Somatocognitive therapy in gynecological pain CPP Chronic pelvic
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Transcript Somatocognitive therapy in gynecological pain CPP Chronic pelvic
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%
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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
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Examples:
Polyneuropathy
Central post stroke pain
Pain in MS
Examples:
Fibromyalgia
IBS
CPP
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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.).
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SMT – movement patterns after 3 months and at 1 year follow up after therapy
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VAS after therapy and at 1 year follow up
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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)
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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)
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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
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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.
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SMT Respiration scores –
before and after therapy
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SMT Gait scores –
before and after therapy
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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
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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
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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
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