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Smertebehandling

Smertebehandling. Kompetansegruppa for smertebehandling på Sunnaas Sykehus v/ Tor S. Haugstad, overlege, prof. dr. med. Moderate. Severe. Prevalence of Chronic Pain in Europe - by Country – Based on Complete Screener Data –.

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Smertebehandling

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  1. Smertebehandling Kompetansegruppa for smertebehandling på Sunnaas Sykehus v/ Tor S. Haugstad, overlege, prof. dr. med.

  2. Moderate Severe Prevalence of Chronic Pain in Europe - by Country – Based on Complete Screener Data – Overall Prevalence = 19% (n=46,394)Moderate 13% Severe 6% 30% 27% 26% 23% 21% 19% 18% 18% 17% 17% 16% 16% 15% 13% 13% 11% Norway (n=2,018) Germany (n=3,832) Israel (n=2,244) Poland (n=3,812) Italy (n=3,849) Denmark (n=2,169) Belgium (n=2,451) Switzerland (n=2,083) Austria (n=2,004) France (n=3,846) Ireland (n=2,722) Finland (n=2,004) Sweden (n=2,563) UK (n=3,800) Netherlands (n=3,197) Spain (n=3,801) Breivik et al, 2006

  3. Mechanismbaseddivisionofchronicpain (IASP 2008)

  4. CP – epidemiologi (1965-2004) • Materiale fra Europa • Prevalens har økt til over 2.0 pr. 1000 levendefødte • Mindre diplegi, økt hemiplegi • Kognitive utfordringer 23 – 44 % • Språkutfordringer 42 – 81 % • Synsutfordringer 62 – 71 % • Epilepsi 22 – 40 % • Langvarige smertelidelser > 25 % Odding et al, 2006

  5. Operativ behandling for skjelettdeformiteter • Kirurgisk behandling for skoliose aktuelt ved • Bekkenskjevet • Affisert sittebalanse • Trykksår • Smerter når ribbebuen møter hoftebenet • Komplikasjoner i 25 % av tilfellene • Ved luksasjoner/malformasjoner i hofteleddet • Fjerne toppen av lårbenet/avstive hoften/totalprotese Hasler, 2013 Boldingh, 2014

  6. Resultat av treningsprogram • Effekten på smerte og tretthet (fatigue) hoa voksne med CP • Smertereduksjon • Bedring av energinivået • Livskvalitet bedret • For at effekten skal vare, må programmet gå kontinuerlig Vogtle, 2013

  7. From the Paris School ofNeurologyto Somatocognitive Therapy Clockwise from top: Charcotlecturingonhystericalpalsies Duchennedemonstratingelectricalstimulationof nerves controlling facialmuscles Freuddevelopedpsychoanalysis – from hystericalpalsies to interpretationofdreams Reichdevelopedsomaticpsychology – ”body language” and ”musculararmor” as expressionofpsychologicaldefence Mensendieckteachingfunctionalanatomy Beckdevelopedcognitivetherapy – basedontheoryofdysfunctionalcognitiveschemata

  8. Cognitivetherapy • Dysfunctionalcognitiveschematapsychologicaldistress • Example – thenegative triade ofdepression: negative thoughtsof • Self • World • Future • Therapeutic sessions divided in three • Go over experiencessince last session • Workwithcognitiveschemata • New assignments to be practiceduntilnextsession

  9. SMT(Standardized Mensendieck Test) Basedonprinciplesoffunctionalanatomy0 - least optimal 7 - optimal score Haugstad et al, 2006

  10. Buildsoncognitivetherapy and theory Dr. Bess Mensendieck workedwithcognitive elements (1931) – cognitionscontrolmovement Cognitivetherapy later developed by Aaron Beck Short term body orientedtherapy - focusedonthehere and nowand thoughtsaboutmovements Likeworthyworkingalliancebeweentherapist and patient, builtonempathy and dialouge Body awarenessthroughexplorativetreatmentwithfunctional goals - in dailylife Can be understood as a hybrid betweenphysiotherapy and psychotherapy 3-phased lesson- What is learnt and experienced since last time? In daily life? Treatment - Learning new active movements – challenging dysfunctional thoughts. Work with these in daily activities, they will influence on the respiration, the body awareness, the circulation and the fear of movement - manual massagethat gives new tactile experiences - feel the difference between tension and relaxation 3.New assignments given - the therapy unfolds in the activities of daily living Somatocognitive therapy

  11. Longstandingpelvicpain -ChronicPelvicPain (CPP) • Painpersisting in thelower abdomen for a periodexceeding 6 months • Excluded: • Painrelated to menstruationonly • Or only to sex, • Or only in the vulva • 3.8% of all womenbetween 15 – 73 years • By someauthorsclassified as ICD-10 F45.4 – persistent somatoformpaindisorder. (Zondervan 2001, Grace 2004)

  12. The RCT studyofwomenwith CPP • 60 womenwith CPP wererecruited from the National Hospital, OUS • Painwasevaluatedby meansof a VAS on a scale from 0 - 10 before and aftertreatment and afteroneyear • Psychometricassessment GHQ-30 beforetreatment and afteroneyear • Evaluation of motor patternswith SMT before and aftertreatment and afteroneyear (7 is optimal function, 0 is leastoptimal). The evaluatorwasblindedwithrespect to whetherthe SMT wasbefore or aftertreatment, or afteroneyear • Palpationofthemuscles in thepelvic region • A clinicalhistory/interviewwastakenbefore and aftertreatment

  13. CPP - Descriptionofthepatients • Average score for painexperienceamongthe 60 womenwith CPP was6.01 • The mean age for all 60 were31 y • 75 % of all ofthe 60 had moderate to strongpain under or afterintercourse • 50 % describedthelower abdomen as swollen,and they have difficultywearing jeans due to allodynia • 25 % toldthatthepainstartedafter an infectionin thebladder or in kidneyregion, or after an abortion • The CPP patients in thestudyhadpreviouslyperformed in averagetwosurgicalprosedureseach(explorativelaparoscopies, resectionofovariancysts, hysterctomy, extirpationoftheadnexae, etc.).

  14. SMT – movementpatternsafter 3 months -and at 1 yearfollow up aftertherapy

  15. VAS aftertherapy and at 1 yearfollow up

  16. GHQ-30 - PsychologicalDistressbefore and 1 yearaftertherapy GHQ- 30 after 1 y: • No change in the STGT group (slightlyworse) • In the MSCT groupsignificantimprovement in the scores for anxiety (p=0.00) and coping(p=0.01), alsoimprovement in the scores for depression (p=0.06) Haugstad GK, Haugstad TS, Kirste UM, Leganger S, Malt UF. Continuingimprovementofchronicpelvicpain in womenaftershort-term Mensendiecksomatocognitivetherapy; resultsof a 1-y follow – up study Am J ObstGyn 2008 ;199:615.e1-615.e8

  17. Comments from editor in American Journal ofGynecology & Obstetrics (2008)

  18. ProvokedVestibulodynia PVD • Affectingapproximately 12 - 30 % ofpremenopausalwomen • Describedas a sharp or burningsensation at thevulvarvestibule • Erythema/hypersensitivity/allodyniaofdefined area ofthe vestibulum mayoccur • Dyspareunia, or painfulsexualintercourse, is the most commoncomplaint • May occureven in the absence of relevant visible findings. (Moyal-Barracco & Lynch 2004, Goldfinger 2009) • Few RCT and follow – up studies; • ComparingEMG biofeedbackand lidocaine gel – significantincreases in vestibulare paintresholds, qualityoflife, and sexualfuncion(Danielsson 2006). • Comparevestibulectomyandgroupcognitive- behaviortherapyand EMG biofeedbackfor treatment – all threesignificantpainreduction –after 2.5 y all threegroupcontinued to improve(Bergeron 2008). • ComparingCognitvebehavioraltherapy and supportivePsychotherapy- the CAT groupreportedgreaterimprovement (Masheb 2009).

  19. PVD and somatocognitivetherapy-A follow up study • Follow up studyat the Oslo University College • No studies have ever examinethemovementpatterns in thesepatientswith PVD • Physiotherapy students, under supervision • Patientsweretreated for 6 weeks; twicea week, for 1 hour – 12 hourswith somatocognitive therapy • In thisstudywehave treated 25 patients • TestedwithSMT, VAS, GHQ – 30 and TAMPA scaleofKinesofobiabefore and aftersomatocognitivetreatment and after 6 months

  20. Someofthe elements in somatocognitivetreatmentof PVD patients Learning body awarenessthrough; • body tension and relaxation in dailymovement • newexperiencesofownrespirationpattern Be awareof vulva, getnewsensationsthrough; • squeeze and relaxthepelvicfloor • gentlyapply lotion to the vulva • applycold and warmcloths • tryingcarefullythesmallesttampon – after a whiletry sex againifthey have a partner The patientstrythesesmallsteps in betweenthetherapy sessions, in thedailylife, and sharetheexperienceswiththerapist.

  21. SMT Respiration scores –before and aftertherapy

  22. SMT Gait scores –before and aftertherapy

  23. Pain score before and aftertherapy

  24. PsychologicalDistress – GHQ-30 andTAMPA ScaleofKinesophobia6 monthsaftertherapy • GHQ – 30: significantlyimproved scores for anxiety and depressionat 6 monthsfollow up • TAMPA scaleofkinesophobia:significantlyreduced scores for fearofmovement, and fearofpain at 6 monthsfollow up

  25. CONCLUSION • Promisingresultsusing somatocognitive therapy for thesegynecologicalpatientswithlongstandingpainsyndromes • More studies areneeded, includingothergroupsofpatients (like low back pain, neck and shoulderpain, generalizedpain, PTDS) usingthisnewapproachcombiningphysiotherapy and psychotherapy • Weneed to understand themechanismsbehindthedevelopmentoftheselongstandingpainsyndromes, related to peripheral sensors, peripheral nerves and thecentralnervous system, as well as themechanismsbehindtheeffectof somatocognitive therapy In lumineTuovidebimus lumen

  26. Konklusjon: • Ved CP med langvarig smerte kan operasjon hjelpe i noen tilfeller • Treningsprogrammer hjelper mot smerter og tretthet så lenge de holdes ved like • Behandlingsprogrammer basert på innsiktsorienterte og kognitivt baserte teknikker bør utprøves • Sunnaas har fokus på smertetilstander hos CP-pasienter

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