SmertebehandlingKompetansegruppa for smertebehandling på

Sunnaas Sykehusv/ Tor S. Haugstad, overlege, prof. dr. med.

Tor S. Haugstad Columbia NY

Prevalence of Chronic Pain in Europe - by Country– Based on Complete Screener Data –

14 %

13 %

12 %

17 %

15 %

13 %

19 %

21 %

8 %

13 %

8 %

9 %

4 %

5 %

7 %

4 %

0 % 50 %

5 %

8 %

9 %

10 %

10 %

10 %

7 %

12 %

6 %

6 %

10 %

5 %

5 %

4 %

5 %

6 %

0 % 50 %

Severe

Moderate

Norway (n=2,018)

Poland (n=3,812)

Italy (n=3,849)

Belgium (n=2,451)

Finland (n=2,004)

Austria (n=2,004)

Sweden (n=2,563)

Netherlands (n=3,197)

Germany (n=3,832)

Israel (n=2,244)

Denmark (n=2,169)

Switzerland (n=2,083)

France (n=3,846)

UK (n=3,800)

Ireland (n=2,722)

Spain (n=3,801)

30%

27%

26%

23%

21%

19%

18%

18%

17%

17%

16%

16%

15%

13%

13%

11%

Overall Prevalence = 19% (n=46,394)

Moderate 13% Severe 6%

Tor S. Haugstad Columbia NY Breivik et al, 2006

Mechanism based division of chronic pain (IASP 2008)

Perifere nociceptive

Neuropathic Central non-nociceptive

inflammation/periferal mechanic tissue damage

Damage or affection of periferal/central nerve tissue

Central disturbance in pain processing in CNS (allodynia/hyperalgesia)

NSAID/opioid response

Responds to both periferal and central farmacological treatment

TCA and neurodrugs are most effective

Triggered by stress

Examples:OsteoarthritisRACancer pain

Examples:PolyneuropathyCentral post stroke painPain in MS

Examples:FibromyalgiaIBSCPP

Tor S. Haugstad Columbia NY

Tor S. Haugstad Columbia NY

CP – epidemiologi (1965-2004)Materiale fra EuropaPrevalens har økt til over 2.0 pr. 1000

levendefødteMindre diplegi, økt hemiplegiKognitive utfordringer 23 – 44

%Språkutfordringer 42 – 81 %Synsutfordringer 62 – 71

%Epilepsi 22 – 40 %Langvarige smertelidelser > 25 %

Tor S. Haugstad Columbia NY

Odding et al, 2006

Operativ behandling for skjelettdeformiteter

Kirurgisk behandling for skoliose aktuelt vedBekkenskjevetAffisert sittebalanseTrykksårSmerter når ribbebuen møter hoftebenet

Komplikasjoner i 25 % av tilfelleneVed luksasjoner/malformasjoner i hofteleddet

Fjerne toppen av lårbenet/avstive hoften/totalprotese

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Hasler, 2013Boldingh, 2014

Resultat av treningsprogramEffekten på smerte og tretthet (fatigue) hoa

voksne med CPSmertereduksjonBedring av energinivåetLivskvalitet bedretFor at effekten skal vare, må programmet gå

kontinuerlig

Tor S. Haugstad Columbia NY

Vogtle, 2013

Tor S. Haugstad Columbia NY

From the Paris School of Neurology to Somatocognitive Therapy

Clockwise from top:1. Charcot lecturing on hysterical

palsies2. Duchenne demonstrating electrical

stimulation of nerves controlling facial muscles

3. Freud developed psychoanalysis – from hysterical palsies to interpretation of dreams

4. Reich developed somatic psychology – ”body language” and ”muscular armor” as expression of psychological defence

5. Mensendieck teaching functional anatomy

6. Beck developed cognitive therapy – based on theory of dysfunctional cognitive schemata

Cognitive therapyDysfunctional cognitive schemata psychological

distressExample – the negative triade of depression:

negative thoughts of SelfWorldFuture

Therapeutic sessions divided in threeGo over experiences since last sessionWork with cognitive schemataNew assignments to be practiced until next

sessionTor S. Haugstad Columbia NY

SMT(Standardized Mensendieck Test) Based on principles of functional anatomy

0 - least optimal 7 - optimal score

Tor S. Haugstad Columbia NY

Posture Score

Global/line of gravity  

Ancle  Knee  Pelvis  Back  Shoulder  Neck  Average     Gait Score

Global  Foot roll  Propolsion  Rotation  Average     Movement Score

Global  Frontal armlift  Vertical armlift  Sagital armswing  Diagonal armswing  

Balance/hip flexion  

Average     Sitting posture Score

Global  Support  Pelvis  Back  Average     Respiration Score

Global  Armlift  Pelvic lift  Average         Haugstad et al, 2006

Somatocognitive therapy Builds on cognitive therapy

and theory Dr. Bess Mensendieck

worked with cognitive elements (1931) – cognitions control movement

Cognitive therapy later developed by Aaron Beck

Short term body oriented therapy - focused on the here and now and thoughts about movements

Likeworthy working alliance beween therapist and patient, built on empathy and dialouge

Body awareness through explorative treatment with functional goals - in daily life

Can be understood as a hybrid between physiotherapy and psychotherapy

3-phased lesson-1.What is learnt and

experienced since last time? In daily life?

2.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 massage that gives new tactile experiences- feel the difference between tension and relaxation

3. New assignments given - the therapy unfolds in the activities of daily living

Tor S. Haugstad Columbia NY

Longstanding pelvic pain - Chronic Pelvic Pain (CPP)Pain persisting in the lower

abdomen for a period exceeding 6 months

Excluded: Pain related to

menstruation only Or only to sex, Or only in the vulva

3.8% of all women between 15 – 73 years

By some authors classified as ICD-10 F45.4 – persistent somatoform pain disorder.

(Zondervan 2001, Grace 2004)

Tor S. Haugstad Columbia NY

The RCT study of women with CPP

60 women with CPP were recruited from the National Hospital, OUS

Pain was evaluated by means of a VAS on a scale from 0 - 10 before and after treatment and after one year

Psychometric assessment GHQ-30 before treatment and after one year

Evaluation of motor patterns with SMT before and after treatment and after one year (7 is optimal function, 0 is least optimal). The evaluator was blinded with respect to whether the SMT was before or after treatment, or after one year

Palpation of the muscles in the pelvic regionA clinical history/interview was taken before and after

treatment

Tor S. Haugstad Columbia NY

CPP - Description of the patientsAverage score for pain experience among the 60 women with

CPP was 6.01The mean age for all 60 were 31 y75 % of all of the 60 had moderate to strong pain under or

after intercourse50 % described the lower abdomen as swollen, and they have

difficulty wearing jeans due to allodynia

• 25 % told that the pain started after an infection in the bladder or in kidney region, or after an abortion

• The CPP patients in the study had previously performed in average two surgical prosedures each (explorative laparoscopies, resection of ovarian cysts, hysterctomy, extirpation of the adnexae, etc.).

Tor S. Haugstad Columbia NY

SMT – movement patterns after 3 months -and at 1 year follow up after therapy

Tor S. Haugstad Columbia NY

VAS after therapy and at 1 year follow up

Tor S. Haugstad Columbia NY

GHQ-30 - Psychological Distress before and 1 year after therapy

GHQ- 30 after 1 y:No change in the STGT group (slightly worse)

In the MSCT group significant improvement in the scores for anxiety (p=0.00) and coping (p=0.01), also improvement in the scores for depression (p=0.06)

Haugstad GK, Haugstad TS, Kirste UM, Leganger S, Malt UF. Continuing improvement of chronic pelvic pain in women after short-term Mensendieck somatocognitive therapy; results of a 1-y follow – up study Am J Obst Gyn 2008 ;199:615.e1-615.e8

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Comments from editor in American Journal of Gynecology & Obstetrics (2008)

Tor S. Haugstad Columbia NY

Provoked Vestibulodynia PVD

Tor S. Haugstad Columbia NY

• Affecting approximately 12 - 30 % of premenopausal women

• Described as a sharp or burning sensation at the vulvar vestibule

Erythema/hypersensitivity/allodynia of defined area of the vestibulum may occur

Dyspareunia, or painful sexual intercourse, is the most common complaint

May occur even in the absence of relevant visible findings.

(Moyal-Barracco & Lynch 2004, Goldfinger 2009)

Few RCT and follow – up studies;

1. Comparing EMG biofeedback and lidocaine gel – significant increases in vestibulare pain tresholds, quality of life, and sexual funcion (Danielsson 2006).

2. Compare vestibulectomy and group cognitive- behavior therapy and EMG biofeedback for treatment – all three significant pain reduction –after 2.5 y all three group continued to improve (Bergeron 2008).

3. Comparing Cognitve behavioral therapy and supportive Psychotherapy - the CAT group reported greater improvement (Masheb 2009).

PVD and somatocognitive therapy-A follow up study

Follow up study at the Oslo University CollegeNo studies have ever examine the movement

patterns in these patients with PVDPhysiotherapy students, under supervisionPatients were treated for 6 weeks; twice a

week, for 1 hour – 12 hours with somatocognitive therapy

In this study we have treated 25 patients Tested with SMT, VAS, GHQ – 30 and TAMPA

scale of Kinesofobia before and after somatocognitive treatment and after 6 months

Tor S. Haugstad Columbia NY

Some of the elements in somatocognitive treatment of PVD patients

Learning body awareness through; body tension and relaxation in daily movement new experiences of own respiration pattern

Be aware of vulva, get new sensations through; squeeze and relax the pelvic floor gently apply lotion to the vulva apply cold and warm cloths trying carefully the smallest tampon – after a while try

sex again if they have a partner

The patients try these small steps in between the therapy sessions, in the daily life, and share the experiences with therapist.

Tor S. Haugstad Columbia NY

SMT Respiration scores –before and after therapy

Tor S. Haugstad Columbia NY

SMT Gait scores –before and after therapy

Tor S. Haugstad Columbia NY

Pain score before and after therapy

Before treatment After treatment After 6 months0123456789

108.75

5.04

1.88

VAS

Tor S. Haugstad Columbia NY

Psychological Distress – GHQ-30 andTAMPA Scale of Kinesophobia 6 months after therapy

GHQ – 30: significantly improved scores for anxiety and depression at 6 months follow up

TAMPA scale of kinesophobia: significantly reduced scores for fear of movement, and fear of pain at 6 months follow up

Tor S. Haugstad Columbia NY

CONCLUSION

Promising results using somatocognitive therapy for these gynecological patients with longstanding pain syndromes

More studies are needed, including other groups of patients (like low back pain, neck and shoulder pain, generalized pain, PTDS) using this new approach combining physiotherapy and psychotherapy

We need to understand the mechanisms behind the development of these longstanding pain syndromes, related to peripheral sensors, peripheral nerves and the central nervous system, as well as the mechanisms behind the effect of somatocognitive therapy

Tor S. Haugstad Columbia NY In lumine Tuo videbimus 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

Tor S. Haugstad Columbia NY