A case of mistaken identity? The role of injury representations in chronic musculoskeletal pain.

PURPOSE: To explore how patients construe bodily injury, examine how injury representations change over the course of a rehabilitation program and how injury representations influence adaptation and recovery trajectories. METHODS: A case study method was used with qualitative interviews as the primary data source. Qualitative semi-structured interviews were conducted three times over the course of a 12-week intensive interdisciplinary occupational rehabilitation program with one interview 1 month following discharge. To capture changes in rehabilitation trajectories, data analysis employed a narrative approach informed by Bury (progression, regression, and stability) and Frank's (chaos, restitution, and quest) approaches. RESULTS: Sixteen patients (10 men and 6 women) were disabled as a result of persistent pain and impairment from a variety of work injuries participated. Progression/restitution narratives were characterized by the transformation of bone and nerve problems to include soft tissue elements. These participants expanded their scope of injury representations and appraisal to include neurobiological aspects of chronic pain and dimensions of psychosocial well-being, and linked diagnostic representations to self-management strategies in a functional manner. CONCLUSION: Body representations of injury morphology and pain mechanisms are important objects of fear and acceptance for injury recovery. Active strategies that encourage a "hands on" understanding of diagnosis may prove most effective in treating persistent pain. IMPLICATIONS FOR REHABILITATION: Patient representations of pain and body injury are windows into the personal experience of individuals with chronic musculoskeletal pain. When patients enter programs, practitioners need to assess what the patient believes is wrong with their body and what will be helpful in rectifying the problem. Based on their initial assessment, practitioners need to direct education and activity toward shifting patient beliefs to include elements of soft tissue and a broader scope of pain sensitization and psychological impact. Activity-based intervention is essential for creating coherence between injury and pain representations and coping action. During rehabilitation, practitioners need to monitor patient beliefs about their injury. Shifting beliefs are signs that the patient is adopting a more adaptive cognitive stance toward their injury. Lack of movement indicates that the message is not getting through and the approach needs to be modified. When working with patients to transform beliefs, a collaborative approach might be best to increase trust and reduce reactance.

Work reintegration and cardiovascular disease: medical and rehabilitation influences.

INTRODUCTION: Research into work reintegration following cardiovascular disease onset is limited in its clinical and individual focus. There is no research examining worker experience in context during the return to work process. METHODS: Qualitative case study method informed by applied ethnography. Worker experience was assessed through longitudinal in-depth interviews with 12 workers returning to work following disabling cardiac illness. Workplace context (Canadian auto manufacturing plant) was assessed through site visits and meetings with stakeholders including occupational health personnel. Data was analyzed using constant comparison and progressive coding. RESULTS: Twelve men (43-63 years) participated in the study. Results revealed that unyielding production demands and performance monitoring pushed worker capacities and caused "insidious stress". Medical reassurance was important in the workers' decisions to return to work and stay on the job but medical restrictions were viewed as having limited relevance owing to limited understanding of work demands. Medical sanction was important for transient absence from the workplace as well as permanent disability. Cardiac rehabilitation programs were beneficial for lifestyle modification and building exercise capacity, but had limited benefit on work reintegration. Occupational health provided monitoring and support during work reintegration. CONCLUSIONS: Medical reassurance can be an important influence on worker representations of disease threat. Medical advice as it pertained to work activities was less valued as it lacked considerations of work conditions. Cardiac rehabilitation lacked intensity and relevance to work demands. Occupational health was reassuring for workers and played an important role in developing return to work plans.

Comparative effectiveness of accommodating and weight resistance training modes.

Six men and six women trained the elbow flexors of both arms 3 d.wk-1 for 20 wk. In each training session, one arm did 3-5 sets of 10 maximal concentric actions on an accommodating resistance device (ARD), the other arm 3-5 sets of 8-12 coupled eccentric/concentric actions (repetitions) to volitional failure (8-12 RM) on a weight resistance device (WRD). The average "intensity" (force of concentric actions) was approximately 1.25 times greater in ARD training, the average "volume" (number of actions x force of actions) 1.6 times greater in WRD training, and the time required to complete a training session the same for each. Both types of training produced significant increases in a single maximum weight lift (1 RM on the WRD), in the peak force of a single maximal concentric action measured on the ARD and an isovelocity dynamometer, and in biceps, brachialis, and total elbow flexor cross-sectional area (CSA). Biceps Type I and II fiber area did not change significantly. WRD training produced greater increases than ARD training in the 1 RM test on the WRD and in brachialis CSA. The data indicate that both of these common training regimens effectively increase strength and muscle mass, but the weight training regimen may be more effective for increasing muscle mass.

Response to resistance training in young women and men.

Six women and 6 men trained the elbow flexors 3 days per week for 20 wks, one arm performing in each session 3-5 sets of 10 maximal concentric actions on an accommodating resistance device, the other arm 3-5 sets of 8-12 coupled eccentric/concentric actions on a weight training device. With results collapsed across the two training modes, the women made significantly (p < 0.05) greater relative increases than men in strength measured on the weight (116 vs. 46%) and accommodating (99 vs. 46%) resistance devices, and greater absolute (3.5 vs. -1.3 N.m) and relative (13.7 vs. -3.2%) increases in strength measured on an isokinetic dynamometer. Absolute (cm2) and relative (%) biceps, brachialis, and total elbow flexor cross-sectional area (from CT scans) increased significantly; however, the women's vs. men's respective relative and absolute increases did not differ significantly: biceps (13 vs. 7%, 0.9 vs. 1.0 cm2), brachialis (53 vs. 31%, 2.1 vs. 2.3 cm2), and total (26 vs. 15%, 3.1 vs. 3.3 cm2) flexor area. Biceps type I and II fiber area, and the II/I area ratio did not increase significantly. The data indicate that in response to the same short-term training program, muscle size increases similarly in women and men but women make greater relative increases in strength.