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  • 1.
    Börsbo, Björn
    et al.
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Neuroscience and Locomotion, Rehabilitation Medicine.
    Lemming, Dag
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Neuroscience and Locomotion, Rehabilitation Medicine. Östergötlands Läns Landsting, Centre for Medicine, Pain and Rehabilitation Centre.
    Utredning och klinisk undersökning av personer med kronisk smärta2006In: Rehabiliteringsmedicin - Teori och praktik / [ed] Jörgen Borg, Lund: Studenlitteratur , 2006, 1, p. 91-96Chapter in book (Other academic)
    Abstract [sv]

      Kapitel om rehabiliteringsmedicinens utveckling och nuvarande plats i sjukvården samt begrepp och metodik inleder boken. I två delar ges därefter rehabiliteringsmedicinska aspekter på de dominerande sjukdomsgrupperna - komplexa smärttillstånd respektive skador och sjukdomar i nervsystemet. Som avslutning beskrivs bland annat  stressrelaterade tillstånd. Läroboken är avsedd för grundutbildning av läkare, arbetsterapeuter och sjukgymnaster, logopeder samt för läkare under AT-tjänstgöring. Den är också lämplig som introduktion i specialistutbildningen i rehabiliteringsmedicin, geriatrik, neurologi och smärtlindring. Vidareutbildningar av olika vårdyrkesgrupper kan ha nytta av boken och den kan också användas som referenslitteratur av yrkesverksamma med intresse för rehabiliteringsmedicin.

  • 2.
    Gerdle, Björn
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Medicine, Pain and Rehabilitation Centre.
    Lemming, Dag
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Medicine, Pain and Rehabilitation Centre.
    Kristiansen, Jesper
    Cyncron A/S.
    Larsson, Britt
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Medicine, Pain and Rehabilitation Centre.
    Peolsson, Michael
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences.
    Rosendal, Lars
    National Research Centre for the Working Environment.
    Biochemical alterations in the trapezius muscle of patients with chronic whiplash associated disorders (WAD): A microdialysis study2008In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 12, no 1, p. 82-93Article in journal (Refereed)
    Abstract [en]

    The mechanisms behind the development of chronic trapezius myalgia in patients with whiplash associated disorders (WAD) appear to involve both peripheral and central components, but the specific contribution of alterations in muscle is not clear. Female patients with WAD and involvement of trapezius (N = 22) and female controls (N = 20; CON) were studied during an experiment compromised of rest (baseline), 20 min repetitive low-force exercise and 120 min recovery. Their interstitial concentrations of serotonin (5-HT), glutamate, lactate, pyruvate, potassium, interleukin-6 (IL-6), and blood flow were determined in the trapezius muscle using a microdialysis technique. Pressure pain thresholds (PPT) over trapezius and tibialis anterior muscles were also assessed. In WAD, we found signs of generalized hypersensitivity according to PPT. The WAD group had significantly higher interstitial [IL-6] and [5-HT] in the trapezius than the CON. [Pyruvate] was overall significantly lower in WAD, and with lactate it showed another time-pattern throughout the test. In the multivariate regression analysis of pain intensity [5-HT] was the strongest regressor and positively correlated with pain intensity in WAD. In addition, blood flow, [pyruvate], and [potassium] influenced the pain intensity in a complex time dependent way. These findings may indicate that peripheral nociceptive processes are activated in WAD with generalized hypersensitivity for pressure and they are not identical with those reported in chronic work-related trapezius myalgia, which could indicate different pain mechanisms.

  • 3.
    Lemming, Dag
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Medicine, Pain and Rehabilitation Centre.
    Experimental Aspects on Chronic Whiplash-Associated Pain2008Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Introduction: Chronic pain after whiplash trauma (chronic WAD) to the neck is still a common clinical problem in terms of pain management, rehabilitation and insurance claims. In contrast to the increased knowledge concerning mechanisms of chronic pain in general, no clinical guidelines exist concerning assessment, pain control and rehabilitation of patients with chronic WAD.

    Aim: The general aim of this thesis was to use experimental techniques to better understand the complex mechanisms underlying chronic pain after whiplash trauma. The specific aims of papers I and II were mainly to use analgesic drugs with different target mechanisms alone or in combinations to assess their effects on pain intensity (VAS). Experimental pain techniques were used in all studies to assess deep tissue sensitivity (electrical, mechanical and chemical stimuli). Paper IV aimed at assessing deep tissue sensitivity to mechanical and chemical stimulation. The aim in paper III was to investigate if biochemical changes in interstitial muscle tissue (trapezius muscle) could be detected in WAD patients.

    Materials and Methods: The thesis is based on three different groups of patients with chronic WAD. In paper III and IV two different groups of healthy controls also participated. All patients were initially assessed in the pain and rehabilitation centre. In paper I (30 patients) and II (20 patients) two different techniques of drug challenges were used. In paper I: morphine, ketamine and lidocaine were used as single drugs. In paper II: remifentanil, ketamine and placebo were used in combinations and together with experimental pain assessments. Microdialysis technique was used in paper III (22 patients from study IV and 20 controls). In paper IV (25 patients and 10 controls) a new quantitative method, computerized cuff pressure algometry, was used in combination with intramuscular saline. In all papers, experimental pain techniques for deep tissue assessment (except cutaneous electrical stimulation in paper I) were used in different combinations: intramuscular hypertonic saline infusion, intramuscular electrical stimulation and pressure algometry.

    Results and Conclusion: There are multiple mechanisms behind chronic whiplash-associated pain, opioid sensitive neurons, NMDA-receptors and even sodium channels might play a part. A significant share of the patients were pharmacological non-responders to analgesic drugs targeting the main afferent mechanisms involved in pain transmission, this implies activation of different pain processing mechanisms (i.e. enhanced facilitation or changes in the cortical and subcortical neuromatrix). Experimental pain assessments and drug challenges together indicate a state of central hyperexcitability. Ongoing peripheral nociception (paper III), central sensitization and dysregulation of pain from higher levels in the nervous system may interact. These findings are likely to be present early after a trauma, however it is not possible to say whether they are trauma-induced or actually represents pre-morbid variations. Clinical trials with early assessments of the somatosensory system (i.e., using experimental pain) and re-evaluations, early intervention (i.e. rehabilitation) and intensified pain management could give further knowledge.

    List of papers
    1. The responses to pharmacological challenges and experimental pain in patients with chronic whiplash-associated pain
    Open this publication in new window or tab >>The responses to pharmacological challenges and experimental pain in patients with chronic whiplash-associated pain
    Show others...
    2005 (English)In: The Clinical Journal of Pain, ISSN 0749-8047, E-ISSN 1536-5409, Vol. 21, no 5, p. 412-421Article in journal (Refereed) Published
    Abstract [en]

    Objectives: This study evaluates the analgesic responses to intravenous administration of morphine, lidocaine, and ketamine and their relations to duration of chronic pain after whiplash trauma. In addition, experimental muscle pain sensitivity and its correlation to pain duration and pharmacological responses were assessed.

    Methods: Thirty-three patients with diagnosed whiplash-associated disorder grade II in the chronic stage, according to the Quebec classification, were included. The pharmacological evaluation was performed in a randomized, double-blind, cross-over design and consisted of a 30-minute period of intravenous administration of morphine (0.3 mg/kg), lidocaine (5 mg/kg), ketamine (0.3 mg/kg), or placebo (isotonic saline). Intensity ratings of habitual pain on a visual analogue scale were taken before, during, and after the infusion. The patients were classified as nonresponders, placebo-responders, or responders (minimum 50% decrease of pain intensity) of the drugs. Pressure pain thresholds and intramuscular and cutaneous electrical stimulation pain thresholds were measured. The pain intensity during experimental muscle pain by intramuscular hypertonic saline was also recorded. Experimental pain assessments were performed on the lower legs outside the habitual painful area.

    Results: Thirty patients completed the study; 2 were placebo responders and 10 were nonresponders. Of 18 responders, there were 15 morphine responders, 11 lidocaine responders, and 14 ketamine responders. In the patients with whiplash-associated disorder duration less than 2 years, 7 responded to morphine, 5 to lidocaine, and 8 to ketamine. In the patients with pain duration longer than 2 years, 8 responded to morphine, 6 to lidocaine, and 6 to ketamine. Thus, no pattern with respect to pain duration was found. Seventeen patients participated in the experimental pain assessment, and no significant differences in the variables of the intramuscular and cutaneous stimulation and intramuscular-induced pain with respect to response to the pharmacological challenges or whiplash-associated disorder duration existed.

    Discussion: The pharmacological challenges identified subgroups of patients with chronic whiplash-associated disorder that might be considered before instituting therapeutic interventions or research. However, the pattern of responses to the pharmacological challenges did not show any clear relationships with pain duration or the experimental pain tests.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-12919 (URN)10.1097/01.ajp.0000126155.82815.fc (DOI)
    Available from: 2008-01-30 Created: 2008-01-30 Last updated: 2017-12-13
    2. Managing chronic whiplash associated pain with a combination of low-dose opioid (remifentanil) and NMDA-antagonist (ketamine)
    Open this publication in new window or tab >>Managing chronic whiplash associated pain with a combination of low-dose opioid (remifentanil) and NMDA-antagonist (ketamine)
    Show others...
    2007 (English)In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 11, no 7, p. 719-732Article in journal (Refereed) Published
    Abstract [en]

    The aim was to investigate the efficacy of a combination of low-dose remifentanil (REMI) and ketamine (KET) compared to the single drugs and placebo (P) on whiplash associated pain (WAD) in a double-blind, randomized, placebo-controlled, cross-over study.

    Twenty patients with chronic (>1 year) WAD were included. Four different drug combinations were tested in four sessions: placebo/placebo (P/P), placebo/remifentanil (P/REMI), ketamine/placebo (KET/P) and ketamine/remifentanil (KET/REMI). Target concentrations were 1 and 2 ng/ml (stepwise) for remifentanil and 100 ng/ml for ketamine.

    Habitual pain intensity was assessed on a visual analogue scale (VAS). Experimental pain was assessed with electrical stimulation (single and repeated) of tibialis anterior (TA) muscle, pressure pain algometry applied over infraspinatus (IS) and TA muscles and VAS scores after intramuscular hypertonic saline infusion in TA.

    KET/REMI significantly reduced habitual pain. KET/REMI infused at low REMI target concentration (1 ng/ml) significantly elevated electrical intramuscular pain thresholds (single and repeated). Pain thresholds to electrical stimulation were similarly increased by both P/REMI and KET/REMI at 2 ng/ml target concentration. Pressure pain thresholds were increased by both KET/REMI and P/REMI. VAS-scores after intramuscular saline were also similarly decreased by both REMI combinations. Seven out of 20 subjects were non-responders (<50% pain relief). No correlation was found between effects on spontaneous pain and experimental pain.

    KET/REMI showed an analgesic effect on habitual pain. Experimental pain was attenuated by both combinations containing the opioid, however, KET seemed to enhance the effect of REMI on electrical pain thresholds when a low REMI target concentration was used.

    Keywords
    WAD, Neck pain, Remifentanil, Ketamine, Experimental pain, Pain assessment
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-12920 (URN)10.1016/j.ejpain.2006.11.002 (DOI)
    Available from: 2008-01-30 Created: 2008-01-30 Last updated: 2017-12-13
    3. Biochemical alterations in the trapezius muscle of patients with chronic whiplash associated disorders (WAD): A microdialysis study
    Open this publication in new window or tab >>Biochemical alterations in the trapezius muscle of patients with chronic whiplash associated disorders (WAD): A microdialysis study
    Show others...
    2008 (English)In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 12, no 1, p. 82-93Article in journal (Refereed) Published
    Abstract [en]

    The mechanisms behind the development of chronic trapezius myalgia in patients with whiplash associated disorders (WAD) appear to involve both peripheral and central components, but the specific contribution of alterations in muscle is not clear. Female patients with WAD and involvement of trapezius (N = 22) and female controls (N = 20; CON) were studied during an experiment compromised of rest (baseline), 20 min repetitive low-force exercise and 120 min recovery. Their interstitial concentrations of serotonin (5-HT), glutamate, lactate, pyruvate, potassium, interleukin-6 (IL-6), and blood flow were determined in the trapezius muscle using a microdialysis technique. Pressure pain thresholds (PPT) over trapezius and tibialis anterior muscles were also assessed. In WAD, we found signs of generalized hypersensitivity according to PPT. The WAD group had significantly higher interstitial [IL-6] and [5-HT] in the trapezius than the CON. [Pyruvate] was overall significantly lower in WAD, and with lactate it showed another time-pattern throughout the test. In the multivariate regression analysis of pain intensity [5-HT] was the strongest regressor and positively correlated with pain intensity in WAD. In addition, blood flow, [pyruvate], and [potassium] influenced the pain intensity in a complex time dependent way. These findings may indicate that peripheral nociceptive processes are activated in WAD with generalized hypersensitivity for pressure and they are not identical with those reported in chronic work-related trapezius myalgia, which could indicate different pain mechanisms.

    Keywords
    Lactate, Pyruvate, Serotonin, Glutamate, Muscle pain, Sensitization, Whiplash
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-12921 (URN)10.1016/j.ejpain.2007.03.009 (DOI)
    Available from: 2008-01-30 Created: 2008-01-30 Last updated: 2017-12-13
    4. Facilitated temporal summation and generalized hyperalgesia in whiplash associated disorder
    Open this publication in new window or tab >>Facilitated temporal summation and generalized hyperalgesia in whiplash associated disorder
    Show others...
    2008 (English)Article in journal (Refereed) Submitted
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-12922 (URN)
    Available from: 2008-01-30 Created: 2008-01-30
  • 4.
    Lemming, Dag
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Multimodal Rehabilitation Programs (MMRP) for patients with longstanding complex pain conditions – The need for quality control with follow-up studies of patient outcomes2016In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 10, p. 104-105Article in journal (Refereed)
  • 5.
    Lemming, Dag
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Börsbo, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Sjörs, Anna
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Lind, Eva-Britt
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Arendt-Nielsen, Lars
    Laboratory for Experimental Pain Research and Center for Neuroplasticity and Pain, Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
    Graven-Nielsen, Thomas
    Center for Neuroplasticity and Pain, Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Cuff Pressure Pain Detection Is Associated with Both Sex and Physical Activity Level in Nonathletic Healthy Subjects2017In: Pain medicine (Malden, Mass.), ISSN 1526-2375, E-ISSN 1526-4637, Vol. 18, no 8, p. 1573-1581Article in journal (Refereed)
    Abstract [en]

    Purpose. The aim of this study was to evaluate pressure pain sensitivity on leg and arm in 98 healthy persons (50 women) using cuff algometry. Furthermore, associations with sex and physical activity level were investigated.

    Method. Normal physical activity level was defined as Godin Leisure-Time Exercise Questionnaire (GLTEQ) score ≤ 45 and high activity level as GLTEQ > 45. A pneumatic double-chamber cuff was placed around the arm or leg where a single chamber was inflated. The cuff inflation rate (1 kPa/s) was constant, and pain intensity was registered continuously on a 10 cm electronic visual analogue scale (VAS). The pain detection threshold (PDT) was defined as when the pressure was perceived as painful, and pain tolerance (PTT) was when the subject terminated the cuff inflation. For PTT, the corresponding VAS score was recorded (VAS-PTT). The protocol was repeated with two chambers inflated.

    Result. Only single cuff results are given. For women compared with men, the PDT was lower when assessed in the arm (P = 0.002), PTTs were lower in the arm and leg (P < 0.001), and the VAS-PTT was higher in the arm and leg (P < 0.033). Highly active participants compared with less active had higher PDT (P = 0.027) in the leg. Women showed facilitated spatial summation (P < 0.014) in the arm and leg and a steeper VAS slope (i.e., the slope of the VAS pressure curve between PDT and PPT) in the arm and leg (P < 0.003).

    Conclusion. This study indicates that reduced pressure pain sensitivity is associated both with male sex and physical activity level.

  • 6.
    Lemming, Dag
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Börsbo, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Sjörs, Anna
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences.
    Lind, Eva-Britt
    Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Arendt-Nielsen, Lars
    Center for Sensory-Motor Interaction (SMI), Laboratory for Experimental Pain Research, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
    Graven-Nielsen, Thomas
    Center for Sensory-Motor Interaction (SMI), Laboratory for Experimental Pain Research, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Single-point but not tonic cuff pressure pain sensitivity is associated with level of physical fitness: a study of non-athletic healthy subjects2015In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 5, article id e0125432Article in journal (Refereed)
    Abstract [en]

    Exercise is often used for pain rehabilitation but the link between physical activity level and pain sensitivity is still not fully understood. Pressure pain sensitivity to cuff algometry and conditioned pain modulation (CPM) were evaluated in highly active men (n=22), normally active men (n=26), highly active women (n=27) and normally active women (n=23) based on the Godin Leisure-Time Exercise Questionnaire. Cuff pressure pain sensitivity was assessed at the arm and lower leg. The subjects scored the pain intensity on an electronic Visual Analogue Scale (VAS) during ten minutes with 25 kPa constant cuff pressure and two minutes with zero pressure. The maximal VAS score and area under the VAS-curve were extracted. Pressure pain thresholds (PPT) were recorded by manual pressure algometry on the ipsilateral tibialis anterior muscle before, during and after the tonic arm stimulation.

    Tonic cuff stimulation of the arm and leg resulted in higher VAS peak scores in women compared with men (p<0.04). In all groups the PPTs were reduced during and after the cuff stimulation compared with baseline (p=0.001). PPT were higher in men compared with women (p=0.03) and higher in highly physical active compared with normal active (p=0.048). 

    Besides the well-known gender difference in pressure pain sensitivity this study demonstrates  that a high physical fitness degree in non-athletic subjects is associated with increased pressure pain thresholds but does not affect cuff pressure pain sensitivity in healthy people.

  • 7.
    Lemming, Dag
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences.
    Graven-Nielsen, T.
    Sörensen, Jan
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences.
    Arendt-Nielsen, L.
    Gerdle, Björn
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences.
    Facilitated temporal summation and generalized hyperalgesia in whiplash associated disorder2008Article in journal (Refereed)
  • 8.
    Lemming, Dag
    et al.
    Linköping University, Department of Medical and Health Sciences, Rehabilitation Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Pain and Rehabilitation Centre.
    Graven-Nielsen, Thomas
    Aalborg University, Denmark .
    Sörensen, Jan
    Linköping University, Department of Medical and Health Sciences, Rehabilitation Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Pain and Rehabilitation Centre.
    Arendt-Nielsen, Lars
    Aalborg University, Denmark .
    Gerdle, Björn
    Linköping University, Department of Medical and Health Sciences, Rehabilitation Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Sinnescentrum, Pain and Rehabilitation Centre.
    Widespread pain hypersensitivity and facilitated temporal summation of deep tissue pain in whiplash associated disorder: an explorative study of women2012In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 44, no 8, p. 648-657Article in journal (Refereed)
    Abstract [en]

    Objective: Widespread deep tissue pain hyperalgesia was evaluated in women with chronic whiplash associated disorder (n=25) and controls (n=10) using computerized cuff pressure algometry and hypertonic saline infusion. Methods: A pneumatic double-chamber cuff was placed around: (i) the arm and (ii) the leg. Cuff inflation rate was constant and the pain intensity was registered continuously on a visual analogue scale (VAS); thresholds of detection and tolerance were extracted. For assessment of spatial summation the protocol was repeated with a single-chamber cuff inflated around the leg. Temporal summation of pain was assessed from the leg with constant cuff pressure stimulation at 2 different pressure intensities for 10 min. Hypertonic saline was infused in the tibialis anterior muscle. Results: Cuff pressure pain thresholds were lower in subjects with whiplash associated disorder compared with controls (pless than0.05). Tonic pressure stimulation evoked higher maximal VAS and larger areas under the VAS curve in subjects with whiplash associated disorder compared with controls (pless than0.05). The pain threshold and tolerance were higher during single cuff than double cuff stimulation. The area under the VAS curve after intramuscular saline infusion was larger in whiplash associated disorder (pless than0.05). Conclusion: The results indicated widespread hyperalgesia in chronic whiplash associated disorder and facilitated temporal summation outside the primary pain area, suggesting involvement of central sensitization.

  • 9.
    Lemming, Dag
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences.
    Sörensen, Jan
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences.
    Graven-Nielsen, Thomas
    Center for Sensory-Motor Interaction, Laboratory for Experimental Pain Research, Aalborg University, Denmark.
    Arendt-Nielsen, Lars
    Center for Sensory-Motor Interaction, Laboratory for Experimental Pain Research, Aalborg University, Denmark.
    Gerdle, Björn
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences.
    The responses to pharmacological challenges and experimental pain in patients with chronic whiplash-associated pain2005In: The Clinical Journal of Pain, ISSN 0749-8047, E-ISSN 1536-5409, Vol. 21, no 5, p. 412-421Article in journal (Refereed)
    Abstract [en]

    Objectives: This study evaluates the analgesic responses to intravenous administration of morphine, lidocaine, and ketamine and their relations to duration of chronic pain after whiplash trauma. In addition, experimental muscle pain sensitivity and its correlation to pain duration and pharmacological responses were assessed.

    Methods: Thirty-three patients with diagnosed whiplash-associated disorder grade II in the chronic stage, according to the Quebec classification, were included. The pharmacological evaluation was performed in a randomized, double-blind, cross-over design and consisted of a 30-minute period of intravenous administration of morphine (0.3 mg/kg), lidocaine (5 mg/kg), ketamine (0.3 mg/kg), or placebo (isotonic saline). Intensity ratings of habitual pain on a visual analogue scale were taken before, during, and after the infusion. The patients were classified as nonresponders, placebo-responders, or responders (minimum 50% decrease of pain intensity) of the drugs. Pressure pain thresholds and intramuscular and cutaneous electrical stimulation pain thresholds were measured. The pain intensity during experimental muscle pain by intramuscular hypertonic saline was also recorded. Experimental pain assessments were performed on the lower legs outside the habitual painful area.

    Results: Thirty patients completed the study; 2 were placebo responders and 10 were nonresponders. Of 18 responders, there were 15 morphine responders, 11 lidocaine responders, and 14 ketamine responders. In the patients with whiplash-associated disorder duration less than 2 years, 7 responded to morphine, 5 to lidocaine, and 8 to ketamine. In the patients with pain duration longer than 2 years, 8 responded to morphine, 6 to lidocaine, and 6 to ketamine. Thus, no pattern with respect to pain duration was found. Seventeen patients participated in the experimental pain assessment, and no significant differences in the variables of the intramuscular and cutaneous stimulation and intramuscular-induced pain with respect to response to the pharmacological challenges or whiplash-associated disorder duration existed.

    Discussion: The pharmacological challenges identified subgroups of patients with chronic whiplash-associated disorder that might be considered before instituting therapeutic interventions or research. However, the pattern of responses to the pharmacological challenges did not show any clear relationships with pain duration or the experimental pain tests.

  • 10.
    Lemming, Dag
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Medicine, Pain and Rehabilitation Centre.
    Sörensen, Jan
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Medicine, Pain and Rehabilitation Centre.
    Graven-Nielsen, Thomas
    Center for Sensory-Motor Interaction (SMI), Laboratory for Experimental Pain Research, Aalborg University, Denmark.
    Lauber, Rolf
    Department of Anesthesiology, University Hospital, Bern, Switzerland.
    Arendt-Nielsen, Lars
    Center for Sensory-Motor Interaction (SMI), Laboratory for Experimental Pain Research, Aalborg University, Denmark.
    Gerdle, Björn
    Linköping University, Department of Clinical and Experimental Medicine, Rehabilitation Medicine . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Medicine, Pain and Rehabilitation Centre.
    Managing chronic whiplash associated pain with a combination of low-dose opioid (remifentanil) and NMDA-antagonist (ketamine)2007In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 11, no 7, p. 719-732Article in journal (Refereed)
    Abstract [en]

    The aim was to investigate the efficacy of a combination of low-dose remifentanil (REMI) and ketamine (KET) compared to the single drugs and placebo (P) on whiplash associated pain (WAD) in a double-blind, randomized, placebo-controlled, cross-over study.

    Twenty patients with chronic (>1 year) WAD were included. Four different drug combinations were tested in four sessions: placebo/placebo (P/P), placebo/remifentanil (P/REMI), ketamine/placebo (KET/P) and ketamine/remifentanil (KET/REMI). Target concentrations were 1 and 2 ng/ml (stepwise) for remifentanil and 100 ng/ml for ketamine.

    Habitual pain intensity was assessed on a visual analogue scale (VAS). Experimental pain was assessed with electrical stimulation (single and repeated) of tibialis anterior (TA) muscle, pressure pain algometry applied over infraspinatus (IS) and TA muscles and VAS scores after intramuscular hypertonic saline infusion in TA.

    KET/REMI significantly reduced habitual pain. KET/REMI infused at low REMI target concentration (1 ng/ml) significantly elevated electrical intramuscular pain thresholds (single and repeated). Pain thresholds to electrical stimulation were similarly increased by both P/REMI and KET/REMI at 2 ng/ml target concentration. Pressure pain thresholds were increased by both KET/REMI and P/REMI. VAS-scores after intramuscular saline were also similarly decreased by both REMI combinations. Seven out of 20 subjects were non-responders (<50% pain relief). No correlation was found between effects on spontaneous pain and experimental pain.

    KET/REMI showed an analgesic effect on habitual pain. Experimental pain was attenuated by both combinations containing the opioid, however, KET seemed to enhance the effect of REMI on electrical pain thresholds when a low REMI target concentration was used.

  • 11.
    Levin, Britta
    et al.
    Totalförsvarets forskningsinstitut, FOI, Stockholm.
    Tribukait, Arne
    Omgivningsfysiologi, Kungl. Teknsika Högskolan, Stockholm.
    Lemming, Dag
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Eiken, Ola
    Omgivningsfysiologi, Kungl. Teknsika Högskolan, Stockholm.
    Utvärdering av utbildning i spatial desorientering; redovisning av frågeformulär2011Report (Other academic)
    Abstract [en]

    A combined introductory training course in spatial disorientation (SD) and flight with night vision goggles (NVG) is provided by AMST Systemtechnik GmbH, on-site in the Ranshofen facility in Austria. This course was subject to an extensive evaluation in conjunction with the participation of two groups of Swedish pilots in the fall of 2010. The part of the evaluation included in this report concerns the students' own opinions and is based on open and rating questions together with additional free comments. The students believed that it is important to perform both basic and recurrent SDtraining. In general, SD-theory was much appreciated and they requested a more comprehensive theoretical education than previously received. The students also stated that the training at AMST in an efficient manner increases ones understanding of illusions, gives an increased ability to recognize an illusion, and to overcome an illusion should it occur. Regarding the night vision (NV) part the students claimed that the training efficiently increases ones understanding of NVrelated problems associated with night vision goggles (NVG), gives an increased ability to recognize NV-related phenomena, and enhances ones preparedness for flight using NVG. The students stressed that the course to a larger extent should have been coordinated with their previous or currently planned SD/NV training both regarding timeframe and content. In cases when a student already on a previous occasion had experienced a given illusion or NV-phenomenon, the present training was considered a valuable addition and a rehearsal. The students regarded the training as partially inefficient and had expected more theory and time spent in the simulator. A large number of students in combination with limited access to simulator equipment led to substantial delay between missions. The students believed that their SD-training could be improved and proposed a number of ideas for development.

  • 12.
    Lindström, Pål
    et al.
    Susano Rehab AB, Malmö, Sweden.
    Lemming, Dag
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Lantz Lenander, Eva
    Susano Rehab AB, Malmö, Sweden.
    Jönsson, Rolf
    Apport Rehab, Kristianstad, Sweden.
    Sverige behöver riktlinjer för oberoende medicinska utredningar [Sweden needs guidelines for independent medical evaluations]2015In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 112, article id DHRZArticle in journal (Other academic)
    Abstract [sv]

    En oberoende medicinsk utredning kräver ett tydligt etiskt ställningstagande från utövaren, anser Pål Lindström och medförfattare. De föreslår tydliga etiska riktlinjer baserade på internationell standard, anpassade för svenska förhållanden.

  • 13.
    Tribukait, Arne
    et al.
    School of Technology and Health, Royal Institute of Technology, KTH, Solna, Sweden.
    Eiken, Ola
    School of Technology and Health, Royal Institute of Technology, KTH, Solna, Sweden.
    Lemming, Dag
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Pain and Rehabilitation Center.
    Levin, Britta
    FOI, Linköping, Sweden.
    Use of an adjustable hand plate in studying the perceived horizontal plane during simulated flight2013In: Aviation, Space and Environmental Medicine, ISSN 0095-6562, E-ISSN 1943-4448, Vol. 84, no 7, p. 739-745Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Quantitative data on spatial orientation would be valuable not only in assessing the fidelity of flight simulators, but also in evaluation of spatial orientation training. In this study a manual indicator was used for recording the subjective horizontal plane during simulated flight.

    METHODS: In a six-degrees-of-freedom hexapod hydraulic motion platform simulator, simulating an F-16 aircraft, seven fixed-wing student pilots were passively exposed to two flight sequences. The first consisted in a number of coordinated turns with visual contact with the landscape below. The visually presented roll tilt was up to a maximum 670. The second was a takeoff with a cabin pitch up of 100, whereupon external visual references were lost. The subjects continuously indicated, with the left hand on an adjustable plate, what they perceived as horizontal in roll and pitch. There were two test occasions separated by a 3-d course on spatial disorientation.

    RESULTS: Responses to changes in simulated roll were, in general, instantaneous. The indicated roll tilt was approximately 30% of the visually presented roll. There was a considerable interindividual variability. However, for the roll response there was a correlation between the two occasions. The amplitude of the response to the pitch up of the cabin was approximately 75%; the response decayed much more slowly than the stimulus.

    DISCUSSION: With a manual indicator for recording the subjective horizontal plane, individual characteristics in the response to visual tilt stimuli may be detected, suggesting a potential for evaluation of simulation algorithms or training programs.

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