Some, but not all, patients experience full symptom resolution and a positive rehabilitation process after ACL reconstruction: an interview study.

PURPOSE: To gain a deeper understanding of patients' experiences over 5 years after anterior cruciate ligament (ACL) reconstruction. METHODS: Seventeen semi-structured interviews were performed with patients treated with ACL reconstruction at least 5 years earlier without a second knee injury. Interviews were transcribed and analyzed using qualitative content analysis according to methods described by Graneheim and Lundman. RESULTS: Patients' long-term experiences after an ACL reconstruction were summarized as: "to cope or not to cope, that is the question", and five main categories: (1) Adapting life after knee symptom: the past will not come back; (2) An arduous and demanding rehabilitation: sailing against the wind; (3) Accepting what cannot be changed: biting the bullet; (4) Being satisfied with results: end of a chapter; (5) Apprehensively peregrinating on an unknown road. CONCLUSIONS: More than 5 years after ACL reconstruction, patients can experience full symptom resolution and the ACL injury process as positive, or experience persistent symptoms and are forced to accept negative life-changing choices due to the injury. LEVEL OF EVIDENCE: IV.

Diagnostic and therapeutic care pathway for fibromyalgia.

Early diagnosis and timely and appropriate treatments positively influence the history of fibromyalgia syndrome (FM), with favourable repercussions at clinical, psychological, social and economic levels. Notwithstanding, there are still significant problems with timeliness of diagnosis, access to pharmacological therapies - particularly to innovative ones - and appropriate and effective taking in charge of patients. All the aforementioned factors have a great impact on FM patients' quality of life. Indeed, even though the World Health Organisation recognised FM as a chronic condition in the International Classification of Diseases 10th edition (ICD-10), many countries still fail to recognise the syndrome, and this negatively influences the capability to appropriately protect and care for patients. This is the case in several European Countries. In Italy, a few Regions have started to put in place precise indications for people suffering from FM, aiming at the implementation of diagnostic-therapeutic pathways. The Diagnostic-Therapeutic Care Pathway (DTCP) provides an important tool to meet the needs of patients suffering from chronic diseases. They present the organisation of an integrated assistance network. This includes a seamless path for disease prevention, diagnosis and treatment, by means of cooperation among physicians and other healthcare professionals.

Fibromyalgia position paper.

Fibromyalgia syndrome is one of the most common causes of chronic widespread pain, but pain accompanies a wide range of ancillary symptoms. To date, its aetiopathogenesis remains elusive, and diagnosis is exquisitely clinical, due to the lack of biomarkers or specific laboratory alterations in fibromyalgia patients. This position paper has the purpose to summarise the current scientific knowledge and expert opinions about the main controversies regarding fibromyalgia syndrome, namely: (i) fibromyalgia definition and why it is still not recognised in many countries as a distinct clinical entity; (ii) fibromyalgia severity and how to evaluate treatment outcome; (iii) how to treat fibromyalgia and which is a correct approach to fibromyalgia patients.

Moderate- to high intensity aerobic and resistance exercise reduces peripheral blood regulatory cell populations in older adults with rheumatoid arthritis.

OBJECTIVE: Exercise can improve immune health and is beneficial for physical function in patients with rheumatoid arthritis (RA), but the immunological mechanisms are largely unknown. We evaluated the effect of moderate- to high intensity exercise with person-centred guidance on cells of the immune system, with focus on regulatory cell populations, in older adults with RA. METHODS: Older adults (≥65 years) with RA were randomized to either 20-weeks of moderate - to high intensity aerobic and resistance exercise (n = 24) or to an active control group performing home-based exercise of light intensity (n = 25). Aerobic capacity, muscle strength, DAS28 and CRP were evaluated. Blood samples were collected at baseline and after 20 weeks. The frequency of immune cells defined as adaptive regulatory populations, CD4 + Foxp3 + CD25 + CD127- T regulatory cells (Tregs) and CD19 + CD24hiCD38hi B regulatory cells (Bregs) as well as HLA-DR-/lowCD33 + CD11b + myeloid derived suppressor cells (MDSCs), were assessed using flow cytometry. RESULTS: After 20 weeks of moderate- to high intensity exercise, aerobic capacity and muscle strength were significantly improved but there were no significant changes in Disease Activity Score 28 (DAS28) or CRP. The frequency of Tregs and Bregs decreased significantly in the intervention group, but not in the active control group. The exercise intervention had no effect on MDSCs. The reduction in regulatory T cells in the intervention group was most pronounced in the female patients. CONCLUSION: Moderate- to high intensity exercise in older adults with RA led to a decreased proportion of Tregs and Bregs, but that was not associated with increased disease activity or increased inflammation. TRIAL REGISTRATION: Improved Ability to Cope With Everyday Life Through a Person-centered Training Program in Elderly Patients With Rheumatoid Arthritis - PEP-walk Study, NCT02397798. Registered at ClinicalTrials.gov March 19, 2015.

Moderate-to-high intensity exercise with person-centered guidance influences fatigue in older adults with rheumatoid arthritis.

Fatigue is described as a dominant and disturbing symptom of rheumatoid arthritis (RA) regardless of the advances in pharmacological treatment. Fatigue is also found to correlate with depression. The objective was to evaluate the impact of moderate-to-high intensity, aerobic and resistance exercise with person-centered guidance on fatigue, anxiety and depression, in older adults with RA. Comparisons were made between older adults (> 65 years) with RA taking part in a 20-week moderate-to-high intensity exercise at a gym (n = 36) or in home-based exercise of light intensity (n = 38). Assessments were performed at baseline, at 20 weeks, and at 52 weeks. Outcomes were differences in Multidimensional Fatigue Inventory (MFI-20), Visual Analog Scale Fatigue (VAS fatigue), and Hospital Anxiety and Depression Scale (HADS). Analysis of metabolomics was also performed. The subscales "physical fatigue" and "mental fatigue" in MFI-20 and symptoms of depression using HADS depression scale improved significantly at week 20 in the exercise group compared with the control group. Exercise did not influence global fatigue rated by VAS or subscales "reduced motivation", "reduced activity" and "general fatigue" in MFI-20. No significant change was found on the anxiety index of HADS. The improvements in physical fatigue were associated with changes in the metabolism of lipids, bile acids, the urea cycle and several sugars. Moderate-to-high intensity exercise with person-centered guidance decreased fatigue and improved symptoms of depression and were accompanied by metabolic changes in older adults with RA.

Controlled, cross-sectional, multi-center study of physical capacity and associated factors in women with fibromyalgia.

BACKGROUND: Health and physical capacity are commonly associated with disease, age, and socioeconomic factors. The primary objective of this study was to investigate the degree to which physical capacity, defined as muscle strength and walking ability, is decreased in women with fibromyalgia (FM), as compared to healthy women, who are matched for age and level of education. The secondary aim was to investigate whether muscle strength and walking ability are associated with age, symptom duration, activity limitations and, Body Mass Index (BMI) in women with FM and control subjects. METHODS: This controlled, cross-sectional, multi-center study comprised 118 women with FM and 93 age- and education-level-matched healthy women. The outcome measures were isometric knee-extension force, isometric elbow-flexion force, isometric hand-grip force, and walking ability. Differences between the groups were calculated, and for the women with FM analyses of correlations between the measures of physical capacity and variables were performed. RESULTS: The women with FM showed 20% (p < 0.001) lower isometric knee-extension force, 36% (p < 0.001) lower isometric elbow-flexion force, 34% (p < 0.001) lower isometric hand-grip force, and 16% lower walking ability (p < 0.001), as compared to the healthy controls. All measures of muscle strength in women with FM showed significant weak to moderate relationship to symptom duration (rs = - 0.23-0.32) and walking ability (rs = 0.25-0.36). Isometric knee-extension force correlated with activity limitations, as measured using the SF-36 Physical function subscale (rs=0.23, p = 0.011). CONCLUSIONS: Physical capacity was considerably decreased in the women with FM, as compared to the age- and education-level-matched control group. All measures of physical capacity showed a significant association with symptom duration. Knee-extension force and walking ability were significantly associated with activity limitations, age, and BMI. It seems important to address this problem and to target interventions to prevent decline in muscle strength. Assessments of muscle strength and walking ability are easy to administer and should be routinely carried out in the clinical setting for women with FM. TRIAL REGISTRATION: ClinicalTrials.gov identification number: NCT01226784 , Oct 21, 2010.

Acute effects of physical exercise on the serum insulin-like growth factor system in women with fibromyalgia.

BACKGROUND: Increased Serum insulin-like growth factor-1 (S-IGF-1) has been noted after physical activity in healthy subjects, while the acute release of S-IGF-1 in relation to exercise has not previously been studied in women with fibromyalgia (FM). S-IGF-1 and its binding protein (S-IGFBP-3) are mediated by growth hormone and have anabolic effects on the skeletal muscle. Aim of the study was to investigate acute release of IGF-1 after aerobic exercise in women with FM. METHODS: The acute effect of physical exercise on S-IGF-1 and S-IGFBP-3 were studied in 22 women with FM and in 27 healthy controls during moderate and high-intensity cycling (i.e. ratings 12-13 and 15-17, on Borg's perceived exertion scale (RPE), respectively). Self-reported pain and fatigue were recorded. Differences within and between the two groups were analyzed. RESULTS: After 15 min of bicycling, S-IGF-1 and S-IGFBP-3 increased both within the group with FM and in the healthy controls (p < 0.01). The increases in S-IGF-1 did not significantly differ between the women with FM and the healthy control group (mean increase 11 ± 10 vs. 11 ± 15 ng/ml and 13 ± 10 vs. 19 ± 22 ng/ml) when bicycling at moderate or high intensity, respectively. Self-reported pain and fatigue during exercise, irrespective of intensity, were higher in women with FM compared with healthy controls (p < 0.001). CONCLUSIONS: Fifteen minutes bicycling at moderate intensity was sufficient to acutely mobilise S-IGF-1 in women with FM similarly to healthy controls in spite of higher score of fatigue and pain in women with FM. Hence, patients with FM were able to activate their skeletal muscle metabolism during a short, moderate bout of exercise and were not resistant to training effects. The result is important for encouraging clinical rehabilitation of patients with FM who commonly exercise at a moderate, rather than at a high-intensity level. TRIAL REGISTRATION: ClinicalTrials.govNCT01592916 , May 4, 2012.

Benefits of resistance exercise in lean women with fibromyalgia: involvement of IGF-1 and leptin.

BACKGROUND: Chronic pain and fatigue improves by exercise in fibromyalgia (FM) but underlying mechanisms are not known. Obesity is increased among FM patients and associates with higher levels of pain. Symptom improvement after aerobic exercise is affected by body mass index (BMI) in FM. Metabolic factors such as insulin-like growth factor 1 (IGF-1) and leptin may be involved. In this study, the aim was to evaluate the role of metabolic factors in lean, overweight and obese women during resistance exercise, in relation to symptom severity and muscle strength in women with FM. METHODS: Forty-three women participated in supervised progressive resistance exercise, twice weekly for 15-weeks. Serum free and total IGF-1, IGF-binding protein 3 (IGFBP3), adiponectin, leptin and resistin were determined at baseline and after 15-weeks. Level of current pain was rated on a visual analogue scale (0-100 mm). Level of fatigue was rated by multidimensional fatigue inventory (MFI-20) subscale general fatigue (MFIGF). Knee extension force, elbow flexion force and handgrip force were assessed by dynamometers. RESULTS: Free IGF-1 (p = 0.047), IGFBP3 (p = 0.025) and leptin (p = 0.008) were significantly decreased in lean women (n = 18), but not in the overweight (n = 17) and the obese (n = 8). Lean women with FM benefited from resistance exercise with improvements in current pain (p= 0.039, n = 18), general fatigue (MFIGF, p = 0.022, n = 18) and improved elbow-flexion force (p = 0.017, n = 18). In overweight and obese women with FM there was no significant improvement in pain or fatigue but an improvement in elbow flexion (p = 0.049; p = 0.012) after 15 weeks of resistance exercise. CONCLUSION: The clearest clinical response to resistance exercise was found in lean patients with FM. In these individuals, individualized resistance exercise was followed by changes in IGF-1 and leptin, reduced pain, fatigue and improved muscular strength. In overweight and obese women FM markers of metabolic signaling and clinical symptoms were unchanged, but strength was improved in the upper limb. Resistance exercise combined with dietary interventions might benefit patients with FM and overweight. TRIAL REGISTRATION: The trial was registered 21 of October 2010 with ClinicalTrials.gov identification number: NCT01226784 .

The translocator protein gene is associated with symptom severity and cerebral pain processing in fibromyalgia.

The translocator protein (TSPO) is upregulated during glia activation in chronic pain patients. TSPO constitutes the rate-limiting step in neurosteroid synthesis, thus modulating synaptic transmission. Related serotonergic mechanisms influence if pro- or anti-nociceptive neurosteroids are produced. This study investigated the effects of a functional genetic polymorphism regulating the binding affinity to the TSPO, thus affecting symptom severity and cerebral pain processing in fibromyalgia patients. Gene-to-gene interactions with a functional polymorphism of the serotonin transporter gene were assessed. Fibromyalgia patients (n=126) were genotyped regarding the polymorphisms of the TSPO (rs6971) and the serotonin transporter (5-HTTLPR/rs25531). Functional magnetic resonance imaging (n=24) was used to study brain activation during individually calibrated pressure pain. Compared to mixed/low TSPO affinity binders, the high TSPO affinity binders rated more severe pain (p=0.016) and fibromyalgia symptoms (p=0.02). A significant interaction was found between the TSPO and the serotonin transporter polymorphisms regarding pain severity (p<0.0001). Functional connectivity analyses revealed that the TSPO high affinity binding group had more pronounced pain-evoked functional connectivity in the right frontoparietal network, between the dorsolateral prefrontal area and the parietal cortex. In conclusion, fibromyalgia patients with the TSPO high affinity binding genotype reported a higher pain intensity and more severe fibromyalgia symptoms compared to mixed/low affinity binders, and this was modulated by interaction with the serotonin transporter gene. To our knowledge this is the first evidence of functional genetic polymorphisms affecting pain severity in FM and our findings are in line with proposed glia-related mechanisms. Furthermore, the functional magnetic resonance findings indicated an effect of translocator protein on the affective-motivational components of pain perception.

Effects of Person-Centered Physical Therapy on Fatigue-Related Variables in Persons With Rheumatoid Arthritis: A Randomized Controlled Trial.

OBJECTIVE: To examine effects of person-centered physical therapy on fatigue and related variables in persons with rheumatoid arthritis (RA). DESIGN: Randomized controlled trial. SETTING: Hospital outpatient rheumatology clinic. PARTICIPANTS: Persons with RA aged 20 to 65 years (N=70): intervention group (n=36) and reference group (n=34). INTERVENTIONS: The 12-week intervention, with 6-month follow-up, focused on partnership between participant and physical therapist and tailored health-enhancing physical activity and balancing life activities. The reference group continued with regular activities; both groups received usual health care. MAIN OUTCOME MEASURES: Primary outcome was general fatigue (visual analog scale). Secondary outcomes included multidimensional fatigue (Bristol Rheumatoid Arthritis Fatigue Multi-Dimensional Questionnaire) and fatigue-related variables (ie, disease, health, function). RESULTS: At posttest, general fatigue improved more in the intervention group than the reference group (P=.042). Improvement in median general fatigue reached minimal clinically important differences between and within groups at posttest and follow-up. Improvement was also observed for anxiety (P=.0099), and trends toward improvements were observed for most multidimensional aspects of fatigue (P=.023-.048), leg strength/endurance (P=.024), and physical activity (P=.023). Compared with the reference group at follow-up, the intervention group improvement was observed for leg strength/endurance (P=.001), and the trends toward improvements persisted for physical (P=.041) and living-related (P=.031) aspects of fatigue, physical activity (P=.019), anxiety (P=.015), self-rated health (P=.010), and self-efficacy (P=.046). CONCLUSIONS: Person-centered physical therapy focused on health-enhancing physical activity and balancing life activities showed significant benefits on fatigue in persons with RA.

Seasonal variations in fatigue in persons with rheumatoid arthritis: a longitudinal study.

BACKGROUND: Fatigue is a prominent symptom in persons with rheumatoid arthritis (RA). Although this symptom has been described to vary in duration and frequency little is known about fluctuations in fatigue over time and season. The aim of this study was to describe monthly and seasonal variations in fatigue, in persons with RA of working age. METHODS: Sixty-five participants diagnosed with RA and aged 20-65 years were recruited from a rheumatology clinic in Sweden. The participants provided self-assessments of their fatigue at seven time points during the four seasons using a 0-100 mm visual analogue scale (VAS) and the Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire (BRAF-MDQ). Multiple regression analysis using mixed models was used to analyze changes in fatigue over time. RESULTS: The mean ± SD of fatigue rated on the VAS was 51 ± 13, indicating substantial fatigue. Analysis of monthly variation showed statistically significant variation in fatigue ratings concerning VAS fatigue score (p < 0.01) as well as the BRAF-MDQ total score and Living, Cognition (p < 0.001), and Physical (p < 0.05) sub-scores, but not the BRAF-MDQ Emotional sub-score. The greatest variations were seen from January to September, with higher fatigue ratings in January. The changes in VAS fatigue scores over time were considered to be of clinical importance. Analysis of seasonal variation revealed a statistically significant seasonal variation in fatigue levels, with higher fatigue values during the winter as measured by VAS fatigue score (p < 0.01) as well as BRAF-MDQ total score (p < 0.01) and Physical and Living sub-scores (both p < 0.01). The greatest variation was seen between winter and autumn for VAS fatigue and between winter and summer for BRAF-MDQ total score and Physical and Living sub-scores. There were no statistical differences in fatigue levels, monthly or seasonal, between sexes or age groups. CONCLUSIONS: The majority of rating scales used in this study showed fluctuations in fatigue, general and physical fatigue being significantly greater during the winter. As fatigue is a substantial symptom in many persons with RA, this information is important for rheumatology professionals when dealing with persons with RA in routine care.

Profile of circulating microRNAs in fibromyalgia and their relation to symptom severity: an exploratory study.

Fibromyalgia (FM) is characterized by generalized chronic pain and reduced pain thresholds. Disturbed neuroendocrine function and impairment of growth hormone/insulin-like growth factor-1 is common. However, the pathophysiology of FM is not clear. MicroRNAs are important regulatory factors reflecting interface of genes and environment. Our aim was to identify characteristic microRNAs in FM and relations of specific microRNAs with characteristic symptoms. A total of 374 circulating microRNAs were measured in women with FM (n = 20; median 52.5 years) and healthy women (n = 20; 52.5 years) by quantitative PCR. Pain thresholds were examined by algometry. Pain [fibromyalgia impact questionnaire (FIQ) pain] levels were rated (0-100 mm) using FIQ. Fatigue (FIQ fatigue) was rated (0-100 mm) using FIQ and multidimensional fatigue inventory general fatigue. Sleep quantity and quality (1-4) rated from satisfactory to nonsatisfactory. Higher scores indicate more severe symptoms. Eight microRNAs differed significantly between FM and healthy women. Seven microRNAs, miR-103a-3p, miR-107, let-7a-5p, miR-30b-5p, miR-151a-5p, miR-142-3p and miR-374b-5p, were lower in FM. However, levels of miR-320a were higher in FM. MiR-103a-3p correlated with pain (r = 0.530, p = 0.016) and sleep quantity (r = 0.593, p = 0.006) in FM. MiR-320a correlated inversely with pain (r = -0.468, p = 0.037). MiR-374b-5p correlated inversely with pain threshold (r = -0.612, p = 0.004). MiR-30b-5p correlated with sleep quantity (r = 0.509, p = 0.022), and let-7a-5p was associated with sleep symptoms. When adjusted for body mass index, the correlation of sleep quantity with miR-103a and miR-30b was no longer significant. To our knowledge, this is the first study of circulating microRNAs in FM. Levels of several microRNAs differed significantly in FM compared to healthy women. Three microRNAs were associated with pain or pain threshold in FM.

Psychometric properties of the Stress and Crisis Inventory (SCI-93) in females with fibromyalgia and chronic widespread pain.

BACKGROUND: Fibromyalgia (FM) and chronic widespread pain (CWP) are commonly associated with symptoms such as fatigue, stiffness, tension, exhaustion and psychological distress. Research on biological markers of the degree of stress symptoms has been conducted for decades. However, biological markers do not offer sufficient information for clinical practice, and thus, validated rating scales are still the best assessment option. The Stress and Crisis Inventory-93 (SCI-93) was designed to assess the severity of symptoms that are primarily related to the autonomous nervous system. OBJECTIVE: The purpose of this study was to evaluate the psychometric properties of the SCI-93 with regard to known-group validity, internal consistency and test-retest reliability. METHODS: The study included 166 women with FM or CWP in addition to 157 age-matched healthy women. The test-retest reliability was investigated in 40 women with FM. RESULTS: A one-factor solution was chosen, which explained 53% of the total variance; Cronbach's alpha was 0.98. The group of patients with FM and CWP showed significantly higher SCI-93 total scores than the healthy reference group (mean = 76.4 ± 24.9 vs. mean = 24.9 ± 21.3; P < 0.001), supporting known-group validity. In the test-retest reliability study, the intra class correlation for the SCI-93 total score was 0.95. CONCLUSIONS: The SCI-93 demonstrated satisfactory known-group validity and test-retest reliability. The instrument appears to reflect well the severity of autonomous symptoms.

Smoking is associated with reduced leptin and neuropeptide Y levels and higher pain experience in patients with fibromyalgia.

Smoking deregulates neuroendocrine responses to pain supporting production of neuropeptide Y (NpY) by direct stimulation of nicotinic receptors or by inhibiting adipokine leptin. Present study addressed the effect of cigarette smoking on adipokines and pain parameters, in 62 women with fibromyalgia (FM) pain syndrome with unknown etiology. Pain was characterized by a visual analogue scale, tender point (TP) counts, pressure pain threshold, and neuroendocrine markers NpY and substance P (sP). Levels of IGF-1, leptin, resistin, visfatin, and adiponectin were measured in blood and cerebrospinal fluid. Current smokers (n = 18) had lower levels of leptin compared to ex-smokers (n = 25, P = 0.002), while the expected NpY increase was absent in FM patients. In smokers, this was transcribed in higher VAS-pain (P = 0.04) and TP count (P = 0.03), lower pain threshold (P = 0.01), since NpY levels were directly related to the pain threshold (rho = 0.414) and inversely related to TP counts (rho = -0.375). This study shows that patients with FM have no increase of NpY levels in response to smoking despite the low levels of leptin. Deregulation of the balance between leptin and neuropeptide Y may be one of the essential mechanisms of chronic pain in FM.

Physical activity with person-centered guidance supported by a digital platform or with telephone follow-up for persons with chronic widespread pain: Health economic considerations along a randomized controlled trial.

OBJECTIVES: The aim was to investigate the resource use and costs associated with the co-creation of a physical activity plan for persons with chronic widespread pain (CWP) followed by support through a digital platform, compared to telephone follow-up. METHODS: In this 12-month cost comparison study following up results after a randomized controlled trial, individuals with CWP, aged 20-65 years, were recruited at primary healthcare units in Western Sweden. All participants developed a person-centered health-enhancing physical activity plan together with a physiotherapist. Participants were then randomized to either an intervention group (n = 69) who had a follow-up visit after 2 weeks and was thereafter supported through a digital platform, or an active control group (n = 70) that was followed up through one phone call after a month. Costs to the health system were salary costs for the time recorded by physiotherapists when delivering the interventions. RESULTS: The reported time per person (2.8 h during the 12 months) corresponded to costs of SEK 958 (range: 746-1,517) for the initial visits and follow-up (both study groups), and an additional 2.5 h (corresponding to a mean SEK 833; range: 636-1,257) for the time spent in the digital platform to support the intervention group. CONCLUSION: After co-creation of a physical activity plan, it was more costly to support persons through a digital platform, compared to telephone follow-up.

Factors promoting improvements in symptoms and health in women with fibromyalgia and chronic widespread pain: a qualitative interview study.

PURPOSE: To describe experiences of improvement among women with chronic widespread pain (CWP). MATERIALS AND METHODS: Recruitment was made from a cohort of women with CWP who participated in a 10- to 12-year follow-up study in 2016. The inclusion criterion was an improvement of at least 30% on a visual analog scale of pain intensity between baseline and follow-up. Seventeen women participated in semi-structured interviews. Data were analysed using qualitative content analysis. RESULTS: The analysis resulted in three categories with eight subcategories: Experience of improvement included feeling better despite persisting symptoms and to be capable of more activity. Developing strategies for better health included choosing to act to improve health, developing a constructive mental approach to the illness, and changing one's view of oneself and one's life. Contextual factors supporting improvement included support from healthcare, social support from one's environment, and reduced load in daily life. CONCLUSIONS: Experiences of health improvement involved active changes as well as contextual factors. Clinical implications of this study are that increased knowledge regarding pain management, increased physical activity, and reduced stress could contribute to symptom improvement in persons with CWP.

The women's own actively chosen changes and contextual factors appear to be important for the improvement of chronic widespread pain.Treatments that contribute to increased knowledge regarding pain management, increased level of physical activity, and reduced stress were found to be of importance for the improvement of chronic widespread pain.Women with chronic widespread pain could be gained by person-centered rehabilitation based on their individual needs and resources.

Person-centred health plans for physical activity in persons with chronic widespread pain (CWP) - a retrospective descriptive review.

PURPOSE: Physical activity is recommended as first-choice treatment in chronic pain conditions. The aim was to describe the content and perceptions of person-centred health plans, and to evaluate patients' implementation of the health plan in their everyday life. MATERIALS AND METHODS: A descriptive retrospective review was conducted of person-centred health plans to support physical activity in 133 participants. Quantitative content analysis was used to analyse the content of the health plans. Questionnaires on physical activity and on implementation and perception of the health plans, and a test of physical capacity were administered. RESULTS: Participants' goals were found to be related to physical function (n = 118), general health (n = 90), activity and participation (n = 80) and symptoms (n = 35). Participants identified personal (n = 174), social (n = 69) and material resources (n = 36). They identified fears and obstacles related to health issues (n = 95), difficulties getting it done (n = 41), competing priorities (n = 19) and contextual factors (n = 12). Participants identified need for external support (n = 110). Participants' level of physical activity and physical capacity increased significantly during the first 6 months of the study. CONCLUSION: The person-centred approach seems helpful in enhancing motivation to achieve set goals and strengthen self-efficacy in physical activity also supported by increased physical activity and physical capacity. Implications for rehabilitationA person-centred approach can be helpful to enhance motivation to achieve set goals and self-efficacy to manage symptoms when engaging in physical activity.Shared documentation of a personal health plan helps to visualize resources to promote regular physical activity as well as alternative ways to reach set goals.The co-created health-plan captures the participant's goals, resources, fears and need of support, helps the participant to overcome challenges, and supports the participant to be physically active.

Expertise and individually tailored interventions are expected by pregnant women with pelvic girdle pain who seek physical therapy: a qualitative study.

BACKGROUND: Pelvic girdle pain (PGP) in pregnancy may result in activity limitations and thus a negative impact on the individual woman's everyday life. Women's expectations when they seek physical therapy because of PGP are not yet known. OBJECTIVE: To explore pregnant women's lived experience of PGP and what needs and expectations they express prior to a physical therapy consultation. METHODS: A qualitative study using a descriptive phenomenological method. Interviews conducted with 15 pregnant women seeking physical therapy because of PGP, recruited through purposive sampling at one primary care rehabilitation clinic. RESULTS: PGP was described by four themes; An experience with larger impact on life than expected, A time for adjustments and acceptance, A feeling of insecurity and concern, A desire to move forward. PGP had a large impact on the pregnant women´s life. Thoughts of PGP as something to be endured was expressed, the women therefore accepted the situation. Finding strategies to manage everyday life was hard and when it failed, the women described despair and a need for help. They expected the physical therapist to be an expert who would see them as individuals and provide advice that could make their everyday life easier. CONCLUSION: Our results reveal that pregnant women with PGP delay seeking physical therapy until their situation becomes unmanageable and they run out of strategies for self-care. The women express, in light of their individual experiences, needs and expectations for professional management and advice tailored to their individually unique situation.

The Vastus Lateralis Muscle Interstitium Proteome Changes after an Acute Nociception in Patients with Fibromyalgia Compared to Healthy Subjects-A Microdialysis Study.

Fibromyalgia (FM) is a complex disorder and a clinical challenge to diagnose and treat. Microdialysis is a valuable tool that has been used to investigate the interstitial proteins and metabolites of muscle in patients with fibromyalgia. The implantation of the catheter in the muscle causes acute tissue trauma and nociception. The aim of this study was to investigate acute proteome changes in the vastus lateralis muscle in women fibromyalgia patients (FM) and healthy subjects (CON). A further aim was to study if a 15-week resistance exercise program in FM had any influence on how chronic painful muscle responds to acute nociception. Twenty-six women patients with FM and twenty-eight CON were included in this study. A microdialysis catheter (100 kilo Dalton cut off, membrane 30 mm) was inserted in the vastus lateralis muscle, and samples were collected every 20 min. Subjects rated pain before catheter insertion, directly after, and every 20 min of sample collection. Dialysate samples from time points 0-120 were pooled and considered trauma samples due to the catheter insertion. The samples were analyzed with nano-liquid chromatography-tandem mass spectrometry (nLC-MS/MS). Advanced multivariate data analysis was used to investigate protein profile changes between the groups. Multivariate data analysis showed significant (CV-ANOVA p = 0.036) discrimination between FM and CON based on changes in 26 proteins. After the 15-week exercise intervention, the expression levels of the 15 proteins involved in muscle contraction, response to stimulus, stress, and immune system were increased to the same expression levels as in CON. In conclusion, this study shows that microdialysis, in combination with proteomics, can provide new insights into the interstitial proteome in the muscle of FM. In response to acute nociception, exercise may alter the innate reactivity in FM. Exercise may also modulate peripheral muscle proteins related to muscle contraction, stress, and immune response in patients with FM.

The effects of a 15-week physical exercise intervention on pain modulation in fibromyalgia: Increased pain-related processing within the cortico-striatal- occipital networks, but no improvement of exercise-induced hypoalgesia.

Dysfunctional top-down pain modulation is a hallmark of fibromyalgia (FM) and physical exercise is a cornerstone in FM treatment. The aim of this study was to explore the effects of a 15-week intervention of strengthening exercises, twice per week, supervised by a physiotherapist, on exercise-induced hypoalgesia (EIH) and cerebral pain processing in FM patients and healthy controls (HC). FM patients (n = 59) and HC (n = 39) who completed the exercise intervention as part of a multicenter study were examined at baseline and following the intervention. Following the exercise intervention, FM patients reported a reduction of pain intensity, fibromyalgia severity and depression. Reduced EIH was seen in FM patients compared to HC at baseline and no improvement of EIH was seen following the 15-week resistance exercise intervention in either group. Furthermore, a subsample (Stockholm site: FM n = 18; HC n = 19) was also examined with functional magnetic resonance imaging (fMRI) during subjectively calibrated thumbnail pressure pain stimulations at baseline and following intervention. A significant main effect of exercise (post > pre) was observed both in FM patients and HC, in pain-related brain activation within left dorsolateral prefrontal cortex and caudate, as well as increased functional connectivity between caudate and occipital lobe bordering cerebellum (driven by the FM patients). In conclusion, the results indicate that 15-week resistance exercise affect pain-related processing within the cortico-striatal-occipital networks (involved in motor control and cognition), rather than directly influencing top-down descending pain inhibition. In alignment with this, exercise-induced hypoalgesia remained unaltered.