review provides insight into gender issues in the process of rehabilitation and outcomes such as return to work. We suggest that work and family considerations are the two most important issues in the rehabilitation process and that differences between men and women are likely to occur.

Health Subjectivities and Labor Market Participation

Decisions around retirement and continued labor market participation are of great significance for those who make them, as well as policy makers, researchers, welfare states, and pension programs. The literature acknowledges the multifaceted nature of these choices and particularly the interaction of key variables—job satisfaction, financial status, caring responsibilities, spouse’s plans, and health. This article explores this latter factor, challenging assumptions that it can be treated as an unproblematic independent variable. Analyzing qualitative data from interviews with 96 people approaching or in the midst of retirement, the subjective experience of health and its effect on decisions was strongly evident. The socialized context—as shaped at societal, organizational, household, and individual-life-historical levels—was crucial in understanding how similar symptoms of morbidity resulted in widely varying decisions/outcomes. Direct interpersonal experiences, shaped by social structures, were useful in explaining the prevalence of health pessimism, despite general increases in life expectancy.

Biographical disruption of injured workers in chronic pain

PURPOSE

This research explored how injured workers living with work-related chronic pain rethink and reconstruct their biographical experience.

METHOD

This qualitative study used a grounded theory approach to data collection and analysis. Semi-structured focus groups were conducted to gather data and analysis was performed by the coding of emergent themes.

RESULTS

Analysis of the focus groups revealed the impact that chronic pain has on the social components of an injured worker's life; particularly their sense of self, their relationship to others and how they perceive themselves in social situations.

CONCLUSIONS

Injured workers experienced changes (physical, psychological and social transformations) that led to biographical disruption; a change in self-identity, which in turn contributed to changes in important relationship dynamics. Injured workers spoke of repeated losses - loss of self, relationships and of the life imagined. Understanding the meaning of these losses could improve the conditions surrounding the injured worker's biographical reconstruction and facilitate the rehabilitation process.

Factors associated with increased pain communication by older adults

The purpose of this secondary analysis study was to identify factors associated with increased pain communication by older adults. Data were obtained from 312 older adults with osteoarthritis pain. Content analysis was conducted using criteria from the American Pain Society's "Guidelines for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis" to identify important pain management information described by the older adults in response to general questions about their pain. Gender was the only factor associated with increased pain communication from the predictor variables of age, education, gender, ethnicity, race, marital status, pain intensity, functional pain interference, treatment from a practitioner for arthritis and for pain, and pain relief. The lack of association between pain communication and factors such as pain intensity suggests that practitioners should routinely elicit specific pain information from older adults who have a history of chronic painful conditions such as osteoarthritis.

Is chronic pain associated with somatization/hypochondriasis? An evidence-based structured review

STUDY DESIGN

This is an evidence-based structured review.

OBJECTIVES

The objectives of this review were to answer the following questions: (1) Are somatization/hypochondriasis associated with chronic pain? (2) Is the degree of somatization/hypochondriasis related to pain levels? (3) Does pain treatment improve somatization/hypochondriasis? (4) Are some pain diagnoses differentially associated with somatization/hypochondriasis?

METHODS

Fifty-seven studies which fulfilled inclusion criteria and had high quality scores were sorted by the above-mentioned objectives. Agency for health care policy and research guidelines were utilized to type and characterize the strength/consistency of the study evidence within each objective.

RESULTS

Somatization and hypochondriasis were both consistently associated with chronic pain (consistency ratings B and A, respectively). Study evidence indicated a correlation between pain intensity and presence of somatization and hypochondriasis (consistency rating A and B, respectively). Pain treatment improved somatization and hypochondriasis (consistency rating B and A, respectively). Some chronic pain diagnostic groups somatized more (consistency rating B).

CONCLUSIONS

Somatization is commonly associated with chronic pain and may relate to pain levels.

Experiences of moving with persistent pain—A qualitative study from a patient perspective

OBJECTIVE

The aim of the present study was to use a phenomenological approach to explore how patients with persistent musculoskeletal pain experienced moving with their pain.

DESIGN

In-depth interviews were performed by a physical therapy researcher with many years' experience with the rehabilitation of patients with persistent musculoskeletal pain.

SETTING

The patients took part in individual rehabilitation at two different physical therapy departments. All but one patient opted to be interviewed in a room at the physical therapy department.

METHOD

The sample was purposive and consisted of 10 Swedish outpatients with heterogeneous nonmalignant persistent musculoskeletal pain.

SUBJECTS

The interviews were analyzed according to a qualitative method known as the Empirical Phenomenological Psychological (EPP) method. The results were coded, analyzed, and described in typologies.

RESULTS

The experience of moving with pain implied much more than pure physical movement. Pain was a threatening challenge to the informants' existence and identity. Three typologies were identified: failed adaptation, identity restoration, and finding the way out.

CONCLUSIONS

In conclusion, to move with persistent pain was described by the informants as having deep existential impact on the individual's life. It was also evident that all of the informants experienced a dramatic change in their identity. These experiences would most likely affect the patients' chances of recovery. To help him/her through the rehabilitation process, we need to extend our knowledge about what it means to the patient in an existential context to be unable to move as before.

Work performance and pain intensity during exercise. A before-and-after study of a cognitive-behavioural treatment in primary care of young immigrant patients

PURPOSE

To explore the efficacy of an exercise programme (EP) in primary care on work performance and pain intensity in young immigrants having pain.

SUBJECTS

Patients on long-term sick leave, aged 20-45 years, categorized by sex and 'high education' (>/=8 years) or 'little education' (0-7 years).

METHODS

The 4-week EP was combined to weekly, patient-doctor, dialogue sessions about pain. Two doctors established the clinical status, explored attitudes to exercise and stationary pain behaviour. The EP included daily sessions of an all-round training (15 exercises on five devices in three rounds) led by a physiotherapist, who neglected dysfunctional behaviours. The target for the training was a good work performance (1.5 points), consisting of endurance during a session (0=one round, 1=two rounds, 2=three rounds) and work behaviour (0=bad, 1=acceptable, 2=good), as well as reduced pain intensity measured on a visual analogue scale. Non-parametric statistics were used to detect significant differences between the before-and-after values.

RESULTS

Forty-four men and 73 women, median education 7 years, participated. Nearly all were immigrants. All had muscular pain; 72% were anxious about the pain and 14% were depressed. At the start, nearly all were negative about exercise but participated anyway and significantly improved their work performance (p<0.001) from very low starting values (in median 0.0). Only the highly educated men reached the target levels. The highly educated persons reported less pain, while some men and women with little education reported more pain. The doctors also noted a significant decline in stationary pain behaviour in all sub-groups.

CONCLUSIONS

A good efficacy regarding work performance and pain intensity was seen only in the highly educated group.

The impact of neuropathic pain on relationships

AIM

This paper is a report of a study exploring the impact of neuropathic pain on family, social and working relationships among patients at a pain clinic serving a large urban area.

BACKGROUND

Neuropathic pain is a particularly distressing type of chronic pain which is extremely difficult to manage successfully. It produces a range of unpleasant symptoms and adversely affects patients' quality of life, but little is known about its personal impact.

METHOD

A descriptive and exploratory approach was used and 10 participants participated in three focus groups in 2005. Because of the low response rate of 20% from the initial sample, a second sample of 16 patients was invited to participate. However, only one person responded and therefore it was not possible to convene an additional group.

FINDINGS

The unpleasant and bizarre nature of neuropathic pain underpinned much of its impact in terms of respondents' difficulties in maintaining a range of relationships. For closer relationships, key difficulties centred on the reduction in quality and/or number of personal relationships. For more distant relationships and those with professionals, frustration at the invisibility of their pain and their own failure to communicate symptoms and its consequences were central.

CONCLUSION

More extensive work is needed to improve our understanding of how neuropathic pain is experienced, how it affects close and more distant kinds of relationships, and how healthcare professionals might best support people with persistent neuropathic pain to maintain personal and social relationships, and to communicate their pain effectively.

Older people's experiences of patient-centered treatment for chronic pain: a qualitative study

INTRODUCTION

Older adults with chronic pain who seek treatment often are in a health care environment that emphasizes patient-directed care, a change from the patriarchal model of care to which many older adults are accustomed.

OBJECTIVE

To explore the experiences of older adults seeking treatment for chronic pain, with respect to patient-directed care and the patient-provider relationship.

DESIGN

In-depth interviews with 15 Caucasian older adults with chronic pain who had been evaluated at a university-based pain clinic. All interviews were audiotaped and the transcripts were analyzed using a grounded theory based approach.

RESULTS

Older adults with chronic pain vary in their willingness to be involved in their treatment decisions. Many frequently participate in decisions about their pain treatment by asking for or refusing specific treatments, demanding quality care, or operating outside of the patient-provider relationship to manage pain on their own. However, others prefer to let their provider make the decisions. In either case, having a mutually respectful patient-provider relationship is important to this population. Specifically, participants described the importance of "being heard" and "being understood" by providers.

CONCLUSIONS

As some providers switch from a patriarchal model of care toward a model of care that emphasizes patient activation and patient-centeredness, the development and cultivation of valued patient-provider relationships may change. While it is important to encourage patient involvement in treatment decisions, high-quality, patient-centered care for older adults with chronic pain should include efforts to strengthen the patient-provider relationship by attending to differences in patients' willingness to engage in patient-directed care and emphasizing shared decision-making.

Endurance and contest: women's narratives of endometriosis

Endometriosis is an often painful medical condition in which, in response to hormones associated with the menstrual cycle, the uterine lining grows in the peritoneum and other organs, bleeding into the surrounding organs and tissues. Diagnosis is not always straightforward, and women and health professionals alike may have difficulties recognizing period pain as a sign of anomaly, considering it instead as an inevitable part of menstruation. This article describes the illness narratives of Australian women with endometriosis, drawing on data collected during a study conducted in Victoria in 2004-5. Thirty women (aged 20-78 years) from various socio-demographic backgrounds participated in in-depth interviews. We explore the influence of socio-demographic background and social and family norms on women's illness narratives of endurance and contest. Narratives of endurance are characterized by the normalization of period pain by young women, their families and health professionals, and, with diagnosis, long-term exposure to biomedical treatments. In contrast, narratives of contest are dominated by how women's subjective experience is challenged by doctors, their requirements for a patient-centered approach, and their desire to have access to complementary treatments.

Understanding, embracing, rejecting: Women's negotiations of disability constructions and categorizations after becoming chronically ill

The purpose of this article is to elucidate the various responses women have to being, or not being, categorized as disabled within specific spheres (e.g., medical, state) or places (e.g., doctor's office, work) after developing a contested chronic illness. Drawing on interviews conducted with 55 women living with fibromyalgia syndrome in Ontario, Canada, we examine how they come to understand various constructions of disability and whether or not they reflect their sense of self, and how and why they either embrace or reject external categorizations of themselves as disabled by the state or medical professionals. In doing so we contribute to the limited geographic literature which stresses the importance of spatiality and ways of being in place to ill and impaired persons' negotiations of the self and relationships with others. We find that negotiating disability was, for many, an emotionally charged and complex process, drawing on one or more strategies: reluctantly employing some meanings associated with 'being disabled' to achieve material ends, creating an understanding of disability that is most in keeping with one's sense of self, embracing other meanings to the extent that they offer a legitimate basis for identity, and/or rejecting disability in the interests of sustaining an existing identity. For those women in need of forms of state assistance such as income support and health care, state institutions exert powerful pressures to come to terms with what disability means in one's life - particularly as medical and state authorities classify people as 'disabled enough' or 'not disabled enough' for entitlement to state resources.

Illness experience in fibromyalgia syndrome: a metasynthesis of qualitative studies

There is growing interest in synthesizing qualitative research. Despite certain philosophical and methodological difficulties, such syntheses are potentially useful in enriching the insights of empirical qualitative work in a particular area. This paper reports an interpretive review of research into the subjective experience of fibromyalgia syndrome (FMS), utilizing principles of metasynthesis. Twenty-three separate studies were identified. Each study was evaluated using methodological criteria to provide a context for interpretation of substantive findings. Principal findings were extracted and synthesized under four broad categories: experience of symptoms, search for diagnosis, legitimacy, and coping. Our findings re-emphasised the point that pain in FMS is ambiguous and invisible, raising questions of credibility and legitimacy. People with a diagnosis of FMS appear to frame the experience of symptoms within the biomedical model, where FMS is viewed as an organic entity potentially identifiable through biomedical tests. The subjective meaning and perceived legitimacy of the diagnostic label appear to be important factors in the subjective experience of FMS. Coping strategies adopted can be subsumed under Mannerkorpi, K., Kroksmark, T., Ekdahl, C. [1999. How patients with fibromyalgia experience their symptoms in everyday life. Physiotherapy Research International, 4(2), 110-122.] notions of 'struggling', 'adapting', 'in despair' and 'giving up'. Most studies had at least one identified methodological shortcoming, though it is not straightforward to identify the significance of such shortcomings. We conclude that there is scope for further research into the subjective experience of FMS, and into the methodology of metasynthesis, especially in relation to methodological appraisal.

Striving for balance: A grounded theory study of health experiences of nurses with musculoskeletal problems

BACKGROUND

Musculoskeletal disorders (MSD) are one of the major causes of the high levels of long-term sickleave and early retirement, and healthcare personnel are among the occupational groups most affected. Only limited research in the area has focused on the experiences of those affected, and to increase the understanding of MSD, all dimensions of the health experiences need to be taken into consideration.

OBJECTIVES

The aim of this paper was to explore the experiences of illness and wellness among female healthcare personnel with musculoskeletal symptoms.

DESIGN

A qualitative grounded theory approach guided the study in data collection and analysis.

SETTINGS

Medical and surgical ward units at three hospitals; one university hospital and two minor hospitals.

PARTICIPANTS

Eight women, registered nurses and nursing aides, with neck, shoulder and/or back problems in early stages.

METHODS

A grounded theory approach was used with narrative thematic interviews and parallel data analysis with constant comparisons.

RESULTS

The analysis revealed a process of striving to reach a balance between illness and wellness, through accepting and handling illness. Illness appeared as a threat and an experience, while experiences of wellness were simultaneously nurtured. The informants were striving for balance through an inner reasoning leading to acceptance and by handling illness in various ways depending on the character of the illness.

CONCLUSION

This paper indicates the diversity of the illness experience, the parallel importance of wellness, and the process of balancing these two in order to feel well enough. As previous research has shown that MSD has a multifactorial cause, a holistic view of health promotion, prevention and rehabilitation may provide a more effective tool than the bodily physical focus most frequently used today.

Bridging the gap between pain and gender research: a selective literature review

Evidence suggests that males and females differ with respect to the perception and experience of pain. Much of this work focuses on biological factors, yet it is also acknowledged that psychosocial issues are important. Within humans, socially and culturally constructed meanings of being and acting as a man or a woman should help us understand sex-related differences in pain. However, such an approach has not been widely adopted, partly because of problems conveying sex and gender concepts. We argue here for an assimilation of gender studies concepts into pain research as a means of developing our understanding of the psychosocial influences on pain in men and women. In order to bridge the gap between gender studies and pain, we draw on theoretical developments in such gender concepts, and illustrate their application to pain. We make use of Doise's [Doise W. Levels of explanation in social psychology [Mapstone E, Trans.]. Cambridge (UK): Cambridge University Press. 1986 [original work published 1982]] meta-theoretical model of levels of explanation in social psychology to show how gender may be conceptualized at an intra-individual, situational, positional and ideological level of analysis. We then selectively review existing gender and pain research using these different levels of explanation. In doing so we also highlight that by considering the gender conceptualizations underpinning such studies we are able to point to directions for future research. We conclude by arguing that this approach opens up a new avenue for pain researchers, which we hope will further our understanding of this interesting phenomena.

Representations: an important key to understanding workers' coping behaviors during rehabilitation and the return-to-work process

INTRODUCTION

Every year many workers are excluded from work because of a work disability attributable to a musculoskeletal disorder (MSD). Factors associated with the development and persistence of the work disability can be related to the worker, work environment, compensation policies, healthcare system and insurance system. Workers' understanding/representations of their disability are associated with coping behaviors aimed at helping them adapt to or solve their health problem. A representation is a complex, organized entity incorporating thoughts, beliefs, and attitudes regarding a particular subject. Representations have been studied in anthropology, sociology and psychology since the 1960s, but often in a compartmentalized way. These representations provide an important key to understanding what motivates workers during rehabilitation and the return-to-work process. To build upon disciplinary knowledge and better understand workers' efforts to cope with their persistent disability, this article therefore aims to pool the different knowledge available on the illness representation concept, from the fields of anthropology, sociology and psychology in order to gain a better understanding of its application in the MSD context.

METHODS

An electronic literature search (French, English) from 1960 on was conducted in medical, paramedical and social science databases (MedLINE, PsychINFO, CINAHL, etc.) using predetermined key words. After screening abstracts based on a set of criteria, content analysis was performed on the 131 articles retained.

RESULTS

The theoretical models and approaches can be divided into three categories: (1) personal experience; (2) interactionist; and (3) sociocultural. The models found in sociology and anthropology are mainly descriptive and developed in a medical context, and only rarely in an occupational health context. However, these models could add elements to psychosocial models that are more dynamic and oriented toward understanding the reasons behind specific behaviors.

CONCLUSION

Bridging the gap between these disciplines will help us achieve a new level of knowledge that will, by taking social interactions into account, enhance understanding of workers' representations, and the behaviors they adopt to manage their MSD-related disability.