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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 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 – 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
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
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
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
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
Cognitivetherapy • Dysfunctionalcognitiveschematapsychologicaldistress • 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
SMT(Standardized Mensendieck Test) Basedonprinciplesoffunctionalanatomy0 - least optimal 7 - optimal score Haugstad et al, 2006
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
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)
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
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.).
SMT – movementpatternsafter 3 months -and at 1 yearfollow up aftertherapy
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
Comments from editor in American Journal ofGynecology & Obstetrics (2008)
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).
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
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.
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
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
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