Somatocognitive therapy in gynecological pain CPP Chronic pelvic

Report
Kompetansegruppa for smertebehandling på
Sunnaas Sykehus
v/ 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 –
Norway (n=2,018)
Poland (n=3,812)
Italy (n=3,849)
Belgium (n=2,451)
Austria (n=2,004)
21 %
Overall Prevalence =
(n=46,394)
19%
Moderate
Severe 6%
9%
19 %
8%
13%
30%
Germany (n=3,832)
27%
Israel (n=2,244)
12 %
7%
5%
17%
10 %
17%
13 %
13 %
26%
Denmark (n=2,169)
10 %
6%
16%
15 %
8%
23%
Switzerland (n=2,083)
10 %
6%
16%
4%
21%
France (n=3,846)
10 %
5%
15%
9%
17 %
Finland (n=2,004)
12 %
7%
19%
Ireland (n=2,722)
Sweden (n=2,563)
13 %
5%
18%
UK (n=3,800)
Netherlands (n=3,197)
14 %
4%
18%
0%
Tor S. Haugstad Columbia NY
4%
13%
8% 5%
13%
Spain (n=3,801) 5 % 6 %
50 %
Moderate
Severe
11%
0%
50 %
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:
Osteoarthritis
RA
Cancer pain
Tor S. Haugstad Columbia NY
Examples:
Polyneuropathy
Central post stroke pain
Pain in MS
Examples:
Fibromyalgia
IBS
CPP
Tor S. Haugstad Columbia NY
CP – epidemiologi (1965-2004)
 Materiale fra Europa
 Prevalens har økt til over 2.0 pr. 1000 levendefødte
 Mindre diplegi, økt hemiplegi
 Kognitive utfordringer
 Epilepsi
23 – 44 %
42 – 81 %
62 – 71 %
22 – 40 %
 Langvarige smertelidelser
> 25 %
 Språkutfordringer
 Synsutfordringer
Odding et al, 2006
Tor S. Haugstad Columbia NY
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
Tor S. Haugstad Columbia NY
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
Tor S. Haugstad Columbia NY
From the Paris School of Neurology
to Somatocognitive Therapy
Clockwise from top:
1. Charcot lecturing on hysterical palsies
2. 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
Tor S. Haugstad Columbia NY
Cognitive therapy
 Dysfunctional cognitive schemata  psychological distress
 Example – the negative triade of depression:
negative thoughts of
 Self
 World
 Future
 Therapeutic sessions divided in three
 Go over experiences since last session
 Work with cognitive schemata
 New assignments to be practiced until next session
Tor S. Haugstad Columbia NY
Posture
SMT
(Standardized
Mensendieck Test)
Based on principles of
functional anatomy
0 - least optimal
7 - optimal score
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
Global
Armlift
Pelvic lift
Average
Tor S. Haugstad Columbia NY
Score
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
Tor S. Haugstad Columbia NY
 3-phased lesson1. 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
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 region
A clinical history/interview was taken before and after
treatment
Tor S. Haugstad Columbia NY
CPP - Description of the patients
 Average score for pain experience among the 60 women



•
•
with CPP was 6.01
The mean age for all 60 were 31 y
75 % of all of the 60 had moderate to strong pain under
or after intercourse
50 % 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
Tor S. Haugstad Columbia NY
Comments from editor in American Journal of
Gynecology & Obstetrics (2008)
Tor S. Haugstad Columbia NY
Provoked Vestibulodynia PVD
•
•



Affecting approximately 12 30 % of premenopausal
women
Described as a sharp or
burning sensation at the
vulvar vestibule
Erythema/hypersensitivity/all
odynia 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)
Tor S. Haugstad Columbia NY
 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.
3.
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).
Comparing Cognitve behavioral
therapy and supportive
Psychotherapy - the CAT group
reported greater improvement
(Masheb 2009).
PVD and somatocognitive therapyA follow up study
 Follow up study at the Oslo University College
 No studies have ever examine the movement
patterns in these patients with PVD
 Physiotherapy students, under supervision
 Patients 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
10
9
8
7
6
5
4
3
2
1
0
8.75
5.04
1.88
Before treatment
After treatment
VAS
Tor S. Haugstad Columbia NY
After 6 months
Psychological Distress – GHQ-30 and
TAMPA 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

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