12/10/10
Indhold
Henrik Bjarke Madsen
Fysioterapeut
MSc Pain Management
Smertecenter Syd, OUH
• 
Smertens historie
• 
Pain in Europe.
• 
Prædiktorer for udvikling af kroniske smerter.
• 
Smertefysiologi.
• 
Undersøgelse af i klinikken
• 
Behandling og håndtering af kroniske smerter.
IMDT’s stormøde, København 12. oktober 2010
Milesten
Aristotle 350 BC ”a passion of the soul”
Descartes 1649 AD Milesten
Clifford Woolf 1990 Neural plasticity and central sensitizations
Patrick Wall 1965 Gate Control Theory
Findings – The shocking truth
A widespread problem
To af mange definitioner
Prævalens
When considering only moderate to severe chronic pain, the overall prevalence across
Europe is just under one-fifth, with the highest prevalence in Norway, Poland and Italy, the
lowest in Spain.
Prevalence of Chronic Pain by Country – European Summary Based on
Complete Screener Data
"Smerte er en ubehagelig sensorisk og emotionel oplevelse,
forbundet med aktuel eller truende vævsbeskadigelse. Eller
som beskrives i vendinger svarende til en sådan
beskadigelse.” (IASP 1994) 100%
21%
19%
Fin
lan
Po
23%
Au
rw
No
26%
Be
27%
ly
Ita
30%
18%
18%
0%
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ay
Pain is better defined as an awareness of a need state rather
than a sensation. It serve more to promote healing than to
avoid injury. It has more in common with the phenomenon
of hunger and thirst than with seeing or hearing. The period
after injury is divided into the immediate, acute and chronic
stages. In each stage it is shown that pain has only weak
connection to injury but a strong connection to the body state
(Patrick Wall 1979)
100%
Overall Prevalence
(n=46,394)
19%
Isra
De
15%
13%
13%
11%
Sp
Ge
16%
UK
16%
Ire
17%
Fra
17%
0%
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• Just under one in five adults in Europe (19%) suffers from chronic pain.
• Just over one third of European households interviewed in the first questionnaire were found
to have at least one member aged 18 or over who suffers from pain (chronic or otherwise).
• Over 19% of households who reported having pain sufferers contain more than one sufferer.
• When asked about their most recent pain experience 67% or respondents said they had
"moderate pain" (rated as levels of 5, 6, and 7 on a pain scale) and 33% severe pain (rated as
levels of 8,9,10 on a pain scale).
Pain in Europe 2003
12
Pain In Europe – A Report
1
lowest in Spain.
Prevalence of Chronic Pain by Country – European Summary Based on
Complete Screener Data
100%
30%
27%
26%
23%
21%
19%
18%
18%
12/10/10
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100%
Comparison highlights
The prevalence of chronic pain in the population was highest in Norway (30%) and
lowest in Spain (11%).
Overall Prevalence
(n=46,394)
19%
17%
Prævalens
17%
16%
16%
15%
13%
13%
• Norway, Poland and Italy have the highest proportion of moderate and severe chronic
pain sufferers relative to total country populations.
• Highest country prevalence for moderate sufferers: Norway, Poland and Austria
• Highest country prevalence for severe sufferers: Italy, Israel and Norway
Prævalens
11%
Who is suffering?
Comparison
highlights
0%
ain
Sp
A typical chronic pain sufferer would be a middle aged, married woman who has no children still
living at home.
=3
(n
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=3
=2
(n
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(n
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=2
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3
n=
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Fr
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The prevalence of chronic pain in the population was highest in Norway (30%) and
lowest in Spain (11%).
,80
0)
1)
2)
9)
2)
3)
,08
6)
,72
,84
=2
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)
,83
44
• Norway, Poland and Italy have the highest proportion of moderate and severe chronic
pain sufferers relative to total country populations.
• Highest country prevalence for moderate sufferers: Norway, Poland and Austria
Just
under one
in fiveprevalence
adults in Europe
(19%)
suffers from
• Highest
country
for severe
sufferers:
Italy,chronic
Israel pain.
and Norway
Just over one third of European households interviewed in the first questionnaire were found
to have at least one member aged 18 or over who suffers from pain (chronic or otherwise).
Over 19% of households who reported having pain sufferers contain more than one sufferer.
When asked about their most recent pain experience 67% or respondents said they had
"moderate pain" (rated as levels of 5, 6, and 7 on a pain scale) and 33% severe pain (rated as
levels of 8,9,10 on a pain scale).
•
•
•
•
• Across Europe the average age of pain sufferers is 50 years of age.
• In most European countries slightly more women than men suffer pain - 56% of chronic pain
sufferers are female and 44% male.
• Pain sufferers are most likely to live with other people (79%), be married (59%) and have no
children living in the household (71%).
equal
of people between
describedmoderate
their painand
as severe
"constant",
as opposed
"intermittent"
•Nearly
Gender
andnumbers
age are consistent
pain sufferers,
as istothe
(46%
versusof54%).
likelihood
children being present in the household.
• It appears that severe pain sufferers may be somewhat more likely than moderate sufferers to
When
asked to
their pain, the most frequently used adjective by over a quarter
be divorced
ordescribe
separated.
questioned was "aching". Other common adjectives were "annoying", "intense" and "constant"
The least common descriptions were "dull", "tingling" and "nauseating". This only highlights the
difficulty patients have in communicating their pain to their physicians and their families.
Who is suffering?
A typical chronic pain sufferer would be a middle aged, married woman who has no children still
living at home.
12
Pain In Europe – A Report
Where does it hurt?
• Across Europe the average age of pain sufferers is 50 years of age.
• In most European countries slightly more women than men suffer pain - 56% of chronic pain
sufferers are female and 44% male.
• Pain sufferers are most likely to live with other people (79%), be married (59%) and have no
Pain in Europe 2003
children living in the household (71%).
• Gender and age are consistent between moderate and severe pain sufferers, as is the
likelihood of children being present in the household.
• It appears that severe pain sufferers may be somewhat more likely than moderate sufferers to
be divorced or separated.
The back represents by far the most common location for pain, with unspecified back pain
Stabbing
Pain
effecting nearly a quarter of all respondents,
lower back pain 18% and
upper in
backEurope
pain 5%.
Constant
Other significant body areas afflicted with pain were: knees, legs, heads, joints, shoulders,
Annoying
necks, hips, upper back and hands.
The most frequent cause of chronic pain was arthritis/osteoarthritis, which effected over one
third of respondents, followed by herniated or deteriorating discs and traumatic injury. Less
common causes were rheumatoid arthritis, migraine headaches, fracture/deterioration of the
spine, nerve damage, cartilage damage, whiplash and surgery.
Where does it hurt?
Intense
Locations and causes
of pain
Aching
The back represents by far the most common location for pain, with unspecified back pain
effecting nearly a quarter of all respondents, lower back pain 18% and upper back pain 5%.
Other significant body areas afflicted with pain were: knees, legs, heads, joints, shoulders,
necks, hips, upper back and hands.
24%
Arthritis/osteoarthritis
34%
18%
Herniated/
15%
deteriorating discs
16%
To be categorised
as 15%
a chronic pain sufferer, people Traumatic
neededinjury
to have experienced
pain within the
Head
12%
last month. Amongst
sufferers:
14%
Leg
8%
Rheumatoid arthritis
Joints (unspecified)
10%
Migraine
headaches
7%
Shoulder(65%)9%
- Two thirds
had experienced pain on the day of the questionnaire
Back (unspecified)
Lower back
Where does it hurt ?
- 28% in the past
0% week
- 7% within the past month
Locations and causes of pain
Knee
Head
Leg
Joints (unspecified)
Shoulder
0%
100%
0%
100%
Pain In Europe – A Report
24%
18%
16%
15%
14%
10%
9%
Lower back
Prævalens
Knee
The most frequent cause of chronic pain was arthritis/osteoarthritis, which effected over one
third of respondents, followed by herniated or deteriorating discs and traumatic injury. Less
common causes were rheumatoid arthritis, migraine headaches, fracture/deterioration of the
spine, nerve damage, cartilage damage, whiplash and surgery.
Back (unspecified)
2003
34%
Arthritis/osteoarthritis
Herniated/
deteriorating discs
15%
12%
Traumatic injury
7%
Migraine headaches
0%
100%
Pain In Europe – A Report
13
Suffering
from
chronic
pain
has anhaving
undoubted
impact
on people’s
health:subdivided
The median
time
people
reported
suffered
chronic
pain wasemotional
7 years. When
severe pain sufferers were found to have experienced pain for one third longer than moderate
•pain
50%sufferers.
report feeling
theoftime
Overalltired
oneall
fifth
respondents said they had been in pain for 20 years or more.
• 43% said feeling in pain made them feel helpless
•On
44%
said that
their pain
kept
themexperienced
from thinking
or for
concentrating
clearly
average
sufferers
report
having
pain
the past 7 years.
• One in five (21%) chronic pain sufferers had been diagnosed with depression as a result of
their pain
• A staggering 16% said that some days the pain was so bad they wanted to die
8%
Rheumatoid arthritis
100%
Overall one third (35%) reported experiencing pain every minute of their lives "at all times", as
opposed to 31% who experienced it daily and 34% who experienced it several times a week.
• 16% had changed job responsibilities
•Using
Overall,
time scale
lost byabut
chronic
pain sufferers
from work
in the
sixasmonths
was (a
thethe
10 mean
point pain
two thirds
of respondents
rated
theirlast
pain
"moderate"
7.8 days
score
of 5-7) as opposed to "severe" (a score of 8-10).
13
Pain in Europe 2003
One third of people felt their chronic pain had effected relationshipsPain
with family,
friends and 2003
in Europe
work colleagues. Many had negative feelings surrounding pain that had created social isolation.
14
•
•
•
•
•
29% said no one believed how much pain they were in
28% said that they felt alone with their pain
23% felt their employers and colleagues were unsympathetic
18% that their families didn’t understand how pain effected their lives
17% that they were treated differently because of their pain
Pain In Europe – A Report
Most people appear to have fairly positive relationships with doctors, but a sizeable proportion
(43%) felt their doctors to be more focused on their illness than controlling their pain. A small
proportion were sceptical about their doctor’s ability or even their commitment to treating pain.
• 28% said that they didn’t think their doctor knew how to control their pain
• 23% didn’t think they were given enough time to discuss their pain
• 22% said that their doctor never asked about their pain
Varighed ?
Impact on life ?
Nearly two thirds of chronic pain sufferers were willing to try new treatments, but the same
proportion expressed concerns over side effects, and over one third were afraid of becoming
addicted to pain medications. The majority said that they’d prefer to use medications that
resolved their illness rather than treat their pain.
Duration of Pain Reported by Chronic Pain Sufferers – European Summary
(n=4,839)
100%
Comparison highlights
Median Duration
of Pain
7.0 Years
22%
4%
8%
6 Months
to < 1 Year
1 to < 2
Years
20%
17%
• Chronic pain appeared to have the most adverse impact on job retention in the
Denmark and the Netherlands, where 29% of people questioned said they’d lost their
jobs due to pain.
• Swedish and Norwegian employers offered greatest flexibility, with nearly one third of
people being allowed to change job responsibilities to accommodate their pain.
• The problem of social isolation seems most acute in Denmark where the greatest
number of sufferers (50%) felt unable to discuss their pain with other people.
21%
8%
0%
2 to < 5
Years
5 to < 10
Years
10 to < 15
Years
15 to < 20
Years
20 Years
or More
Doctor/Patient relationships
Despite such suffering chronic pain patients in Europe appear a uncomplaining group with
nearly a half saying that they felt that they could "tolerate" at least, a little more pain but some
Pain in Europe 2003
31% said their pain was so severe they could not "tolerate any more".
Overall the survey paints an interesting picture of good doctor/patient
relationships
with 62%2003
of
Pain
in Europe
people saying they felt "very or extremely" satisfied with the doctor treating their pain and an
overwhelming 94% feeling comfortable discussing pain with their doctor. More people discussed
pain with doctors than with their partners, other family members or friends and co workers.
Comparison highlights
• The Finnish had suffered from chronic pain longer than any other country group – a
median time of 9.6 years.
• A higher proportion of severe pain sufferers report suffering from pain "today,"
whereas a higher proportion of moderate pain sufferers report suffering from pain
"within the past week."
• More people in Netherlands (62%) reported suffering constant pain than any other
country, followed by Spain (61%) and Denmark (55%). Poland had the smallest
proportion of people complaining of constant pain.
Quality of life
Suffering chronic pain has an undoubted impact on people’s daily lives, effecting their ability to
undertake a wide variety of physical tasks.
People report that chronic pain effects their ability to undertake certain activities, having an
impact on their independence and interpersonal relationships. One quarter of people felt that
they couldn’t take as much care of themselves or others as they would have liked.
• 27% said that they were less able or unable to maintain relationships with friends and family
16
Pain In Europe – A Report
2
12/10/10
Viden om smerter
Mellem ørene ?
En skidt barndom
• 
Stort set alle mennesker vil opleve akutte smerter.
• 
Ca. 20 % angiver vedvarende smerter.
Ondt i livet ?
- et skidt liv!
Birket-Smith M. Acta Anaesthesiologica Scandinavica 2001;45,9,1114-1124 Akutte smerter
En særlig psyke?
Simple kroniske smerter
- ”et symptom” (brækket
arm,
blindtarmsbetændelse)
- Leder efter årsagen,
behandler/fikser årsagen
og derefter evt.
smertebehandling.
- Prævalens: Næsten 100 %
- Ca. 20 % udvikler
kroniske smerter.
-siger intet om smerteoplevelse
Birket-Smith M. Acta Anaesthesiologica Scandinavica 2001;45,9,1114-1124 Udviklingen fra akutte til kroniske smerter
Eksisterende smerter
- ikke noget med
smerteintensitet at gøre.
- Smerten bliver hvor den
er.
- Sover om natten.
- Ikke depression.
- Ikke hukommelses /
koncentrationsproblemer
- 50 % bliver smertefri i
løbet af 6 år.
- ”a disease in its own right”
- Biologien opfører sig underligt.
- Smerten breder sig (som den vil).
- Et hav af ledsagesymptomer.
- 90 % har påvirket nattesøvn.
- 60 % har behandlingskrævende
depression.
- Stress
- Isolation
- Angstfænomener.
- Svært kompromitteret hukommelse /
koncentration.
- Kommet for at blive.
- Prævalens: 2-10 %
Kronisk komplekse smerter
Potentielle risikofaktorer
Temporal udvikling
Injury
Præ-disponerende faktorer
Udvikling: Misbrug og andre
Persistent
traumer
Psykologisk: Humør,
Uddannelse
Somatisering,
Illness beliefs,
Angst
Stress respons
Depression Alkohol,
Adfærd: Søvnmønster,
Psykologisk skrøbelig
Self-efficacy
Kraftigdisposition
stress respons
Andet: Genetisk
KatastroferingAngst
Dårlig søvn Depression
Katastrofering
Smerteintensitet
Dårlig
søvn ?
Opioid induceret
hyperalgesi
Rygning ?
Sociale support (+/-)
Opioid induceret hyperalgesi ?
Pain free
Pain
Chronic Pain
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12/10/10
Abnorm
smerte
transmission
Psykologiske
processer
Biologiske
processer
Genetiske faktorer
Willis & Coggeshall 1991; Julius &
Basbaum 2001
Noxious stimuli
• 
• 
• 
Stimuli/respons i raske
individer
Køn, alder, etnicitet m.m
Miljømæssige påvirkninger (traume, operation m.m)
Kroniske smerte tilstande
Neuroner
Stimulering af specifikke
receptorere i vævet (der
reagere på potentielt skadeligt
stimuli)
Aktivitet i Aδ & C fibre,
synapse i baghornet og
aktivitet i hjernen.
Ikke smerte, men nociception.
Ion kanaler og
aktionspotentialer
Neuroner & Synapser
Gold & Gebhart 2010
4
12/10/10
Synapser
Rexed Laminae
Ascenderende baner
Pain in the brain
Hunt & Mantyh 2001; Bushnell & Apkarian 2006; Fields et al 2006
Nogle af de relevante områder i
hjernen
Nociception
Slugg et al 2000; Magarl et al 2001
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12/10/10
Sammenhæng mellem nociception og
smerteoplevelse ved akut skade
Fysiologisk vs klinisk smerte
• 
• 
• 
Enten udført på dyr eller
uden vævsskade på raske
individer.
• 
Modulerende faktorer
kontrolleres.
Patienters “attitudes, beliefs,
and personalities” påvirker
markant deres umiddelbare
oplevelse af akutte smerter.
Indikerer at forholdet mellem
vævsskade og smerte er
stærkt variabelt og komplekst
og at der ikke er noget lineært
forhold mellem skade/
nociception og patientens
lidelse/smerteadfærd selv
ved akutte smerter.
Melzack et al 1982
Andre eksempler på ringe sammenhæng
mellem tilstanden i vævet og
smerteoplevelsen
• 
• 
• 
• 
Krigsskader (stor skade/nociception – lille/ingen
smerte) Akut påkørsel (Ofte ingen smerte i op til flere døgn efter
skaden)
Osteoartrose (Ingen sammenhæng mellem radiologiske
fund og symptomer)
• 
I den virkelige verden er smerte ikke en præcis indikation for
hvad der sker i vævet eller for vævets tilstand.
Fibromyalgi/spændingshovedpine (ingen påviselig
nociception – men udbredte smerter)
Årsag ?
Vævsskade & inflammation
• 
Perifer sensibilisering
• 
• 
Central sensibilisering
• 
• 
Smerte modulerende systemer
• 
Abnorm ”smerte” transmission
• 
?
• 
• 
• 
Perifer sensibilisering
Ved vævsskade/inflammation
responderer de nociceptive
neuroner i periferien nu på:
Mindre noxious stimuli (mindre
tærskel) – primær hyperalgesi
Kraftigere fyring mod
baghornet
Spontan aktivitet.
Ex. Meyer et al 2006
6
12/10/10
Ion kanaler og inflammatoriske
mediatorer
Vævsskade og inflammation
Woolf & Salter 2006
• 
 
 
Central sensibilisering
Ved vævsskade/inflammation responderer
de nociceptive neuroner + WDR neuronerne i
baghornet nu på:
Aktiveres ved mindre stimuli fra nociceptive
fibre samt fra ikke nociceptive fibre (Klassisk
heterosynaptisk central sensibilisering) –
primær/sekundær hyperalgesi/allodyni
 
Kraftigere fyring mod hjernen (wind up)
 
Synapserne styrkes (LTP)
 
 
Dannes nye synapser mellem perifere neuron
og neuroner i baghornet (refererede smerter).
Øget receptor fields
Woolf & Salter 2006
Gold & Gebhart 2010
Smertemodulerende systemer
SI & SII – Primary & secondary somatosensory cortex; Sensory-discriminative function
Ins – Insula; Emotional-affective function
ACC, MCC, PCC – anteriore, mid, posteriore cingulate cortex; fear, expectations
PFC – Prefrontal cortex; Cognitive-evaluative function, context-dependent behaviour Hunt & Mantyh 2001; Bushnell & Apkarian 2006; Fields et al 2006
Descenderende baner
Descenderende baner
• 
Prioritering • 
Fear of pain (ex. Fields & Price 2006)
• 
Anxiety (ex. McGrath & Dade 2004)
• 
• 
• 
PAG – RVM – Dorsal horn
On-cells, off-cells, neutral-cells
Expectation/anticipation of pain/pain relief (ex. Vase et al
2003; Koyama et al 2005)
Catastrophization (ex. Edwards et al 2009)
Placebo – reversibelt med naloxon (ex. Voudouris et al 1990;
Rhudy & Meagher 2000; Villemure & Bushnell 2002; Ploghaus et
al 2003; Sawamoto et al 2000)
7
12/10/10
Hvad spiller ellers ind ?
• 
Drug induced hyperalgesia and allodynia
• 
Diet induced Hyperalgesia or allodynia
• 
• 
• 
Changes in the brain
• 
Ændringer i somatosensorisk kortex. Mere reglen end
undtagelsen ved kroniske smerter. (Reversibelt ? – ja, oftest
ved blok af perifert input, ex. CRPS)
Chronic Stress induced hyperalgesia and allodynia (ex. Rivat
et al 2010)
Sleep deprivation and hyperalgesia (ex. Haack et al 2007;
Smith et al 2007; Smith et al 2009)
Gliacells, Astrocytter, NGF, TNF (alfa), IL 1, IL6, Gener etc.
(Benzon Symposia 2010)
SI & SII – Primary & secondary somatosensory cortex; Sensory-discriminative function
Ins – Insula; Emotional-affective function
ACC, MCC, PCC – anteriore, mid, posteriore cingulate cortex; fear, expectations
PFC – Prefrontal cortex; Cognitive-evaluative function, context-dependent behaviour Perifert input ?
• 
Normale biologiske processer, der i langt de fleste tilfælde
normaliseres af sig selv.
 
• 
Hvorfor ikke er de sidste 20 % ?
• 
?
 
 
Spread of sensitisation
• 
Årsag ? Spiller sandsynligvis en væsentlig rolle i muskuloskeletale smerter.
Mange teoretiske koncepter til at forklare forskellige kroniske
muskuloskeletale smerte tilstande, men der er INGEN validerede
forklaringer af hvilke mekanismer der driver kroniske smerter når ikke der
er inflammation.
INGEN link mellem “basic science og clinical practice” i de fleste
muskuloskeletale smerte tilstande. Undtagelsen er tilstande med påvist
inflammation (ex. RA). Selvom eksperimentelle studier har vist at
forskellige væv kan forårsage nociception og smerte så har disse
mekanismer ikke blevet endegyldigt påvist hos patienter med
muskuloskeletale smertetilstande.
Endless hypersensitivity ?
Graven-Nielsen & Arendt-Nielsen 2010, Nature Reviews
Reumathology, jul.
8
12/10/10
Summen af kardemommen anno
2010
Tilbage til patienterne
En meget dynamisk proces/sygdom:
Ikke et symptom, men en sygdom i sin egen ret
Fundamentale ændringer i det perifere og centrale nervesystem
Nervecelle nydannelse / nervecelle død
Involvering af støttevæv i smerteprocessen (ex. gliaceller)
Større udbredning og flytning af ”perceptionscentre” i hjernen
Spotliste i klinikken
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
Smerter i mere end 6 mdr.
Mennesket er ramt både fysisk, psykisk og socialt
Reagerer ikke på sædvanlig behandling
Ringe/ingen sammenhæng mellem smerter og evt. udløsende årsag
Dårlig søvn. Øget træthed Øget irritabilitet. Depression/angst. Kognitive problemer (koncentrationsbesvær, påvirket korttidshukommelse,
nedsat stresstærskel).
Mistet arbejde/skiftet arbejde. Problemer i det huslige arbejde. Fritidsinteresser (ophørt/ændret). Isolationstendens (Omgang med venner og bekendte indskrænket).
Seksuallivet kan være påvirket.
Klinikken
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Smerteanamnese:
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Historie, udvikling,
ledsagesymptomer
Objektivt:
Sensibilitet: QST
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Kulde
Sviende • 
Børste
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Brændende
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Pindprik
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Stikkende/som at gå på glasskår
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Prikkende/jagende
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Sovende
Ord:
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Wind up
Summation – eftersensation
(Wind-up)
Behandling
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På den måde når man ingen
steder med komplekse kroniske
smerter.
9
12/10/10
Biopsykosocial problemstilling
Nyorientering
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Skift fokus fra akut tankegang.
• 
Forklaringsmodeller.
?
Biopsykosocial
behandlingsstrategi
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Medicin:
Paracetamol, NSAID, korttids
opioider, pn medicin,
injektioner er yt (abstinens
smerter, dækker ikke hele
døgnet)
At fjerne smerten = Låst
Hvordan personen
tænker, føler, handler Hvis opioid så depot og kun et
præparat. (balance mellem
effekt/bivirkninger)
i forhold til smerterne
Første valg TCA, Antiepileptika,
SNRI (efecxor)
plastisk og dynamisk
?
=
10