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  • 1. Bjersing, Jan L
    et al.
    Larsson, Anette
    Palstam, Annie
    Sahlgrenska Academy, University of Gothenburg.
    Ernberg, Malin
    Bileviciute-Ljungar, Indre
    Löfgren, Monika
    Gerdle, Björn
    Kosek, Eva
    Mannerkorpi, Kaisa
    Benefits of resistance exercise in lean women with fibromyalgia: involvement of IGF-1 and leptin2017In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 18, no 1, article id 106Article in journal (Refereed)
    Abstract [en]

    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 .

  • 2. Christidis, Nikolaos
    et al.
    Ghafouri, Bijar
    Larsson, Anette
    Palstam, Annie
    Sahlgrenska Academy, University of Gothenburg.
    Mannerkorpi, Kaisa
    Bileviciute-Ljungar, Indre
    Löfgren, Monika
    Bjersing, Jan
    Kosek, Eva
    Ernberg, Malin
    Comparison of the levels of pro-inflammatory cytokines released in the vastus lateralis muscle of patients with fibromyalgia and healthy controls during contractions of the quadriceps muscle - A microdialysis study2015In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 12, article id e0143856Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Fibromyalgia is associated with central hyperexcitability, but it is suggested that peripheral input is important to maintain central hyperexcitability. The primary aim was to investigate the levels of pro-inflammatory cytokines released in the vastus lateralis muscle during repetitive dynamic contractions of the quadriceps muscle in patients with fibromyalgia and healthy controls. Secondarily, to investigate if the levels of pro-inflammatory cytokines were correlated with pain or fatigue during these repetitive dynamic contractions.

    MATERIAL AND METHODS: 32 women with fibromyalgia and 32 healthy women (controls) participated in a 4 hour microdialysis session, to sample IL-1β, IL-6, IL-8, and TNF from the most painful point of the vastus lateralis muscle before, during and after 20 minutes of repeated dynamic contractions. Pain (visual analogue scale; 0-100) and fatigue Borg's Rating of Perceived Exertion Scale; 6-20) were assessed before and during the entire microdialysis session.

    RESULTS: The repetitive dynamic contractions increased pain in the patients with fibromyalgia (P < .001) and induced fatigue in both groups (P < .001). Perceived fatigue was significantly higher among patients with fibromyalgia than controls (P < .001). The levels of IL-1β did not change during contractions in either group. The levels of TNF did not change during contractions in patients with fibromyalgia, but increased in controls (P < .001) and were significantly higher compared to patients with fibromyalgia (P = .033). The levels of IL-6 and IL-8 increased in both groups alike during and after contractions (P's < .001). There were no correlations between pain or fatigue and cytokine levels after contractions.

    CONCLUSION: There were no differences between patients with fibromyalgia and controls in release of pro-inflammatory cytokines, and no correlations between levels of pro-inflammatory cytokines and pain or fatigue. Thus, this study indicates that IL-1β, IL-6, IL-8, and TNF do not seem to play an important role in maintenance of muscle pain in fibromyalgia.

  • 3. Ericsson, Anna
    et al.
    Palstam, Annie
    Sahlgrenska Academy, University of Gothenburg.
    Larsson, Anette
    Löfgren, Monika
    Bileviciute-Ljungar, Indre
    Bjersing, Jan
    Gerdle, Björn
    Kosek, Eva
    Mannerkorpi, Kaisa
    Resistance exercise improves physical fatigue in women with fibromyalgia: a randomized controlled trial2016In: Arthritis Research & Therapy, ISSN 1478-6354, E-ISSN 1478-6362, Vol. 18, article id 176Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Fibromyalgia (FM) affects approximately 1-3 % of the general population. Fatigue limits the work ability and social life of patients with FM. A few studies of physical exercise have included measures of fatigue in FM, indicating that exercise can decrease fatigue levels. There is limited knowledge about the effects of resistance exercise on multiple dimensions of fatigue in FM. The present study is a sub-study of a multicenter randomized controlled trial in women with FM. The purpose of the present sub-study was to examine the effects of a person-centered progressive resistance exercise program on multiple dimensions of fatigue in women with FM, and to investigate predictors of the potential change in fatigue.

    METHODS: A total of 130 women with FM (age 22-64 years) were included in this assessor-blinded randomized controlled multicenter trial examining the effects of person-centered progressive resistance exercise compared with an active control group. The intervention was performed twice a week for 15 weeks. Outcomes were five dimensions of fatigue measured with the Multidimensional Fatigue Inventory (MFI-20). Information about background was collected and the women also completed several health-related questionnaires. Multiple linear stepwise regression was used to analyze predictors of change in fatigue in the total population.

    RESULTS: A higher improvement was found at the post-treatment examination for change in the resistance exercise group, as compared to change in the active control group in the MFI-20 subscale of physical fatigue (resistance group Δ -1.7, SD 4.3, controls Δ 0.0, SD 2.7, p = 0.013), with an effect size of 0.33. Sleep efficiency was the strongest predictor of change in the MFI-20 subscale general fatigue (beta = -0.54, p = 0.031, R (2) = 0.05). Participating in resistance exercise (beta = 1.90, p = 0.010) and working fewer hours per week (beta = 0.84, p = 0.005) were independent significant predictors of change in physical fatigue (R (2) = 0.14).

    CONCLUSIONS: Person-centered progressive resistance exercise improved physical fatigue in women with FM when compared to an active control group.

    TRIAL REGISTRATION: ClinicalTrials.gov NCT01226784 . Registered 21 October 2010.

  • 4. Ernberg, M
    et al.
    Christidis, N
    Ghafouri, B
    Bileviciute-Ljungar, I
    Löfgren, M
    Bjersing, J
    Palstam, Annie
    Sahlgrenska Academy, University of Gothenburg.
    Larsson, A
    Mannerkorpi, K
    Kosek, E
    Plasma cytokine levels in fibromyalgia and their response to 15 weeks of progressive resistance exercise or relaxation therapy2018In: Mediators of Inflammation, ISSN 0962-9351, E-ISSN 1466-1861, Vol. 2018, article id 3985154Article in journal (Refereed)
    Abstract [en]

    The aims of this study were to compare circulating cytokines between FM and healthy controls and to investigate the effect on cytokine levels by 15 weeks of progressive resistance exercise or relaxation therapy in FM. Baseline plasma cytokine levels and clinical data were analyzed in 125 women with FM and 130 age-matched healthy women. The FM women were then randomized to progressive resistance exercise (n = 49) or relaxation (n = 43). Baseline IL-2, IL-6, TNF-α, IP-10, and eotaxin were higher in FM than in healthy controls (P < 0.041), whereas IL-1β was lower (P < 0.001). There were weak correlations between cytokine levels and clinical variables. After both interventions, IL-1ra had increased (P = 0.004), while IL-1β had increased in the relaxation group (P = 0.002). Changes of IFN-γ, IL-2, IL-4, IL-6, IL-8, and IL-17A were weakly correlated with changes of PPT, but there were no significant correlations between changes of cytokine and changes in other clinical variables. The elevated plasma levels of several cytokines supports the hypothesis that chronic systemic inflammation may underlie the pathophysiology of FM even if the relation to clinical variables was weak. However, 15 weeks of resistance exercise, as performed in this study, did not show any anti-inflammatory effect on neither FM symptoms nor clinical and functional variables. This trial is registered with ClinicalTrials.gov NCT01226784, registered October 21, 2010. The first patient was recruited October 28, 2010.

  • 5. Ernberg, Malin
    et al.
    Christidis, Nikolaos
    Ghafouri, Bijar
    Bileviciute-Ljungar, Indre
    Löfgren, Monika
    Larsson, Anette
    Palstam, Annie
    Sahlgrenska Academy, University of Gothenburg.
    Bjersing, Jan
    Mannerkorpi, Kaisa
    Gerdle, Björn
    Effects of 15 weeks of resistance exercise on pro-inflammatory cytokine levels in the vastus lateralis muscle of patients with fibromyalgia2016In: Arthritis Research & Therapy, ISSN 1478-6354, E-ISSN 1478-6362, Vol. 18, no 1, article id 137Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: This study aimed at investigating the effect of a resistance exercise intervention on the interstitial muscle levels of pro-inflammatory cytokines in fibromyalgia (FMS) and healthy controls (CON).

    METHODS: Twenty-four female patients with FMS (54 ± 8 years) and 27 female CON (54 ± 9 years) were subjected to intramuscular microdialysis of the most painful vastus lateralis muscle before and after 15 weeks of progressive resistance exercise twice per week. Baseline dialysates were sampled in the resting muscle 140 min after insertion of the microdialysis catheter. The participants then performed repetitive dynamic contractions (knee extension) for 20 min, followed by 60 min rest. Pain intensity was assessed with a 0-100 mm visual analogue scale (VAS), and fatigue was assessed with Borg's RPE throughout microdialysis. Dialysates were sampled every 20 min and analyzed with Luminex for interleukin (IL)-1β, tumor necrosis factor (TNF) alpha, IL-6, and IL-8.

    RESULTS: At both sessions and for both groups the dynamic contractions increased pain (P < 0.012) and fatigue (P < 0.001). The levels of TNF were lower in the FMS group than the CON group at both sessions (P < 0.05), but none of the other cytokines differed between the groups. IL-6 and IL-8 increased after the dynamic contractions in both groups (P < 0.010), while TNF increased only in CON (P < 0.05) and IL-1β did not change. Overall pain intensity was reduced after the 15 weeks of resistance exercise in FMS (P < 0.05), but there was no changes in fatigue or cytokine levels.

    CONCLUSION: Progressive resistance exercise for 15 weeks did not affect the interstitial levels of IL-1β, TNF, IL-6, and IL-8 in the vastus lateralis muscle of FMS patients or CON.

    TRIAL REGISTRATION: Clinicaltrials.gov NCT01226784 , registered 21 October 2010.

  • 6. Lange, Elvira
    et al.
    Palstam, Annie
    The Sahlgrenska Academy, University of Gothenburg.
    Gjertsson, Inger
    Mannerkorpi, Kaisa
    Aspects of exercise with person-centred guidance influencing the transition to independent exercise: a qualitative interview study among older adults with rheumatoid arthritis2019In: European Review of Aging and Physical Activity, ISSN 1813-7253, E-ISSN 1861-6909, Vol. 16, no 4Article in journal (Refereed)
    Abstract [en]

    Background: Besides being health enhancing and disease preventing, exercise is also an important part of the management of chronic conditions, including the inflammatory joint disease rheumatoid arthritis (RA). However, older adults with RA present a lower level of physical activity than healthy older adults. The aim of this qualitative study was to explore aspects of participation in moderate- to high-intensity exercise with person-centred guidance influencing the transition to independent exercise for older adults with RA.

    Methods: A qualitative interview study was conducted. In-depth interviews with 16 adults with RA aged between 68 and 75 years, who had taken part in the intervention arm of a randomized controlled trial performing moderate- to- high-intensity exercise with person-centred guidance, were analysed using qualitative content analysis.

    Results: The analysis resulted in six main categories: A feasible opportunity to adopt exercise, Experiencing positive effects of exercise, Contextual factors affect the experience of exercise, Developing knowledge and thinking, Finding one's way, and Managing barriers for exercise. The exercise with person-centred guidance was described as a feasible opportunity to start exercising as a basis for the transition to independent exercise. They described developing knowledge and thinking about exercise during the intervention enabling them to manage the transition to independent exercise. Finding one's own way for exercise became important for sustaining independent exercise. Lastly, barriers for exercise and strategies for overcoming these were described. Reduced physical health, both temporary and permanent, was described as a considerable barrier for exercise.

    Conclusion: The participants described several aspects of participating in exercise that influenced and facilitated their transition to independent exercise. The exercise was experienced as manageable and positive, by a careful introduction and development of an individual exercise routine in partnership with a physiotherapist. This seems to have favored the development of self-efficacy, with importance for future independent exercise. Reduced physical health, both temporary and permanent, was described as a considerable barrier for exercise. The personal process of trying to make the exercise one's own, and developing knowledge about exercise and new thoughts about oneself, seemed to prepare the participants for managing independent exercise and overcoming barriers.

  • 7. Larsson, Anette
    et al.
    Palstam, Annie
    Sahlgrenska Academy, University of Gothenburg.
    Bjersing, Jan
    Löfgren, Monika
    Ernberg, Malin
    Kosek, Eva
    Gerdle, Björn
    Mannerkorpi, Kaisa
    Controlled, cross-sectional, multi-center study of physical capacity and associated factors in women with fibromyalgia2018In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 19, no 1, article id 121Article in journal (Refereed)
    Abstract [en]

    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.

  • 8. Larsson, Anette
    et al.
    Palstam, Annie
    Sahlgrenska Academy, University of Gothenburg.
    Löfgren, Monika
    Ernberg, Malin
    Bjersing, Jan
    Bileviciute-Ljungar, Indre
    Gerdle, Björn
    Kosek, Eva
    Mannerkorpi, Kaisa
    Pain and fear avoidance partially mediate change in muscle strength during resistance exercise in women with fibromyalgia2017In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 49, no 9, p. 744-750Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Resistance exercise results in health benefits in fibromyalgia. The aim of this study was to determine the factors that mediate change in muscle strength in women with fibromyalgia as a result of resistance exercise.

    METHODS: Sixty-seven women with fibromyalgia (age range 25-64 years) were included. Tests of muscle strength and questionnaires related to pain, fear avoidance and physical activity were carried out. Multivariable stepwise regression was used to analyse explanatory factors for change and predictors for final values of knee-extension force, elbow-flexion force and hand-grip force.

    RESULTS: Change in knee-extension force was explained by fear avoidance beliefs about physical activity at baseline, together with change in pain intensity, knee-extension force at baseline, age and body mass index (BMI) (R2=0.40, p = 0.013). Change in elbow-flexion force was explained by pain intensity at baseline, together with baseline fear avoidance beliefs about physical activity, BMI and elbow-flexion force at baseline (R2 = 0.32, p = 0.043). Change in hand-grip force was explained by hand-grip force at baseline, change in pain intensity and baseline fear avoidance (R2 = 0.37, p = 0.009). Final muscle strength was predicted by the same variables as change, except pain.

    CONCLUSION: Pain and fear avoidance are important factors to consider in rehabilitation using resistance exercise for women with fibromyalgia.

  • 9. Larsson, Anette
    et al.
    Palstam, Annie
    Sahlgrenska Academy, University of Gothenburg.
    Löfgren, Monika
    Ernberg, Malin
    Bjersing, Jan
    Bileviciute-Ljungar, Indre
    Gerdle, Björn
    Kosek, Eva
    Mannerkorpi, Kaisa
    Resistance exercise improves muscle strength, health status and pain intensity in fibromyalgia - a randomized controlled trial2015In: Arthritis Research & Therapy, ISSN 1478-6354, E-ISSN 1478-6362, Vol. 17, article id 161Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Fibromyalgia (FM) is characterized by persistent widespread pain, increased pain sensitivity and tenderness. Muscle strength in women with FM is reduced compared to healthy women. The aim of this study was to examine the effects of a progressive resistance exercise program on muscle strength, health status, and current pain intensity in women with FM.

    METHODS: A total of 130 women with FM (age 22-64 years, symptom duration 0-35 years) were included in this assessor-blinded randomized controlled multi-center trial examining the effects of progressive resistance group exercise compared with an active control group. A person-centred model of exercise was used to support the participants' self-confidence for management of exercise because of known risks of activity-induced pain in FM. The intervention was performed twice a week for 15 weeks and was supervised by experienced physiotherapists. Primary outcome measure was isometric knee-extension force (Steve Strong®), secondary outcome measures were health status (FIQ total score), current pain intensity (VAS), 6MWT, isometric elbow-flexion force, hand-grip force, health related quality of life, pain disability, pain acceptance, fear avoidance beliefs, and patient global impression of change (PGIC). Outcomes were assessed at baseline and immediately after the intervention. Long-term follow up comprised the self-reported questionnaires only and was conducted after 13-18 months. Between-group and within-group differences were calculated using non-parametric statistics.

    RESULTS: Significant improvements were found for isometric knee-extension force (p = 0.010), health status (p = 0.038), current pain intensity (p = 0.033), 6MWT (p = 0.003), isometric elbow flexion force (p = 0.02), pain disability (p = 0.005), and pain acceptance (p = 0.043) in the resistance exercise group (n = 56) when compared to the control group (n = 49). PGIC differed significantly (p = 0.001) in favor of the resistance exercise group at post-treatment examinations. No significant differences between the resistance exercise group and the active control group were found regarding change in self-reported questionnaires from baseline to 13-18 months.

    CONCLUSIONS: Person-centered progressive resistance exercise was found to be a feasible mode of exercise for women with FM, improving muscle strength, health status, and current pain intensity when assessed immediately after the intervention.

    TRIAL REGISTRATION: ClinicalTrials.gov identification number: NCT01226784, Oct 21, 2010.

  • 10. Lundgren-Nilsson, Åsa
    et al.
    Dencker, Anna
    Palstam, Annie
    Sahlgrenska Academy, University of Gothenburg.
    Person, Gert
    Horton, Mike C
    Escorpizo, Reuben
    Küçükdeveci, Ayse A
    Kutlay, Sehim
    Elhan, Atilla H
    Conaghan, Philip G
    Patient-reported outcome measures in osteoarthritis: a systematic search and review of their use and psychometric properties.2018In: RMD Open, E-ISSN 2056-5933, Vol. 4, no 2, article id e000715Article in journal (Refereed)
    Abstract [en]

    Introduction: Patient-reported outcome measures (PROM) or self-completed questionnaires have been used to report outcomes in osteoarthritis (OA) for over 35 years. Choices will always need to be made about what should be measured and, if relevant, what would be the most appropriate PROM to use. The current study aims to describe the available PROMs used in OA and their performance quality, so that informed choices can be made about the most appropriate PROM for a particular task.

    Methods: The study included a systematic search for PROMs that have been in use over 17 years (period 2000-2016), and to catalogue their psychometric properties, and to present the evidence in a user-friendly fashion.

    Results: 78 PROMs were identified with psychometric evidence available. The domains of pain, self-care, mobility and work dominated, whereas domains such as cleaning and laundry and leisure, together with psychological and contextual factors, were poorly served. The most frequently used PROMs included the Western Ontario McMaster Osteoarthritis Index, the Short Form 36 and the Knee Disability and Osteoarthritis Outcome Score which, between them, appeared in more than 4000 papers. Most domains had at least one PROM with the highest level of psychometric evidence.

    Conclusion: A broad range of PROMs are available for measuring OA outcomes. Some have good psychometric evidence, others not so. Some important psychological areas such as self-efficacy were poorly served. The study provides a current baseline for what is available, and identifies the shortfall in key domains if the full biopsychosocial model is to be explored.

  • 11.
    Palstam, Annie
    et al.
    Sahlgrenska Academy, University of Gothenburg.
    Bjersing, Jan L
    Mannerkorpi, Kaisa
    Which aspects of health differ between working and nonworking women with fibromyalgia? A cross-sectional study of work status and health.2012In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 12, article id 1076Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Women with fibromyalgia (FM) describe great difficulties in managing work. Reported work ability in women with FM varies from 34 to 77 percent in studies from different countries. Many factors are suggested to affect the ability to work in women with FM, including pain, fatigue, impaired physical capacity and activity limitations. However, it is difficult to define to which extent symptom severity can be compatible with work. The aim of this study was to investigate which aspects of health differ between working women with FM and nonworking women with FM.

    METHODS: A cross-sectional study of 129 women of working age with FM which included clinical assessment, structured interviews, questionnaires and performance-based tests. The women were categorized as working or nonworking. Aspects of health are presented according to the International Classification of Functioning, Disability and Health (ICF).

    RESULTS: Working women with FM presented better health than nonworking women with FM in ratings of body function (FIQ pain p < 0.001, FIQ fatigue p = 0.006, FIQ stiffness p = 0.009, HADS-Depression p = 0.007). Ratings of overall health status were also significantly better in working women with FM than in nonworking women with FM (FIQ total, eight-item p = 0.001 and SF-36 PCS p < 0.001). No significant differences were found between working- and nonworking women in tests of physical capacity. FIQ pain was an independent explanatory factor for work in stepwise multiple logistic regression analysis (OR 0.95, CI 0.93- 0.98), p < 0.001.

    CONCLUSION: Working women with FM reported better health than nonworking women with FM in terms of pain, fatigue, stiffness, depression, disease specific health status and physical aspects of quality of life, which represent body functions and overall health status. However, they were equally impaired in tests of physical capacity. Moderate pain levels were compatible with work, while severe pain appeared to compromise work. Fatigue was better tolerated, as women scoring severe levels of fatigue worked.

  • 12.
    Palstam, Annie
    et al.
    Sahlgrenska Academy, University of Gothenburg.
    Gard, Gunvor
    Mannerkorpi, Kaisa
    Factors promoting sustainable work in women with fibromyalgia.2013In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 35, no 19, p. 1622-1629Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To examine and describe the factors promoting sustainable work in women with fibromyalgia (FM).

    METHODS: A qualitative interview study. Twenty-seven gainfully employed women with FM participated in five focus group interviews. Their median age was 52 years, ranging from 33 to 62. The interviews were recorded, transcribed verbatim and analysed by qualitative latent content analysis.

    RESULTS: Four categories were identified describing factors promoting sustainable work: the meaning of work and individual strategies were individual promoters while a favourable work environment and social support outside work were environmental promoters. The meaning of work included individual meaning and social meaning. The individual strategies included handling symptoms, the work day and long-term work life. A favourable work environment included the physical and psychosocial work environment. Social support outside work included societal and private social supports.

    CONCLUSIONS: Promoting factors for work were identified, involving individual and environmental factors. These working women with FM had developed advanced well-functioning strategies to enhance their work ability. The development of such strategies should be supported by health-care professionals as well as employers to promote sustainable work in women with FM.

    IMPLICATIONS FOR REHABILITATION: Work disability is a common consequence of fibromyalgia (FM). Working women with FM appear to have developed advanced well-functioning individual strategies to enhance their work ability. The development of individual strategies should be supported by health-care professionals as well as employers to promote sustainable work and health in women with FM.

  • 13.
    Palstam, Annie
    et al.
    Sahlgrenska Academy, University of Gothenburg.
    Larsson, Anette
    Bjersing, Jan
    Löfgren, Monika
    Ernberg, Malin
    Bileviciute-Ljungar, Indre
    Ghafouri, Bijar
    Sjörs, Anna
    Larsson, Britt
    Mannerkorpi, Kaisa
    Perceived exertion at work in women with fibromyalgia: explanatory factors and comparison with healthy women.2014In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 46, no 8, p. 773-80Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate perceived exertion at work in women with fibromyalgia.

    DESIGN: A controlled cross-sectional multi-centre study.

    SUBJECTS AND METHODS: Seventy-three women with fibromyalgia and 73 healthy women matched by occupation and physical workload were compared in terms of perceived exertion at work (0-14), muscle strength, 6-min walk test, symptoms rated by Fibromyalgia Impact Questionnaire (FIQ), work status (25-100%), fear avoidance work beliefs (0-42), physical activity at work (7-21) and physical workload (1-5). Spearman's correlation coefficient and linear regression analysis were conducted.

    RESULTS: Perceived exertion at work was significantly higher in the fibromyalgia group than in the reference group (p = 0.002), while physical activity at work did not differ between the groups. Physical capacity was lower and symptom severity higher in fibromyalgia compared with references (p < 0.05). In fibromyalgia, perceived exertion at work showed moderate correlation with physical activity at work, physical workload and fear avoidance work beliefs (rs = 0.53-0.65, p < 0.001) and a fair correlation with anxiety (rs = 0.26, p = 0.027). Regression analysis indicated that the physical activity at work and fear avoidance work beliefs explained 50% of the perceived exertion at work.

    CONCLUSION: Women with fibromyalgia perceive an elevated exertion at work, which is associated with physical work-related factors and factors related to fear and anxiety.

  • 14.
    Palstam, Annie
    et al.
    Sahlgrenska Academy, University of Gothenburg.
    Larsson, Anette
    Löfgren, Monika
    Ernberg, Malin
    Bjersing, Jan
    Bileviciute-Ljungar, Indre
    Gerdle, Björn
    Kosek, Eva
    Mannerkorpi, Kaisa
    Decrease of fear avoidance beliefs following person-centered progressive resistance exercise contributes to reduced pain disability in women with fibromyalgia: secondary exploratory analyses from a randomized controlled trial2016In: Arthritis Research & Therapy, ISSN 1478-6354, E-ISSN 1478-6362, Vol. 18, no 1, article id 116Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Fibromyalgia (FM) is characterized by persistent widespread pain, increased pain sensitivity and tenderness. Women with FM also report disability, in terms of negative consequences on activities of daily living. Our recent randomized controlled trial (RCT) is the first study of resistance exercise to show positive effects on pain disability. The resistance exercise program of our RCT emphasized active involvement of participants in planning and progression of the exercise, using the principles of person-centeredness, to support each participant's ability to manage the exercise and the progress of it. The aim of this sub-study was to investigate explanatory factors for reduced pain disability in women with FM participating in a 15-week person-centered progressive resistance exercise program.

    METHODS: A total of 67 women with FM were included in this sub-study of an RCT examining the effects of person-centered progressive resistance exercise performed twice a week for 15 weeks. Tests of physical capacity and health-related questionnaires were assessed at baseline and after the intervention period. Multivariable stepwise regression was used to analyze explanatory factors for improvements in pain disability.

    RESULTS: Reduced pain disability was explained by higher pain disability at baseline together with decreased fear avoidance beliefs about physical activity (R (2) = 28, p = 0.005). The improvements in the disability domains of recreation and social activity were explained by decreased fear avoidance beliefs about physical activity together with higher baseline values of each disability domain respectively (R (2) = 32, p = 0.025 and R (2) = 30, p = 0.017). The improvement in occupational disability was explained by higher baseline values of occupational disability (R (2) = 19, p = 0.001).

    CONCLUSION: The person-centered resistance exercise intervention, based on principles of self-efficacy, had a positive effect on recreational, social and occupational disability. The reduced pain disability seemed to be mediated by decreased fear avoidance beliefs. Age, symptom duration, pain intensity, and muscle strength at baseline had no explanatory value for reduced pain disability, indicating that the person-centered resistance exercise program has the potential to work for anyone with FM who has interest in physical exercise. The trial was registered on October 21, 2010 with ClinicalTrials.gov identification number: NCT01226784 .

  • 15.
    Palstam, Annie
    et al.
    Sahlgrenska Academy, University of Gothenburg.
    Mannerkorpi, Kaisa
    Work ability in fibromyalgia: an update in the 21st century2017In: Current Rheumatology Reviews, ISSN 1573-3971, E-ISSN 1875-6360, Vol. 13, no 3, p. 180-187Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Fibromyalgia (FM) is characterized by persistent widespread pain, increased pain sensitivity and tenderness. People with FM also report activity limitations and impaired work ability.

    OBJECTIVE: This article aims to compile the findings of recently published research on work ability in people with fibromyalgia, and to present how work ability is influenced by various aspects.

    METHODS: A systematic search of the literature published from the year 2000 and onwards was conducted. Thirtyfour articles were included in the review.

    RESULT: Symptom severity was found to influence work ability in people with FM. Physically demanding jobs and work tasks were especially troublesome and were reported to constitute higher risks pof work disability. Working people with FM seemed to hold a careful balancing act to manage the risk of overload where well-functioning strategies such as making a career change, working part-time, and developing personal skills were necessary for managing work, in the short- and long term. The support of management and colleagues enabled people with FM to manage the risk of overload at work. Treatment studies evaluating work disability as outcome in FM are scarce. None of the included studies presented any effects on measures of sick-leave or work disability compared with a control group.

    CONCLUSION: More studies of treatment effects on outcomes related to work ability in people with FM, and more longitudinal studies to explore long-term effects of symptoms on work ability and sick leave, are needed in order to be able to plan evidence based rehabilitation to improve or maintain work ability in people with FM.

  • 16.
    Palstam, Annie
    et al.
    University of Gothenburg.
    Sjödin, Astrid
    University of Gothenburg.
    Sunnerhagen, Katharina Stibrant
    University of Gothenburg.
    Participation and autonomy five years after stroke: A longitudinal observational study.2019In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 14, no 7, article id e0219513Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Stroke is the second most common cause of disability in the world. The purpose of this study was to evaluate the participation and autonomy of persons with stroke, five years after a stroke, and to explore potential associations between factors and perceived restrictions in participation and autonomy.

    METHODS: This five-year follow-up survey study included individuals diagnosed with a first-time stroke during 2009-2010, in Gothenburg. The survey included the Impact of Participation and Autonomy-questionnaire (IPA-E), which comprised five domains: Autonomy Indoor, Family Role, Autonomy Outdoor, Work & Education, and Social Life & Relationships. Logistic regression analyses were used to analyze factors associated with participation restrictions.

    RESULTS: At 5 years after a stroke, 457 patients were alive; of these, 281 responded to the follow-up survey. Participation restrictions were most pronounced in the IPA-E domains of Autonomy Outdoors, Work/Education, and Social Life and Relationships. In contrast, restrictions were less pronounced in the IPA-E domains of Autonomy Indoors and Family Role. Severe stroke, older age, and female sex predicted participation restrictions at five years after a stroke. Participation restrictions were partly explained by feelings of depression at five years after stroke. Problems associated with participation restrictions were most frequently observed in the areas of mobility, leisure, and help/support from other people.

    CONCLUSION: This study showed that participation and autonomy were restricted among persons with stroke at five years after the stroke. The domains perceived as most restricted were those that required high levels of physical, social, and cognitive abilities.

  • 17.
    Palstam, Annie
    et al.
    Sahlgrenska Academy, University of Gothenburg.
    Törnbom, Marie
    Sunnerhagen, Katharina Stibrant
    Experiences of returning to work and maintaining work 7 to 8 years after a stroke: a qualitative interview study in Sweden2018In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 8, no 7, article id e021182Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To explore how persons experienced return to work (RTW) and their work situation 7 to 8 years after a stroke.

    DESIGN: An explorative qualitative design with individual interviews. The data analysis was inductive thematic and three researchers collaborated during the analysis process.

    PARTICIPANTS: The study population included five women and eight men who had a stroke during 2009-2010, received care at the Sahlgrenska University Hospital in Gothenburg, Sweden and RTW after stroke and it was a heterogenic sample based on age, occupation, stroke severity and time to RTW.

    RESULTS: The analysis led to four themes; motivated and RTW while struggling with impairments, mixed feelings in the RTW process, still at work though restricted and social support for a sustainable work situation. The themes revealed that participants were motivated to RTW while struggling with impairments. The RTW process evoked mixed feelings of worry and grief over lost functions but also acceptance and gratitude for being able to work. Although maintaining work 7 to 8 years after experiencing a stroke, most were restricted in some way. Fatigue and cognitive impairments meant having to set limits, omit work tasks and rest at work, but also rest during free time and refraining from social activities in order to manage work. Participants avoided work-related stress if they could because of aggravated symptoms and/or fear of a new stroke. Support from supervisors and colleagues was often crucial for a sustainable work situation.

    CONCLUSION: Maintaining work can be a continuous struggle with invisible impairments many years after a stroke. Strategies for managing work are dependent on each individual work situation, where support and understanding at work seem to be crucial for a sustainable work situation.

  • 18.
    Palstam, Annie
    et al.
    The Sahlgrenska Academy, University of Gothenburg.
    Westerlind, Emma
    Persson, Hanna C
    Sunnerhagen, Katharina S
    Work-related predictors for return to work after stroke.2019In: Acta Neurologica Scandinavica, ISSN 0001-6314, E-ISSN 1600-0404, Vol. 139, no 4, p. 382-388Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Disability due to stroke imposes a large burden on individuals, and on society, in terms of impaired work ability and sick leave. The reported return to work (RTW) rate after stroke varies globally and is influenced by a range of different aspects. The aim of this study was to investigate the influence of work-related factors on time to RTW after stroke, and possible differences between the sexes.

    MATERIALS & METHODS: Data from 204 persons with first-time stroke in the years 2009-2010 in Gothenburg, Sweden, who were of working age and had worked prior to their stroke, were analysed. Disease-related characteristics were retrieved from medical records, and work-related- and socio-economic data were collected up to 6 years post-stroke from Statistics Sweden and the Swedish Social Insurance Agency. Cox regression was used to analyse predictors for time to RTW.

    RESULTS: We identified qualified occupation and large organizational size as work-related predictors for shorter time to RTW after stroke. Being male predicted a faster and higher frequency of RTW. Qualified occupation predicted shorter time to RTW in men but not in women. For women, the only predictor for RTW was physical dependency at discharge.

    CONCLUSION: Type of work and organizational size are work-related factors of importance for RTW after stroke. Work-related factors were important for RTW in men, but not in women. Reasons for differences between men and women in work-related factors that influence RTW need to be further investigated to better understand how to support women in the RTW process.

  • 19. Reinholdsson, Malin
    et al.
    Palstam, Annie
    Sahlgrenska Academy, University of Gothenburg.
    Sunnerhagen, Katharina S
    Prestroke physical activity could influence acute stroke severity (part of PAPSIGOT)2018In: Neurology, ISSN 0028-3878, E-ISSN 1526-632X, Vol. 91, no 16, p. e1461-e1467Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate the influence of prestroke physical activity (PA) on acute stroke severity.

    METHODS: Data from patients with first stroke were retrieved from registries with a cross-sectional design. The variables were PA, age, sex, smoking, diabetes, hypertension and statin treatment, stroke severity, myocardial infarction, new stroke during hospital stay, and duration of inpatient care at stroke unit. PA was assessed with Saltin-Grimby's 4-level Physical Activity Level Scale, and stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS). Logistic regression was used to predict stroke severity, and negative binomial regression was used to compare the level of PA and stroke severity.

    RESULTS: The study included 925 patients with a mean age of 73.1 years, and 45.2% were women. Patients who reported light or moderate PA levels were more likely to present a mild stroke (NIHSS score 0 to 5) compared with physically inactive patients in a model that also included younger age as a predictor (odds ratio = 2.02 for PA and odds ratio = 0.97 for age). The explanatory value was limited at 6.8%. Prestroke PA was associated with less severe stroke, and both light PA such as walking at least 4 h/wk and moderate PA 2-3 h/wk appear to be beneficial. Physical inactivity was associated with increased stroke severity.

    CONCLUSIONS: This study suggests that PA and younger age could result in a less severe stroke. Both light PA such as walking at least 4 h/wk and moderate PA 2-3 h/wk appear to be beneficial.

  • 20. Tour, Jeanette
    et al.
    Löfgren, Monika
    Mannerkorpi, Kaisa
    Gerdle, Björn
    Larsson, Anette
    Palstam, Annie
    Sahlgrenska Academy, University of Gothenburg.
    Bileviciute-Ljungar, Indre
    Bjersing, Jan
    Martin, Ingvar
    Kosek, Eva
    Gene-to-gene interactions regulate endogenous pain modulation in fibromyalgia patients and healthy controls-antagonistic effects between opioid and serotonin-related genes.2017In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 158, no 7, p. 1194-1203Article in journal (Refereed)
    Abstract [en]

    Chronic pain is associated with dysfunctional endogenous pain modulation, involving both central opioid and serotonergic (5-HT) signaling. Fibromyalgia (FM) is a chronic pain syndrome, characterized by widespread musculoskeletal pain and reduced exercise-induced hypoalgesia (EIH). In this study, we assessed the effects of 3 functional genetic polymorphisms on EIH in 130 patients with FM and 132 healthy controls. Subjects were genotyped regarding the mu-opioid receptor (OPRM1) gene (rs1799971), the serotonin transporter (5-HTT) gene (5-HTTLPR/rs25531), and the serotonin-1a receptor (5-HT1a) gene (rs6296). The patients with FM had increased pain sensitivity and reduced EIH compared with healthy controls. None of the polymorphisms had an effect on EIH on their own. We found significant gene-to-gene interactions between OPRM1 x 5-HTT and OPRM1 x 5-HT1a regarding activation of EIH, with no statistically significant difference between groups. Better EIH was found in individuals with genetically inferred strong endogenous opioid signaling (OPRM1 G) in combination with weak 5-HT tone (5-HTT low/5-HT1a G), compared with strong 5-HT tone (5-HTT high/5-HT1a CC). Based on the proposed mechanisms of these genetic variants, the findings indicate antagonistic interactions between opioid and serotonergic mechanisms during EIH. Moreover, despite different baseline pain level, similar results were detected in FM and controls, not supporting an altered interaction between opioid and 5-HT mechanisms as the basis for dysfunction of EIH in patients with FM. In summary, our results suggest that, by genetic association, the mu-opioid receptor interacts with 2 major serotonergic structures involved in 5-HT reuptake and release, to modulate EIH.

  • 21.
    Törnbom, Karin
    et al.
    University of Gothenburg.
    Lundälv, Jörgen
    University of Gothenburg.
    Palstam, Annie
    University of Gothenburg.
    Sunnerhagen, Katharina S
    University of Gothenburg.
    "My life after stroke through a camera lens"- A photovoice study on participation in Sweden.2019In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 14, no 9, article id e0222099Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: An increasing number of people with stroke live in their communities, yet the understanding of how their reintegration into society can best be facilitated is incomplete. If needs are not sufficiently met and difficulties overcome, it may result in limited participation and decreased life satisfaction for this group. We aimed to understand life after stroke through the lens of participants' cameras, and hence their views and experiences guided this study.

    METHODS: By the means of photovoice, an action research method, this study was conducted in a collaborative format with six women and five men after stroke. Participants photographed in everyday life for up to four weeks and then met to discuss all images in a focus group setting. Subsequently, participants gave feedback on the method and discussed the upcoming photography exhibition. All photos and the three focus group discussions were analyzed using a thematic analysis with an inductive approach.

    RESULTS: In the focus group discussions, life after stroke were conceptualized through five main themes: a driving force to participate in society; managing everyday life through inventiveness and persistent training; insufficient healthcare and rehabilitation in the long-term perspective; finding meaningful relationships and activities in daily life. Participants' voices are made clear through selected photos, which aim to present each theme and make results easier to understand.

    CONCLUSIONS: Participants found new ways to approach everyday life situations and had thereby regained a sense of control in life. However, it was evident that psychological processes towards adaptation were hindered by depression and that some individuals felt alone in an ongoing struggle. Additionally, available interventions a long time after stroke were not flexible enough to address all participants' needs.

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