Encountering the continuing challenges for women with chronic pain: recovery through recognition

A breathing space: how young Norwegian women engaging psychomotor physiotherapy to address long-term health disorders narrate their experiences

INTRODUCTION

In Norway, as elsewhere, young people may experience psychological distress and long-lasting pain. Such health disorders can be complex, leading some young people to seek psychomotor physiotherapy treatment. Thus far, however, there has been little qualitative investigation of their experiences.

OBJECTIVE

The purpose of this study was to gain new knowledge about the illness experiences of young people with long-term health disorders engaging psychomotor physiotherapy.

METHOD

Qualitative interviews with ten Norwegian women aged 16-24 in psychomotor physiotherapy were analyzed within a narrative framework.

FINDINGS

The participants' treatment experiences take place in the context of a long history of pain, distress, and lack of understanding and support. Their stories tell of being threatened by illness and other difficult life events, and of being placed under further stress by a prolonged and disruptive quest for help within the healthcare system. For participants, psychomotor physiotherapy represents a breathing space where their illness experiences are acknowledged, enabling them to find rest and explore their bodily reactions and habits.

CONCLUSION

Long-term health disorders represent significant disruptions to the daily lives and relationships of young women. It is important to acknowledge the illness experiences of these young women and establish trustful therapeutic relationships. Psychomotor physiotherapy may offer significant potential as a means to help young people explore and make sense of their illness experiences.

Attending to Marginalization in The Chronic Pain Literature: A Scoping Review

Background

There has been a recent and, for many within the chronic pain space, long-overdue increase in literature that focuses on equity, diversity, inclusion, and decolonization (EDI-D) to understand chronic pain among people who are historically and structurally marginalized.

Aims

In light of this growing attention in chronic pain research, we undertook a scoping review of studies that focus on people living with chronic pain and marginalization to map how these studies were carried out, how marginalization was conceptualized and operationalized by researchers, and identify suggestions for moving forward with marginalization and EDI-D in mind to better support people living with chronic pain.

Methods

We conducted this scoping review using critical analysis in a manner that aligns with dominant scoping review frameworks and recent developments made to scoping review methodology as well as reporting guidelines.

Results

Drawing on 67 studies, we begin with a descriptive review of the literature followed by a critical review that aims to identify fissures within the field through the following themes: (1) varying considerations of sociopolitical and socioeconomic contexts, (2) conceptual conflations between sex and gender, and (3) differing approaches to how people living with chronic pain and marginalization are described.

Conclusion

By identifying strengths and limitations in the research literature, we aim to highlight opportunities for researchers to contribute to a more comprehensive understanding of marginalization in chronic pain experiences.

Legitimacy in clinical practice: How patients with chronic muscle pain position themselves in the physiotherapy encounter

RATIONALE, AIMS & OBJECTIVE

Patients who seek healthcare for long-lasting pain and symptoms without a detectable disease must put in extra work to be taken seriously and gain recognition as a patient. However, little is known about how patients' help-seeking is performed in clinical practice. The aim of the current study was to gain knowledge about the ways in which patients with chronic muscle pain position themselves as help-seekers during their first physiotherapy encounter.

METHOD

The material consisted of observation of 10 therapist-patient clinical interviews in primary care clinics and was analyzed using perspectives from discourse theory and the concept of positioning.

RESULTS

The study highlights how the patients positioned themselves in continually shift between two discourses: that of disease (considering the patient as an object under study) and that of illness (positioning the patient as an active and participating but also troubled individual). This shifting of position was negotiated in interaction with the therapist: patients' opportunities to position themselves within the discourse of illness were limited by therapists' focus on facts and causal relationships within the discourse of disease.

CONCLUSION

Patients with chronic muscle pain seek to establish their legitimacy through the positivistic discourse of medicine and also through their compliance with the moral discourse of the patient as someone active, willing to take responsibility for their own health-and therefore worthy of treatment.

The Experiences of Persistent Pain Among Women With a History of Intimate Partner Violence: A Systematic Review

Women experience persistent pain at higher rates than men; however, women are less likely to be provided with adequate or appropriate care and more likely to have their pain experiences dismissed. The purpose of this review is to consider the complex interaction of the biopsychosocial factors in the experience of persistent pain in order to inform improved models of care. Given persistent pain is among the most frequently reported health consequences of intimate partner violence (IPV), this review focused on studies exploring the association between persistent pain and IPV. Three reviewers independently and systematically searched seven databases. Qualitative and quantitative studies describing the association between IPV and persistent pain published between January 2000 and June 2018 were included. Twelve studies met the inclusion criteria. The included studies demonstrated that a history of IPV places an additional burden on women who experience persistent pain that cannot be explained by an underlying psychological condition. Health care practitioners should be aware of this phenomena to ensure diagnosis, assessment, and treatment plans are targeted accordingly. Future policy directives and research should account for and seek to elucidate this additional burden.

Unexplained versus explained symptoms: The difference is not in patients' language use. A quantitative analysis of linguistic markers

OBJECTIVE

Patients with medically unexplained symptoms (MUS) are believed to have a deviant way of talking about complaints. This study systematically compared linguistic markers in symptom presentations of patients with MUS and medically explained symptoms (MES).

METHODS

This content analysis (cross-sectional study) conceptualized relevant linguistic markers based on previous research about MUS communication. Linguistic markers included negations ("not"), intensifiers ("very"), diminishers ("a little"), first or third person subject ("I" vs. "my body"), subjectivity markers ("I think") and abstraction ("I'm gasping for breath" vs. "I'm short of breath"). We also coded valence, reference to physical or mental states, and consultation phase. We compared 41 MUS and 41 MES transcribed video-recorded general practice consultations. Data were analyzed with binary random intercepts models.

RESULTS

We selected and coded 2752 relevant utterances. Patients with MUS used less diminishers compared to patients with MES, but this main effect disappeared when consultation phase was included as predictor. For all other linguistic variables, the analyses did not reveal any variation in language use based on whether patients had MUS or MES. Importantly, utterances' valence and reference to physical or mental state did predict the use of linguistic markers.

CONCLUSION

We observed no systematic variations in linguistic markers for patients who suffered from MUS compared to MES. Patients varied their language use based on utterances' valence and reference to physical or mental states. Current ideas about deviant patient communication may be based on stigmatized perceptions of how patients with MUS communicate, rather than actual differences in their talk.

Gender Medicine and Physiotherapy: A Need for Education. Findings from an Italian National Survey

BACKGROUND

Gender medicine permeates all sectors of medicine, from prevention to treatment and rehabilitation; it aims to customize the care path, ensuring equity in the access to health care system services. It is unclear to what extent physiotherapists' treatment choices align with gender medicine principles. The aim of this survey is to detect the need of Italian physiotherapists to deepen knowledge in gender medicine.

MATERIALS AND METHODS

An 18-item survey assessed the characteristics of responders about knowledge of gender medicine. An online survey was performed in 2020 using SurveyMonkey Software. Data were analyzed by statistical regression.

RESULTS

A total of 617 physiotherapists voluntarily participated in the study (53.84% of the target population). The majority of responders (68.4%) declared having general information about gender medicine, but 55.43% of them claimed to have heard of it but did not know properly what gender medicine was about; 92.38% of the physiotherapists believed that they needed training to acquire knowledge in gender medicine.

CONCLUSIONS

Gender equity matters for health. Moderate knowledge of gender medicine' principles and modest application of these findings were used in clinical practice of physiotherapy. Physiotherapists declared that they need training in gender medicine.

Telling, Hearing, and Believing: A Critical Analysis of Narrative Bioethics

Narrative ethics taps into an inherent human need to tell our own stories centred on our own moral values and to have those stories heard and acknowledged. However, not everyone's words are afforded equal power. The use of narrative ethics in bioethical decision-making is problematized by a disparity in whose stories are told, whose stories are heard, and whose stories are believed. Here, I conduct an analysis of narrative ethics through a critical theory lens to show how entrenched patterns of narrative neglect in medicine are harming not only our capacity to make use of narrative ethics but also our capacity to deliver effective healthcare. To illustrate this point, I use three examples where the patient's gender affects how their stories unfold: autism, weight, and pain management. From these, I argue that the use of narrative ethics without the application of a critical theory lens risks the exacerbation of what Miranda Fricker refers to as "testimonial injustice," the prima facie harm experienced by individuals whose credibility is undermined by others' prejudices. Finally, I suggest that narrative ethics can be a powerful tool for mitigating oppressive practices in medicine if we couple it with critical analysis that enables us to understand the power dynamics at play in storytelling.

Invalidation of chronic pain: a thematic analysis of pain narratives

PURPOSE

Many people with chronic pain report feeling disbelieved or disparaged by others regarding their pain symptoms. Given the widely documented relationship between stress and pain, the importance of identifying psychosocial stressors such as pain-invalidation is apparent. This study was designed to identify and illustrate using first-person narratives, the effects of pain-invalidation by the self, family, friends, and healthcare professionals, toward individuals with chronic pain.

METHOD

A systematic search of five databases was performed using a search strategy consisting of terms related to pain-invalidation. A review of 431 peer-reviewed journal articles, containing narratives from a pool of over 7770 study participants with a wide range of pain conditions, was conducted, followed by a thematic analysis to establish themes of invalidation experienced by those with chronic pain.

FINDINGS

Five major pain-invalidation themes were revealed: Not being believed, lack of compassion, lack of pain awareness/understanding, feeling stigmatized, and critical self-judgement. Themes additional to pain-invalidation included: Threats to Self-Image, Loss of Identity, and Isolation.

CONCLUSION

Themes were largely interrelated and, together, build a picture of how levels of perceived social unacceptability of pain symptoms can impact on the emotional state and self-image of those with chronic pain. As such, pain-invalidation may potentially impede help-seeking or the effectiveness of therapeutic interventions.IMPLICATIONS FOR REHABILITATIONPain-invalidation can occur at the level of the self, social others, or healthcare professionals.Pain-invalidation can arise through a lack of understanding by others in the social network about having chronic pain.Pain-invalidation may be a barrier to seeking therapy for pain management and rehabilitation, and thus, efforts to identify and acknowledge invalidation experiences may be beneficial in the rehabilitation process.

"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.

"Sense of Control": Patients' Experiences of Multimodal Pain Rehabilitation and its Impact in their Everyday Lives

Objective

Long-lasting pain is a challenge for pa-tients’ everyday lives. The aim of this study was to examine how women and men who have participa-ted in multimodal pain rehabilitation experience its impact in their everyday lives.

Patients and methods

Individual semi-structured interviews with 5 women and 3 men who had parti-cipated in multimodal pain rehabilitation at a clinic in Sweden, analysed using qualitative content ana-lysis.

Results

Participants perceived that their “sense of control” increased, which had a positive impact in their everyday life. Sense of control consisted of 3 categories: importance of the patient-provider re-lationship, knowledge gained (especially on body functions and medication), and pain in a social con-text. Three results were discussed in particular: (i) a trustful patient-provider relationship based on confidence in the provider’s expertise was a pre-requisite for pain acceptance; (ii) patients were aware of gender norms in healthcare; (iii) social support was not stressed as important to cope with pain.

Conclusion

The importance of patients’ confidence in the provider’s expertise and patients’ awareness about gender norms need consideration in terms of the patient-provider encounter. The value of social support for pain rehabilitation was found to be less important compared with previous research; this should be explored further.

Facilitation of a Person-Centered Approach in Health Assessment of patients with chronic pain: An Ethnographic Study

A phenomenologically derived assessment tool, Hermes, was developed in a rehabilitation setting for adopting the central ideals of person-centered care and patient participation into health-assessment practices in nursing. This focused ethnographic study aimed at exploring the feasibility of using Hermes for enabling the application of these ideals into assessment of patients with chronic pain upon admission to a rehabilitation center. Participants were patients with chronic pain, enrolled in rehabilitation, and their nurses. Data were collected by participant observation and interviews, and analyzed by thematic analysis. By the use of Hermes, the impact of illness was explored through supportive connection and dialogue with open, reflective, and interpretative features; understanding of the illness situation was enhanced; and possibilities provided in adjusting to health issues of concern. In sum, Hermes facilitated person-centered participation of patients with chronic pain in their health assessment and made a phenomenological philosophy usable in nursing-assessment practices.

'You want to show you're a valuable employee': A critical discourse analysis of multi-perspective portrayals of employed women with fibromyalgia

Background Advice on fibromyalgia, a chronic illness primarily affecting women, often presents it as incompatible with work and rarely covers how to remain employed. Yet many women do. Objectives We aimed to understand how these women, their family members, and workmates portrayed employees with fibromyalgia, and how these portrayals helped women retain employment. Methods We interviewed 22 participants, comprising five triads and three dyads of people who knew each other. Using the methodology of critical discourse analysis, we analysed the interview data within and across the triads/dyads through coding, narrative summaries, and relational mapping. Results Participants reported stereotypes that employees with fibromyalgia are lazy, malingering, and less productive than healthy workers. Countering these assumptions, participants portrayed the women as normal, valuable employees who did not 'give in' to their illness. The portrayals drew on two discourses, normalcy and mind-controlling-the-body, and a related narrative, overcoming disability. We propose that participants' portrayals helped women manage their identities in competitive workplaces and thereby remain employed. Discussion Our findings augment the very sparse literature on employment with fibromyalgia. Using a new approach, critical discourse analysis, we expand on known job-retention strategies and add the perspectives of two key stakeholders: family members and workmates.

What Works and Does Not Work in a Self-Management Intervention for People With Chronic Pain? Qualitative Systematic Review and Meta-Synthesis

BACKGROUND

Self-management interventions fostering self-efficacy improve the well-being of people with chronic pain.

PURPOSE

The purpose of this study was to synthesize the enablers (what works) and barriers (what does not) of incorporating self-management strategies for people in everyday life after completion of a pain self-management intervention.

DATA SOURCES

Major electronic databases (MEDLINE, AMED, PsycINFO, Cochrane Library, PubMed, CINAHL, Scopus, and Google Scholar) were searched from inception to July 2016.

STUDY SELECTION

Study selection included qualitative and mixed-method studies that explored the perceptions of individuals with chronic pain after completion of a self-management intervention.

DATA EXTRACTION

A thematic analysis approach was used to synthesize the review findings, and a Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach was used to assess the level of confidence.

DATA SYNTHESIS

Thirty-three studies with 512 participants were included. Enablers to self-management included self-discovery-the ability to distinguish self (ie, body, thoughts, and feelings) from pain; feeling empowered by incorporating self-management strategies into practice; and supportive ambience via collaborative relationships with clinicians and support from family and friends. Barriers to self-management included difficulty with sustaining motivation for pain self-management; distress experienced from ongoing pain, anxiety, and depression; and unsupportive relationships with clinicians, family, and friends.

LIMITATIONS

This review only included interventions that involved at least 4 self-management skills; thus, informative studies may have been missed. The follow-up period varied from immediately after the intervention to 72 months following the intervention; therefore, it is uncertain which of the key enablers and barriers were most influential long term. Only articles published in the English language were included; studies conducted in low- and middle-income countries could not be located.

CONCLUSIONS

The sustained effort to self-manage chronic pain could be exhausting, and motivation could wane over time following intervention. Providing intermittent support in the form of booster sessions and peer support groups may be important. Person-centered care via shared decision making and guided problem solving is essential to facilitating ongoing self-management.

"Brave Men" and "Emotional Women": A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain

Background

Despite the large body of research on sex differences in pain, there is a lack of knowledge about the influence of gender in the patient-provider encounter. The purpose of this study was to review literature on gendered norms about men and women with pain and gender bias in the treatment of pain. The second aim was to analyze the results guided by the theoretical concepts of hegemonic masculinity and andronormativity.

Methods

A literature search of databases was conducted. A total of 77 articles met the inclusion criteria. The included articles were analyzed qualitatively, with an integrative approach.

Results

The included studies demonstrated a variety of gendered norms about men's and women's experience and expression of pain, their identity, lifestyle, and coping style. Gender bias in pain treatment was identified, as part of the patient-provider encounter and the professional's treatment decisions. It was discussed how gendered norms are consolidated by hegemonic masculinity and andronormativity.

Conclusions

Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the need of all patients, men and women.

An exploratory study of the experience of fibromyalgia diagnosis in South Africa

Within the conceptual framework of 'medically-ill-defined' conditions, this article focuses on the experiences of 'diagnosis' through a narrative analysis of fibromyalgia (a chronic musculoskeletal pain disorder) in South Africa. In-depth interviews were used to collect narratives from 15 participants. The findings show how the contested and confusing experience of fibromyalgia diagnosis can be understood, by viewing the interactions that patients have with their practitioners, families, peers and colleagues. The currency of fibromyalgia as a diagnosis and the inequalities present in the South African health care system characterise the experiences of symptom recognition, diagnosis and treatment. The analysis reveals how those living with fibromyalgia search for diagnosis, and struggle to maintain legitimacy for their experience in the complex constellation of porous symptoms that appear infrequently. The findings of this study confirm the existing evidence that shows fibromyalgia to be a challenging illness experience, which is attributed to the lack of clarity and legitimacy, and high contestation that surrounds the condition. Additionally, this study presents the ways that limited access to diagnosis and treatment for fibromyalgia in the South African context shapes this specific illness experience, and the value of using narrative approaches to gain insight into how people live with hidden and poorly understood conditions in this environment.

``The pain isn't as disabling as it used to be'': How can the patient experience empowerment instead of vulnerability in the consultation?

Aim: This study explores how doctors can help patients transform vulnerability into strength, instead of increasing a feeling of disempowerment. Methods: The authors analysed their findings from four previously written articles based on qualitative interviews with 10 women with chronic pain, comparing the reported negative consultation experiences with the beneficial effects of good treatment experiences, in order to identify potentials for change. Results: Altering the way in which the women are encountered may empower and help them deal with a painful life. Doctors can challenge stereotyped macro-structures of women's ``unexplained'' pain as hysteria by admitting the shortcomings of medical knowledge. The blame is then put on the medical discipline instead of the individual patient who presents bodily symptoms or reveals help-seeking behaviour that does not fit with biomedical expectations of what illness is and how it should be performed. Thus, the vulnerable position described by the patients can be converted or transformed into strength or resources in spaces that promote empowerment through recognition. Conclusion: Although doctors may feel helpless or puzzled in the consultation, they must take the responsibility for turning the consultation into a space for empowerment of the patient.

A sense of increased living space after participating in multimodal rehabilitation

PURPOSE

The aim was to explore and describe experiences of change related to multimodal rehabilitation (MMR) in participants suffering from persistent musculoskeletal-related pain, in order to increase knowledge about the impact of the rehabilitation.

METHODS

Participants in MMR from an outpatient rehabilitation unit in primary care in Sweden were recruited for interviews about any kind of change they experienced that they thought were related to their participation in the MMR. Systematic text condensation according to Malterud was used to analyze the data.

RESULTS

A total of 14 participants were interviewed. The interview analysis resulted in four categories in which the participants described their experience of change related to the MMR: a new desire for participation, increased embodied knowledge, a stronger sense of feeling empowered and regained hope. The categories interacted and from these categories, one theme emerged: a sense of increased living space.

CONCLUSION

According to these results, it is important to have various entrances to enhance change and to be aware of how these changes interact and can reinforce each other in order to facilitate the participants' empowerment processes toward a sense of increased living space. Implications for rehabilitation The efforts in MMR should be coordinated to be mutually reinforcing as changes in one area could facilitate in others and thus facilitate the participants' empowerment processes. Participants experience change after MMR in areas that standardized assessment questionnaires do not capture and consequently it would be useful to let the participants answer an open question about perceived changes together with standardized questionnaires.

Practices and Attitudes Concerning Endometriosis Among Nurses Specializing in Gynecology

Endometriosis is a chronic disease affecting approximately 10% of fertile women. These women often have negative health care experiences. This study adds new knowledge about endometriosis care in a hospital setting and nurses' attitudes toward the disease. To explore how the personal attitudes of gynecological nurses, their specialized knowledge, and their clinical experiences influenced the way they conceptualized and cared for women with endometriosis, participant observations and semistructured interviews were conducted. Categorization of patients into certain kinds, with more or less legitimate needs, provided an important framework for practice. Specialized knowledge qualified the nurses' views of their patients and seemed to be conducive to sustained patient involvement. However, the organization of care based solely on medical specialization restricted a holistic approach. An important goal is, therefore, to investigate patients' perspectives of health and illness and to create participatory relationships with patients, regardless of their diagnosis.

Pelvic girdle pain affects the whole life--a qualitative interview study in Norway on women's experiences with pelvic girdle pain after delivery

BACKGROUND

The aim of this study was to explore how pelvic girdle pain after delivery influences women's daily life in Norway. Knowledge about living with post-partum pelvic girdle pain is lacking.

METHOD

A phenomenological-hermeneutical design with qualitative semi-structured interviews was used. A strategic selection procedure was chosen to recruit participants from physiotherapy clinics and a regional hospital in Norway. Five women with clinically verified pelvic girdle pain after delivery were included. Data were imported into NVivo9 and analysed in three steps: naïve reading, structural analysis and comprehensive understanding of the text.

RESULTS

Three themes influencing the women's daily life were identified: 1) activity and pain, 2) lack of acknowledgment of pain and disability, and 3) changed roles. A daily life with pain and limited physical activity was difficult to accept and made some of the women feel discouraged, isolated and lonely. Despite this, the women had a positive attitude to their problems, which may have positively increased their ability to cope. The findings also revealed the importance of a reciprocal influence between the woman and her environment, and that social support was crucial.

CONCLUSIONS

Pelvic girdle pain may influence women's lives for months and years after delivery. Health care professionals should appreciate and focus on the patient's knowledge and skills. Understanding the daily experiences of women with pelvic girdle pain might help improve rehabilitation strategies for these patients.

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.

Long-term effect in ADL after an interdisciplinary rehabilitation programme for WAD patients: a mixed-method study for deeper understanding of participants' programme experiences

PURPOSE

To evaluate long-term effects in self-perceived occupational performance and satisfaction in Activities of Daily Living (ADL) for patients with Whiplash Associated Disorders (WAD) with chronic pain in an interdisciplinary rehabilitation programme, and investigate patients' opinions of programme effects.

METHOD

A mixed-method with sequential explanatory design was used. Fifty-three patients with WAD were followed-up 12 months after discharge. The Canadian Occupational Performance Measure was used to evaluate the change in ADL and the Multidimensional Pain Inventory for psychosocial functioning. Telephone interviews, based on five structured questions about the perceived impact of the rehabilitation programme, were made.

RESULTS

The 12-month follow-up showed significant ADL improvement (p < 0.001). There was less interference in daily activities due to pain (p < 0.01), and life control increased. More people were back to work. Interviews revealed the programme's environment as strengthening and safe, and participants felt they were met with respect. Key success factors were to be treated with respect to being part of the social context and to obtain new knowledge.

CONCLUSIONS

The interdisciplinary rehabilitation programme had initiated a process of change towards a more active life for the participants. They had found a new way of managing their lives. Despite the absence of pain reduction, they managed ADL in a better way, had more life control and returned to work to a higher degree.

IMPLICATIONS FOR REHABILITATION

Chronic pain after WAD effects the entire life for many people. Long-term effects on activities of daily living, life control and work ability have shown positive results after an interdisciplinary rehabilitation programme based on behavioural and cognitive principles. The key success factors were to be treated with respect to being a part of a social context and to obtain new knowledge.

'I can't see any reason for stopping doing anything, but I might have to do it differently'--restoring hope to patients with persistent non-specific low back pain--a qualitative study

PURPOSE

To explore the differences in narrative between patients with persistent non-specific low back pain (PLBP) who benefited from a pain management programme, and those who did not benefit.

METHOD

We conducted interviews with 20 patients attending a pain management programme; prior to attending the programme, immediately following the programme and at one year. Our analysis focused on a theoretical sample of patients who either described dramatic life improvements at one year, and who described themselves as much worse. We used the methods of grounded theory.

RESULTS

We found that finding hope was central to good outcome. Patients restored hope by making certain changes; (a) deconstructing specific fears, (b) constructing an acceptable explanatory model (c) reconstructing self identity by making acceptable changes. Those who had not restored hope retained fears of loss of self, remained committed to the biomedical model and were unable to make acceptable changes.

CONCLUSIONS

Our findings may help to operationalise the restoration of hope in patients with PLBP. Firstly, health care professionals need to identify and resolve any specific fears of movement. Secondly, patients need an acceptable explanatory model that fits their experience and personal narrative. Finally our study confirms the centrality of self concept to recovery.

Do dialogues about concepts of pain reduce immigrant patients' reported spread of pain? A comparison between two consultation methods in primary care

OBJECTIVES

Do dialogues about concepts of pain reduce the reported spread of pain more than the usual consultations?

SETTING

A 4-week programme in primary care for immigrants on sick-leave, aged 16-45 years, containing daily exercises and randomised to either four interviews and dialogues about pain with a female doctor (group A) or the usual consultations with a male doctor (group B).

METHODS

Two doctors made the first and the last evaluations (before and after the programme) containing diagnostics of tender-structure locations and depression (yes-no), and ratings of severity of psychosocial stressors. Anxiety about pain was noted (yes-no). The patients pointed to their painful areas and these were noted on pain drawings (0-18 fields). Median values were calculated, and non-parametric statistics were used to test for significant differences between groups and before-and-after values, and the correlation between the number of pain drawing fields and clinical variables.

RESULTS

Forty-five persons participated in the whole programme, Group A (8 men, 15 women), group B (7 men, 15 women). Many of them needed an interpreter. Participants in group A had more tender-structure locations (two vs. one in group B). Nearly half had depression and two-thirds had serious psychosocial stressors. Almost all reported anxiety about pain at the start, but afterwards significantly fewer in group A (22 vs. 16, p < 0.05). In both groups, the number of pain drawing fields decreased significantly from, in median, eight to four (p < 0.001), particularly among the women (A: p < 0.05 vs. B: p < 0.01). Some very distressed participants reported more spread of pain than at the start. Reduced spread of pain was not significantly correlated to any clinical variable.

CONCLUSIONS

Particularly the women in both consultation groups demonstrated much less spread of pain after treatment, despite similar clinical findings and less anxiety about pain in group A. The initially wide spread of pain may thus have been a way of communicating with the doctors.

Cultural cues: review of qualitative evidence of patient-centered care in patients with nonmalignant chronic pain

The purpose of this paper was to examine published qualitative studies that explored the beliefs, values, and behaviors of patients with nonmalignant chronic pain during their interactions with the healthcare system. The findings were used as "cultural cues" to create patient-centered care. A literature review of primary qualitative studies that focused on beliefs, values, or behaviors of patients with chronic nonmalignant pain in the formal healthcare setting was conducted. CINAHL, Medline, Pubmed, PsychInfo, Sociology Abstracts, Cochrane Library Database, Proquest Dissertation and Thesis, and EmBase served as the database for the research. The findings from the studies fell into two categories: beliefs and expectations about appropriate treatment and the behaviors patients may exhibit if they perceive they are not receiving appropriate treatment. Qualitative findings showed that the beliefs, values, and behaviors of patients with nonmalignant chronic pain exhibited during their interactions with the healthcare system created a set of "cultural cues" for providers.

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.

The quest for well-being: self-identified needs of women in chronic pain

Women suffer more chronic pain in most Western countries than men, with considerable consequences for the sufferers. The aim of this phenomenological research was to study self-reported needs of women in chronic pain. The data consisted of ten in-depth interviews, which lasted from 60 to 120 minutes each, with five women in chronic pain, aged 36-53. Twelve needs were identified in the study, which were categorized into three clusters of needs or major quests: The quest to learn to live with the pain, which involves the need for diagnosis; the need to find effective treatment and keep the pain tolerable; the need for helpful advice and information and the need to take care of self and for a different pace and a new life pattern. The quest for support, caring and connection which involves the need for someone close who cares; the need to be connected to others and have someone to care for; the need for practical support e.g. financial support and household assistance and the need for professional support and caring. Finally, the quest for normalcy which involves the need to avoid the sick role and maintain a sense of dignity; the need to focus on personal strengths and prevent discouragement and depression; the need to be involved in decision-making regarding own care and treatment and the need to participate in family and social activities to fight isolation and loneliness. The overriding theme in all these quests is the quest for well-being; physically, mentally, emotionally and socially. Conflicting needs created five major dilemmas in the women's lives. Women in chronic pain may be seen in any clinical setting and health professionals need to be able to recognize their needs in order to be able to give effective care, to cooperate with them and empower them.

Whiplash patients' experience of a multimodal rehabilitation programme and its usefulness one year later

OBJECTIVE

The study aimed to explore and analyse how, 1 year after completing a rehabilitation programme, persons with long-term pain due to whiplash-associated disorders (WAD) experienced their participation, and what knowledge and strategies they had gained from it for handling their daily occupations.

METHODS

The study had an emergent design. Thematised research interviews were conducted with nine informants. The results were analysed according to the constant-comparison grounded-theory method.

RESULTS

Data analysis resulted in one core category, 'learning to manage WAD, a rehabilitation process', and three associated categories: 'chaos in life', 'a light in the tunnel' and 'managing long-term pain'. The core category and the categories describe the process the informants underwent from how they experienced life when starting rehabilitation to one year after completion.

CONCLUSION

The informants described living with long-term whiplash-associated pain as 'chaos' before the rehabilitation programme. Participation helped them realise that there was a possible way for them to control their pain, regain their daily occupation and return to work. One year after rehabilitation the informants had started to accept their situation and regain occupations and life roles.

Patients' experiences of telerehabilitation at home after shoulder joint replacement

We investigated the experience of ten patients who received video-based physiotherapy at home for two months after a shoulder joint replacement. Videoconferencing took place via the patient's home broadband connection at a bandwidth of 256–768 kbit/s. Qualitative interviews were carried out, transcribed and analysed. Through qualitative content analysis six categories were identified: (1) a different reinforced communication; (2) pain-free exercising as an effective routine; (3) from a dependent patient to a strengthened person at home; (4) closeness at a distance; (5) facilitated daily living; and (6) continuous physiotherapy chain. The access to bodily knowledge, continuity, collaboration and being at home were all aspects that contributed to the patients' recovery. The patients described experiences of safety, and strengthening during their daily exercise routine at home. The frequent interplay with the patient during telerehabilitation made it possible for the physiotherapist to make an individual judgement about each patient; this could be one reason for the positive findings. Home video-based physiotherapy may be useful in other kinds of physiotherapy.

‘How do you explain a pain that can't be seen?’: The narratives of women with chronic pelvic pain and their disengagement with the diagnostic cycle

OBJECTIVES

Chronic pelvic pain (CPP) has an adverse effect on women's quality of life. Research has suggested that many women become dissatisfied with their care and withdraw from seeking help despite continuing symptoms. The aim of this study was to explore the processes which lead to disengagement and to understand the psychosocial processes that affect this group of women.

DESIGN

A qualitative narrative approach was used, guided by phenomenological-hermeneutic tradition, and informed by the philosophy of Paul Ricoeur.

METHOD

Thirty-two women with CPP were asked to write their stories about their illness trajectories. These written stories served as data which were analysed thematically according to narrative theory.

RESULTS

In the search for validation and recognition women engaged in the diagnostic cycle. Many women do not complete this cycle, become stuck at a certain point, or re-enter the cycle repeatedly. They can only opt out if the problem is resolved or by choosing to disengage with medical care.

CONCLUSIONS

While the medical consultation was a dominant theme, a complex interaction of factors was required to initiate disengagement. The dualistic nature of the diagnostic process prohibits women from telling their stories. Women were left feeling disempowered and in limbo, and they were at a loss as to how to manage their pain.

The lived political economy of occupational overuse syndrome among New Zealand workers

In New Zealand, as in other industrialised nations, rates of work-related gradual onset injuries increased during the 1980s and 1990s. The perspectives and experiences of workers suffering what became known as occupational overuse injuries in New Zealand offer insights into local lived political economies. Here, we explore the dominant metaphor, 'battling', in participants' narratives. On the face of it, battles were fought over diagnoses, over occupational health and safety in the workplace, and over entitlements to therapy and income compensation. However, participants were also battling to maintain their identities as hard workers, while resisting and challenging normalising technologies of self and morally charged negative identities offered them by employers, state-funded accident and injury insurance agencies, and the medical profession. Inherent in their narratives is a critique of the neo-liberal capitalist political economy that allows workers' bodies to be exploited (and sacrificed) for employers' profits.

An HMO-based prospective pilot study of energy medicine for chronic headaches: whole-person outcomes point to the need for new instrumentation

OBJECTIVES

The purpose of this study was to evaluate an energy healing treatment for possible inclusion as a Kaiser Permanente Northwest (KPNW) Pain Clinic provided therapy, and to identify the appropriate number of treatment sessions for a Pain Clinic protocol, should the intervention prove successful. In addition, our intent was to document the full range of outcomes experienced by patients undergoing energy healing, including whole-person and transformative outcomes should they occur.

SETTING

The setting for this study was Kaiser Permanente Northwest Pain Clinic.

PARTICIPANTS

Thirteen (13) patients with chronic headache who were members of the KPNW Health Plan were recruited through flyers or mailings.

METHODS

Thirteen (13) participants received at least three energy healing sessions at approximately weekly intervals. Assessments were based on pre- and post-treatment qualitative interviews.

INTERVENTION

The treatment consisted of three Healing Touch sessions provided by a Certified Healing Touch Practitioner. Treatments contained elements common to all sessions, and elements that were tailored to the individual subject.

RESULTS

Twelve (12) of 13 participants experienced improvement in frequency, intensity, or duration of pain after three treatments. In addition, 11 of 13 participants experienced profound shifts in their view of themselves, their lives, and their potential for healing and transformation. These changes lasted from 24 hours to more than 6 months at follow-up.

CONCLUSIONS

Energy healing can be an important addition to pain management services. More in-depth qualitative research is needed to explore the diversity of outcomes facilitated by energy healing treatments. Furthermore, the development of new instrumentation is warranted to capture outcomes that reflect transformative change and changes at the level of the whole person.

I never know from one day to another how I will feel: pain and uncertainty in women with endometriosis

Endometriosis is a chronic condition of women in which endometrial tissue is present outside of the uterus. It is characterized by pelvic pain. The aim of this prospective study was to explore women's experience of living with endometriosis. A sample of 30 women was recruited from a dedicated endometriosis clinic. Semistructured interviews were conducted upon recruitment and after one year, these data being supplemented by diary keeping by a volunteer sample. As a storytelling approach was utilized for data collection, narrative analysis was considered most appropriate. The findings are presented using the concept of uncertainty, which has been found in previous research to be a feature of long-term illness. Uncertainty exists around diagnosis, the course of the disease, and the future. It is argued that the way in which the pain of endometriosis is interpreted and managed by women and health professionals is integral to this uncertainty.

Effects of work ability and health promoting interventions for women with musculoskeletal symptoms: a 9-month prospective study

Background

Women working in the public human service sector in 'overstrained' situations run the risk of musculoskeletal symptoms and long-term sick leave. In order to maintain the level of health and work ability and strengthen the potential resources for health, it is important that employees gain greater control over decisions and actions affecting their health – a process associated with the concept of self-efficacy. The aim of this study was to describe the effects of a self-efficacy intervention and an ergonomic education intervention for women with musculoskeletal symptoms, employed in the public sector.

Methods

The design of the study was a 9-month prospective study describing the effects of two interventions, a comprehensive self-efficacy intervention (n = 21) and an ergonomic education intervention (n = 21). Data were obtained by a self-report questionnaire on health- and work ability-related factors at baseline, and at ten weeks and nine months follow-up. Within-group differences over time were analysed.

Results

Over the time period studied there were small magnitudes of improvements within each group. Within the self-efficacy intervention group positive effects in perceived work ability were shown. The ergonomic education group showed increased positive beliefs about future work ability and a more frequent use of pain coping strategies.

Conclusion

Both interventions showed positive effects on women with musculoskeletal symptoms, but in different ways. Future research in this area should tailor interventions to participants' motivation and readiness to change.

Women in chronic pain: sense of control and encounters with health professionals

An evolving theory on "women's sense of control while in chronic pain and the results of the quality of their encounters with health professionals" is introduced in this article. According to the theory, the main challenge of women in chronic pain is to maintain a sense of control of self and the pain to avoid demoralization, which is seen as a potential threat for all women in chronic pain. To retain a sense of control, women are challenged to learn to live with the pain and cope with the unpredictability and incurability of the pain. They are challenged to find meaning in their suffering, to create personal space, and to be self-protective as well as to keep a positive self-image and self-esteem while trying to live a "normal" life in dignity in spite of the pain and warding off isolation and demoralization. Health professionals are seen as potentially powerful people in the lives of women in chronic pain. Empowerment or disempowerment from them greatly influences whether women in chronic pain are demoralized or not.

Vulvar pain: a phenomenological study of couples in search of effective diagnosis and treatment

Vulvar vestibulitis syndrome (VVS), a vulvar pain disorder, continues to puzzle medical and mental health professionals due to its unknown etiology and lack of effective treatment. This study used transcendental phenomenology methodology to explore the experiences of couples in which the woman has a diagnosis of VVS. Sixteen in-depth semi-structured interviews were conducted with 13 heterosexual couples and 3 women. Four essences emerged: (1) In search of ... the medical journey required extensive searching for knowledgeable and respectful practitioners to provide treatment. (2) The process of developing a personal understanding of this disorder led many couples to question their role in causing and maintaining VVS. (3) Developing strategies for coping with painful intercourse led to three strategies: becoming non-sexual, using alternatives to vaginal sex, and altering or enduring painful intercourse. (4) Feelings of isolation were experienced as adapting to this chronic pain syndrome was often a lonely process. Clinical suggestions included: treating the couple, not just the woman with VVS; encouraging couples to broaden definitions about the importance and primacy of vaginal intercourse and suggest alternative sexual activities less likely to cause vulvar pain; developing shared meaning as a couple, and assisting couples in locating physicians and resources. Suggestions are relevant for couples with VVS and those with chronic health problems affecting sexual relationships.

Subjective quality of life according to work status following interdisciplinary work rehabilitation consequent to musculoskeletal disability

INTRODUCTION

Individualized subjective quality of life (ISQoL) is the appraisal of quality of life according to personal values, desired goal attainment and life priorities. "Gap" is a way to operationalize ISQoL. ISQoL is rarely measured by interdisciplinary work rehabilitation (IWR) programs attended by the musculoskeletal disorder (MSD) population. These programs commonly measure pain intensity, physical capacity, perceived disability, distress and return to work.

OBJECTIVES

The aims of this study were to compare ISQoL according to work status and reference values and to explore the relationships between ISQoL and common IWR measures.

METHODS

Six months after completing an IWR program, 40 working and 31 not-working participants completed questionnaires documenting work status, pain, ISQoL gap, health-related quality of life (SF-36, PCS and MCS), perceived disability and distress.

RESULTS

No significant difference in global ISQoL gap was found between working and not-working participants. When compared to reference values considerable variability exists but globally, for both groups, ISQoL gap scores were below average. The following clinical variables were related to global ISQoL (P < 0.05): pain (r = -0.42), PCS (r = -0.37), MCS (r = -0.56), perceived disability (r = 0.37) and distress (r = 0.61). High distress, present in both groups, explains 38% of the global ISQoL gap variance and PCS adds 4%.

CONCLUSION

Following IWR programs for the chronic MSD population, global ISQoL gap is not related to work status. The use of a client-centered interactive computerized measure of ISQoL reveals that domains related to emotional well-being are likely the most problematic for the persistently disabled MSD population.

The stigmatisation of people with chronic back pain

PURPOSE

This study responded to the need for better theoretical understanding of experiences that shape the beliefs, attitudes and needs of chronic back patients attending pain clinics. The aim was explore and conceptualise the experiences of people of working age who seek help from pain clinics for chronic back pain.

METHODS

This was a qualitative study, based on an interpretative phenomenological approach (IPA). During in-depth interviews in their homes, participants were invited to 'tell their story' from the time their pain began. Participants were twelve male and six female patients, aged between 28 and 62 years, diagnosed as having chronic benign back pain. All had recently attended one of two pain clinics as new referrals. The interview transcripts were analysed thematically.

FINDINGS

Stigmatisation emerged as a key theme from the narrative accounts of participants. The findings expose subtle as well as overt stigmatising responses by family, friends, health professionals and the general public which appeared to have a profound effect on the perceptions, self esteem and behaviours of those interviewed.

CONCLUSIONS

The findings suggest that patients with chronic back pain feel stigmatised by the time they attend pain clinics and this may affect their attitudes and behaviours towards those offering professional help. Theories of chronic pain need to accommodate these responses, while pain management programmes need to address the realities and practicalities of dealing with stigma in everyday life.

Understanding rehospitalization risk: can hospital discharge be modified to reduce recurrent hospitalization?

BACKGROUND

A high rate of unnecessary rehospitalization has been shown to be related to a poorly managed discharge processes.

OBJECTIVE

A qualitative study was conducted in order to understand the phenomenon of frequent rehospitalization from the perspective of discharged patients and to determine if activities at the time of discharge could be designed to reduce the number of adverse events and rehospitalization.

DESIGN

Semistructured, open-ended interviews were conducted with 21 patients during their hospital stay at Boston Medical Center. Interviews assessed continuity of care after discharge, need for and availability of social support, and ability to obtain follow-up medical care.

RESULTS

Difficult life circumstances posed a greater barrier to recuperation than lack of medical knowledge. All participants were able to describe their medical condition, the reasons they were admitted to the hospital, and the discharge instructions they received. All reported the types of medications being taken or the conditions for which the medications were prescribed. Recuperation was compromised by factors that contribute to undermining the ability of patients to follow their doctors' recommendations including support for medical and basic needs, substance use, and limitations in the availability of transportation to medical appointments. Distress, particularly depression, further contributed to poor health and undermined the ability to follow doctors' recommendations and the discharge plans.

CONCLUSIONS

Discharge interventions that assess the need for social support and provide access and services have the potential to reduce chronic rehospitalization.

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

PURPOSE

This study aimed to explore, and obtain increased knowledge of, the strategies used by working women with fibromyalgia regarding control of pain, fatigue and other symptoms.

METHOD

Qualitative methods with an emergent design were used. The informants were women with fibromyalgia who had participated in rehabilitation 6-8 years earlier, and were still in work. Diaries, focus groups and individual interviews were used for data collection. Content analysis and grounded theory were used for the analyses.

RESULTS

A model with three categories emerged. The core category 'constant struggle' contains eight sub-categories: enjoying life, taking care of oneself, positive thinking, setting limits, using pain as a guide, creative solutions, learning/being knowledgeable and 'walking a tightrope'. The category 'grieving process' was a prerequisite for managing the struggle and the category 'social support' contained what facilitated the struggle.

CONCLUSION

The informants fought a constant struggle against the symptoms and the consequences of their fibromyalgia. Their strategies were action-oriented and evinced a positive spirit. To have grieved and accepted their situation was a prerequisite for managing, and support from the family was a help in the struggle.

Striking a balance--health experiences of male ambulance personnel with musculoskeletal symptoms: a grounded theory

BACKGROUND

Musculoskeletal disorders (MSD) are a dominant cause to long-term sick leave and early retirement. Some occupational groups are more affected than others and ambulance personnel are among them. Despite a vast amount of research, only a small part focuses the experiences of the affected.

OBJECTIVES

The aim of the study was to explore the experience of illness and wellness in ambulance personnel with musculoskeletal symptoms.

DESIGN

An emerging design was used in accordance with Grounded Theory.

PARTICIPANTS

Informants in the study were ten men with musculoskeletal symptoms, working as ambulance personnel at an ambulance station located in a mid-sized city in Sweden.

METHODS

Narrative interviews were performed, parallel to a constant comparative analysis.

RESULTS

The study resulted in a model, which describes the experience of illness and wellness as characterised by an effort to strike a balance. Wellness through nurturing appeared parallel to encountering illness as an experience and a threat. Accepting and handling illness was of importance to maintaining wellness, and wellness through nurturing was the motivation for accepting and handling illness.

CONCLUSIONS

Enhancing the understanding of wellness and illness makes it possible to avoid undermining the meaningfulness that support accepting and handling illness, and by understanding different aspects of illness prevention can become facilitated. This is of importance as other aspects than solely physical have shown to be similarly important in the development of MSD.

Work-related outcome assessment instruments

Prevention of work disability is a primary goal within treatment of spinal disorders. Work-related outcome measures therefore are essential indices within evidence-based medicine. So far many measures suffer, however, from standardized measurement, standardized terminology, and a lack of theoretical background. This review addresses traditional indicators like work status and sickness absence, and discusses more theory-bound concepts, i.e. work ability, occupational risk factors for recurrence of symptoms and re-injury, work-related attitudes that may become obstacles to recovery, and individual reactions to occupational stressors that increase the risk of maintenance and recurrence of symptoms. The review includes methodological and theoretical considerations and recommendations for the use of work-related outcome measures in future outcome research.

Qualitative methodology for rehabilitation research1

Qualitative research methodology focuses on individuals' lived experiences as they are presented in thoughts, ideas, feelings, attitudes and perceptions. In addition, the research approach emphasizes human behaviour and social interaction. It explores the quality of a phenomenon, not the quantity. This article outlines the major characteristics of qualitative research methodology and gives applications and examples. The aim of qualitative methodology is to develop new knowledge based on participants' own beliefs and experiences, not on pre-defined, testable hypotheses. It is inductive rather than deductive, and it is interpretative rather than predictive. The design is flexible, iterative and emergent and therefore requires of the researcher an ability to change and adapt the research process in accordance with emerging results. Qualitative research is thus different from quantitative research as it allows for flexibility throughout the research process. Several data collection methods can be used, such as individual interviews, focus group discussions or participant observations, in order to gain a deeper understanding of health, illness and rehabilitation. It can be used in combination with quantitative studies, but also as a research method of its own. In health research, the qualitative methodology has gained increasing credibility during the last decade. However, it is not yet frequently used in rehabilitation research. As rehabilitation outcomes are dependent on people's attitudes, thoughts and motivation regarding the rehabilitation process, and as the rehabilitation process in itself builds on social interaction, studies with a qualitative design could become useful tools in the development and improvement of rehabilitation.

Self-Organization in Chronic Pain: A Concept Analysis

The purpose of this article is to examine the concept of self-organization in chronic pain using Rodgers' (2000) evolutionary approach. This article describes the antecedents, attributes, and consequences of self-organization in chronic pain. Self-organization in chronic pain may be achieved through the attributes of being believed, accessing credible resources, and taking action and responsibility. Self-organization occurs when the patient with pain develops a transformed identity, new insights, and is an active, in-control participant in care. Chronic pain is a common and costly problem, and recognition of the key attributes of self-organization in this condition is an important step in promoting positive health outcomes. Rehabilitation nurses play a key role in providing credible resources and working with the patient to take action and responsibility.