Is pijn fijn? Pijn anno Achtergrond informatie Geen pijn. Geniaal? Hulpvraag: pijn

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1 Pijn anno 2017 Is pijn fijn? MSc. R. van der Noord -fysiotherapeut & psychosomatisch fysiotherapeut- Achtergrond informatie Geen pijn 1/5 personen² Geniaal? Hulpvraag: pijn Hoge zorg- en economische kosten. ( miljard euro)³ Hereditale sensibele en autonome neuropathie (HSAN) Lage kwaliteit van leven³ Tevredenheid behandelingen laag (78% ontevreden)³ ²Breivik et al., 2006, ³Dutch Pain Society Epidemiologie van chronische pijn Impact Gemiddelde percentages langdurige pijn: 19% Dualisme (lichaam - geest) pijn = lichamelijk = schade Langdurige pijn > 6 maanden pijn in de laatste maand 2 keer per week 5 op een 10 punt NRS Descartes ( ) Breivik et al

2 Pijn behandelingen Medisch model oorzakenmodel Oorzaak Klacht Interpretatie van Nachemson Culturele invloeden Westen = pijn is medisch-somatisch probleem De pijnrevolutie De gate control theory / de poort theorie Pijn = schade Pijn = lichamelijk Psychologie = aanstelleritis, tussen de oren, ik ben toch niet gek Wall ( ) De pijnrevolutie Sensitisatie & invloed van het brein Medisch model oorzakenmodel Gedragsmodel gevolgenmodel Denken Oorzaak Klacht Voelen Doen Omgeving Bron: Speckens et al,

3 Lichaam fysiotherapie specialisten Lichaam fysiotherapie specialisten Geest psycholoog psychiater Omgeving & relaties Maatschappelijk werk Geest Omgeving & relaties psycholoog psychiater Maatschappelijk werk in de klinische setting Classificaties pijn Nociceptive Pain Neuropathic Pain Non-neuropathic CS pain History of damage to body tissue History of a lesion or disease of the No history of a lesion, damage or in the previous 6-8 weeks. nervous system, or disease of Pain diminishes according to the posttraumatic/postsurgical damage to natural healing phases. No indications from diagnostic Indications from diagnostic examinations examinations to reveal an anomaly of Related to tissue damage or Related to a medical or systemic cause No medical cause for the pain potential damage. An ankle such as, stroke, herpes, diabetes, or established sprain or almost burning a hand some form of neurodegenerative disease Local pain, most often with Pain and sensory dysfunction is Pain is neuroanatomical illogical and diagnostic signs such as: oedema, neuroanatomically logical segmentally unrelated to the primary hematomas, skin colorations etc. source of nociception Inflammatory soup Weefselbeschadiging (nociceptie) Vrijkomen pijnmediatoren (prostaglandine, serotonine, histamine, cytokine, bradykinine) Acute nociceptieve pijn Several regions of hyperalgesia at sites outside and remote to the symptomatic area (still at segmentally unrelated sites) Pain is described as sharp, aching, Pain is frequently described as or throbbing. burning, shooting, or pricking Pain is most frequently described as vague and dull Nijs et al,

4 Acute nociceptieve pijn Aδ-fibres: fast myelinised nerves (warm/cold, pressure, pain) Aβ-fibres: thin myelinised nerves rubbing, vibration (snel lage drempels) C- fibers: slowly non-myelinesed nerves (pain) (langzaam, hogere drempel waarden) Gate control theory Modulatie van pijn Signaal wel of niet door naar het brein Melzack & Wall, Science, Illustratie: Lannoo Campus The inflammatory reflex DAMPS Damage-associated molecular patterns PAMPS Pathogen-associated molecular patterns XAMPS Xenobiotic-associated molecular patterns Verbeteren van de synaptische effectiviteit Gutchinson 2016 Classificaties pijn Nociceptive Pain Neuropathic Pain Non-neuropathic CS pain History of damage to body tissue History of a lesion or disease of the No history of a lesion, damage or in the previous 6-8 weeks. nervous system, or disease of Pain diminishes according to the posttraumatic/postsurgical damage to natural healing phases. No indications from diagnostic Indications from diagnostic examinations examinations to reveal an anomaly of Related to tissue damage or Related to a medical or systemic cause No medical cause for the pain potential damage. An ankle such as, stroke, herpes, diabetes, or established sprain or almost burning a hand some form of neurodegenerative disease Local pain, most often with Pain and sensory dysfunction is Pain is neuroanatomical illogical and diagnostic signs such as: oedema, neuroanatomically logical segmentally unrelated to the primary hematomas, skin colorations etc. source of nociception Pain is described as sharp, aching, Pain is frequently described as or throbbing. burning, shooting, or pricking Several regions of hyperalgesia at sites outside and remote to the symptomatic area (still at segmentally unrelated sites) Pain is most frequently described as vague and dull Nijs et al,

5 Neuropathische pijn Damaged nervous system Classificaties pijn Central nervous system: -Spinal cord injury -Brain damage (stroke, cancer) -Peripheral nerve damage: -operation -radiotherapy -wound -herniated disc -alcohol, toxics, infections Signs: -Sensible changes -Motoric changes -Pain (burning pain) Nociceptive Pain Neuropathic Pain Non-neuropathic CS pain History of damage to body tissue History of a lesion or disease of the No history of a lesion, damage or in the previous 6-8 weeks. nervous system, or disease of Pain diminishes according to the posttraumatic/postsurgical damage to natural healing phases. No indications from diagnostic Indications from diagnostic examinations examinations to reveal an anomaly of Related to tissue damage or Related to a medical or systemic cause No medical cause for the pain potential damage. An ankle such as, stroke, herpes, diabetes, or established sprain or almost burning a hand some form of neurodegenerative disease Local pain, most often with Pain and sensory dysfunction is Pain is neuroanatomical illogical and diagnostic signs such as: oedema, neuroanatomically logical segmentally unrelated to the primary hematomas, skin colorations etc. source of nociception Several regions of hyperalgesia at sites outside and remote to the symptomatic area (still at segmentally unrelated sites) Pain is described as sharp, aching, Pain is frequently described as Pain is most frequently described as or throbbing. burning, shooting, or pricking vague and dull Central sensitisation CS is a term for increased pain sensitivity in from augmentation of responsiveness of central neurons of input of uni-and polimodale receptors, resulting in increased pain sensitivity as well as widespread pain and disproportional pain in patients Both bottom (c-fibers) and top-down mechanims are underlying for CS Allodynia = non painful stimulus is painful (pain without tissue damage) Mechanical allodynia Pressure allodynia Modification!! Nijs et al, 2014 Temporale summatie Wind up Wind up fenomeen 5

6 Long term potentiation Sensitization Modulation Peripheral and Central 1. Descending Pain Inhibition systems Reduce pain; hypoalgesia/analgesia 2. Descending Pain facilitation system Boost pain; hyperalgesia/allodynia Modulation Transmission can be altered Pijn matrix Centrale Sensitisatie CS bij OA van de knie Verhoogde activatie brein Widespread pain J. Monfort et al,

7 Pijnmatrix Pijnmatrix Functionele corticale reorganisatie Smudging Kenniscentrum/ Innovatie van zorgverlening Daenen et al. (2014) D. Butler &L. Moseley explain pain Flor et al. (1997) Flor et al. Neuroscience letters 1997 Verhoogde activatie brein & aanpassingen op de homunculus Hodges et al. (2011) Neurotags Neurotag activatie zorgt voor een output Wanneer de neurotag netwerk voor (die specifieke) pijn geactiveerd wordt ontstaat er een pijn ervaring Gifford LS, the tissues and 1998 Hutchinson 2016 Puentedura & Louw

8 Puentedura & Louw 2012 Hoe gevaarlijk is dit? Dingen dit je hoort, ziet, ruikt, proeft en aanraakt Dingen die je doet Dingen die je zegt Dingen die je denkt en geloofd Plaatsen die je bezoekt Personen in je leven Processen in je lichaam Er ontstaan vele verschillende verschuivingen binnen het organisme Neurotag netwerk wordt beïnvloed door verschillende systemen Endocriene systeem Pijn systeem Motor controle systeem Centrale zenuwstelsel Immune systeem Emoties Stress systeem Respirator systeem Gifford LS, the tissues and 1998 Hutchinson 2016 Klinische diagnostiek voor sensitisatie onderbouwen: Objectiveren van centrale sensitisatie Nijs et al CSI norm scores Establishing Clinically Relevant Severity Levels for the Central Sensitization Inventory. Neblett et al Let op! Combinaties subclinical = 0 to 29 mild = 30 to 39 moderate = 40 to 49 severe = 50 to 59 extreme = 60 to 100 8

9 Gecombineerde pijn-typen Het belang van je intake en het klinisch beeld Centrale Neuropatische sensitisatie pijn pijn Wat is belangrijk? Somatische factoren Wat is belangrijk? Nociceptive pijn Cognitieve factoren Type pijn Neuropatisch pijn Centrale sensitisatie Emotionele factoren Gedrags factoren Pijn analyse Pijneducatie Sociale factoren Wijma et al Motivatie Wijma et al Tot slot PIJN PIJN 9

10 Nociceptie Diagnostische afwijkingen pijn! Idem houding! Bedankt voor uw aandacht Vragen? Robert van der Noord 10