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 –
Overall Prevalence = 19%
(n=46,394)
Moderate 13% Severe 6%
Norway (n=2,018)
Poland (n=3,812)
Italy (n=3,849)
Belgium (n=2,451)
Austria (n=2,004)
Finland (n=2,004)
Sweden (n=2,563)
Netherlands (n=3,197)
13 %
15 %
17 %
21 %
19 %
13 %
8 %
4 %
9 %
8 %
12 %
13 %
14 %
7 %
5 %
4 %
0 %
Tor S. Haugstad Columbia NY
23%
21%
19%
18%
30%
27%
26%
18%
50 %
Moderate
Severe
Germany (n=3,832) 12 % 5 %
Israel (n=2,244) 7 % 10 %
Denmark (n=2,169) 10 % 6 %
Switzerland (n=2,083) 10 % 6 %
France (n=3,846) 10 % 5 %
Ireland (n=2,722) 9 % 4 %
UK (n=3,800) 8 % 5 %
Spain (n=3,801) 5 % 6 %
0 %
Breivik et al, 2006
16%
15%
13%
13%
17%
17%
16%
11%
50 %

Mechanism based division of chronic pain (IASP 2008)
Perifere nociceptive Neuropathic inflammation/periferal mechanic tissue damage
Damage or affection of periferal/central nerve tissue
NSAID/opioid response Responds to both periferal and central farmacological treatment
Central non-nociceptive
Central disturbance in pain processing in CNS
(allodynia/hyperalgesia)
TCA and neurodrugs are most effective
Examples:
Osteoarthritis
RA
Cancer pain
Examples:
Polyneuropathy
Central post stroke pain
Pain in MS
Triggered by stress
Examples:
Fibromyalgia
IBS
CPP
Tor S. Haugstad Columbia NY

Tor S. Haugstad Columbia NY

 Materiale fra Europa
 Prevalens har økt til over 2.0 pr. 1000 levendefødte
 Mindre diplegi, økt hemiplegi
 Kognitive utfordringer
 Språkutfordringer
 Synsutfordringer
 Epilepsi
23 – 44 %
42 – 81 %
62 – 71 %
22 – 40 %
 Langvarige smertelidelser > 25 %
Odding et al, 2006
Tor S. Haugstad Columbia NY

 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

 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

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

 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

SMT
(Standardized
Mensendieck Test)
Based on principles of functional anatomy
Posture
Global/line of gravity
Ancle
Knee
Pelvis
Back
Shoulder
Neck
Average
Gait
Global
Foot roll
Propolsion
Rotation
Average
Movement
Global
Frontal armlift
Vertical armlift
Sagital armswing
Diagonal armswing
Balance/hip flexion
Average
Sitting posture
Global
Support
Pelvis
Back
Average
Respiration
Global
Armlift
Pelvic lift
Average
Tor S. Haugstad Columbia NY
Score
Score
Score
Score
Score
Haugstad et al, 2006

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Builds on cognitive therapy and theory
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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

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Pain persisting in the lower abdomen for a period exceeding
6 months
Excluded:
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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

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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

 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

Tor S. Haugstad Columbia NY

Tor S. Haugstad Columbia NY

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

•
•
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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

1.
2.
3.
Few RCT and follow – up studies;
Comparing EMG biofeedback and
lidocaine gel – significant increases in vestibulare pain tresholds, quality of life, and sexual funcion (Danielsson 2006).
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).

 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

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

Tor S. Haugstad Columbia NY

Tor S. Haugstad Columbia NY

10
9
8
7
6
5
4
3
2
1
0
8,75
Before treatment
Tor S. Haugstad Columbia NY
5,04
After treatment
VAS
1,88
After 6 months

 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

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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

— 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