COMPLEX REGIONAL COMPLEX REGIONAL PELVIC PAIN SYNDROMEPELVIC PAIN SYNDROME ……..

TIME FOR A NEW PARADIGMTIME FOR A NEW PARADIGM

Alain Alain WatierWatier mdmd, LMCC, FRCP, LMCC, FRCPProfessorProfessorofof GastroenterologyGastroenterologyPelvicPelvic FloorFloor UnitUnitCHUS, QuCHUS, Quéébec, Canadabec, Canada

PELVIPELVI --PERINEAL PERINEAL PAINPAIN

BLADDER PAIN SYNDROMEBLADDER PAIN SYNDROME

TESTICULAR PAINTESTICULAR PAIN

VULVODYNIAVULVODYNIA VESTIBULITISVESTIBULITIS

URETHRAL SYNDROMEURETHRAL SYNDROME

LEVATOR ANI SYNDROMELEVATOR ANI SYNDROME

PROCTALGIA FUGAX

IBSIBS

CRONIC PELVIC PAIN IN MANCRONIC PELVIC PAIN IN MAN

ENDOMETRIOSISENDOMETRIOSIS

DYSMENORRHEADYSMENORRHEA

PUDENDAL NEURALGIAPUDENDAL NEURALGIACLUNEAL NEUROPATHYCLUNEAL NEUROPATHY

PELVIC ORGAN CROSS SENSITIZATIONPELVIC ORGAN CROSS SENSITIZATIONNEUROPATHIC PAINNEUROPATHIC PAINCOMPLEX REGIONAL PAIN SYNDROMECOMPLEX REGIONAL PAIN SYNDROMEFIBROMYALGIAFIBROMYALGIAPOST TRAUMATIC STRESS SYNDROMEPOST TRAUMATIC STRESS SYNDROME

As As specialistsspecialistsin in pelvipelvi--perinealperineal pain pain whatwhat cancan wewe learnlearn fromfrom ……

IBS TMD CFS !!!!IBS TMD CFS !!!!ENDOMETRIOSIS !!!!!ENDOMETRIOSIS !!!!!

VestibulitisVestibulitis/CPP//CPP/urethralurethral obstruction/IBSobstruction/IBS/constipation/constipation

CPP/CPP/dyspareuniadyspareunia//urologicalurological problemsproblems/IBS/IBS

IBS/IBS/DyspareuniaDyspareunia//UrethralUrethral problemsproblems/CPP/CPP

UrethralUrethral syndrome/syndrome/dyspareuniadyspareunia/IBS//IBS/abdominal painabdominal pain

CPP/CPP/unexplainedunexplainedgenitalgenital pain/pain/bladderbladder outletoutletobstruction/obstruction/prostatodyniaprostatodynia

FibromyalgiaFibromyalgia/IBS//IBS/vestibulitisvestibulitis

PenismusPenismus//anismusanismus/IBS/IBS

IC/IC/ headacheheadache/FM/IBS//FM/IBS/ depressiondepression//vulvodyniavulvodynia

PELVIC ORGAN CROSSPELVIC ORGAN CROSS--SENSITIZATIONSENSITIZATION

PELVIC PAIN ASSESSMENT FORMPELVIC PAIN ASSESSMENT FORM

Information about painInformation about painPain Pain mapsmapsSurgicalSurgical historyhistoryMedicationsMedicationsObstetricalObstetrical historyhistoryFamilyFamily historyhistoryMedicalMedical historyhistoryHealthHealth habit habit ((SleepSleephabit)habit)MenstrualMenstrual historyhistory ((dysmenorrheadysmenorrhea, , endometriosisendometriosis))GI / GI / EatingEating / / Rome III Rome III criteriacriteria IBSIBSUrinaryUrinary symptomssymptoms(IC)(IC) ((KidneyKidney stones)stones)SexualSexual/ / PhysicalPhysicalabuse abuse historyhistoryPelvicPelvic varicosityvaricosity pain syndromepain syndromeFibromyalgiaFibromyalgiaImpact Impact ofof pain on pain on sexualsexualactivitiesactivitiesCopingCoping mecanismsmecanismsShort Short FormForm McGillMcGill questionnairequestionnaire

Posture, Posture, gaitgait, , backback, abdomen, , abdomen, lowerlower extremitiesextremitiesSacroiliacSacroiliac jointsjointsChanges Changes ofof skin sensation, skin sensation, numbnessnumbness, , tendernesstendernessChanges in Changes in temperaturetemperature, , colourcolourFibromyalgiaFibromyalgiaExternalExternal genitaliagenitaliaQ Q tiptip testtestVaginaVaginaUnimanualUnimanual examinationexaminationMuscle Muscle tendernesstendernessTrigger pointsTrigger pointsBimanualBimanual examinationexaminationAdnexalAdnexal examinationexaminationSpeculumSpeculumexaminationexaminationRectovaginalRectovaginalexaminationexaminationAbdominal Abdominal examinationexaminationRectoscopyRectoscopyPelvicPelvic floorfloor exam by a exam by a trainedtrained PTPT

NEUROPATHIC PAINNEUROPATHIC PAIN

CUTANEOUS NOCICEPTIVE HYPERSENSITIVITYCUTANEOUS NOCICEPTIVE HYPERSENSITIVITY

PERIPHERAL SENSITIZATIONPERIPHERAL SENSITIZATION

CENTRAL SENSITIZATIONCENTRAL SENSITIZATION

ACTIVATION OF DESCENDING FACILITATIONACTIVATION OF DESCENDING FACILITATION

ALTERED INTRACELLULAR SIGNALINGALTERED INTRACELLULAR SIGNALING

ALTERED ION CHANNEL EXPRESSIONALTERED ION CHANNEL EXPRESSION

ABNORMAL FIRING OR AFFERENT AND EFFERENT PAIN PATHW AYSABNORMAL FIRING OR AFFERENT AND EFFERENT PAIN PATHW AYS

ALTERED PHENOTYPE OF LARGE NERVE FIBERSALTERED PHENOTYPE OF LARGE NERVE FIBERS

AUGMENTED INLAMMATORY RESPONSEAUGMENTED INLAMMATORY RESPONSE

IMMUNE SYSTEM INVOLMENT (MICROGLIA)IMMUNE SYSTEM INVOLMENT (MICROGLIA)

GENETIC VARIATIONGENETIC VARIATION

PATHOPHYSIOLOGY OF NEUROPATHICPATHOPHYSIOLOGY OF NEUROPATHICPAINPAIN

ALLODYNIAALLODYNIADYSESTHESIADYSESTHESIAHYPERALGESIAHYPERALGESIAHYPERPATHYHYPERPATHYPARESTHESIAPARESTHESIACAUSALGIACAUSALGIA

SPECIFIC NEUROPATHIC PAIN QUESTIONNAIRESSPECIFIC NEUROPATHIC PAIN QUESTIONNAIRES

QUANTITATIVE SENSORY TESTING (QST)QUANTITATIVE SENSORY TESTING (QST)

GivesGivesa a phenotypicphenotypic mappingmapping andand maymay definedefine patientspatientsthatthat are more are more proneprone to to respondrespondto certain to certain therapeutictherapeuticagents.agents.

BouhassiraBouhassira

QUANTITATIVE SENSORY TESTING (QST)QUANTITATIVE SENSORY TESTING (QST)

SensorySensorythresholdsthresholds for pain, for pain, touchtouch, vibration, , vibration, heatheat, cold., cold.

AA--deltadelta fibersfibers: cold + : cold + coldcold pain pain thresholdsthresholdsCC--fibersfibers: : heatheat + + heatheat pain pain detectiondetection thresholdsthresholdsAA--betabeta fibersfibers: vibration : vibration detectiondetection thresholdsthresholds

PermitsPermits to to definedefine differentdifferent somatosensorysomatosensoryphenotypesphenotypes

DoesDoesitit help help thethe pain pain clinicianclinician ????

NSAIDsNSAIDs

Inhibition Inhibition ofof serotoninserotonin andand NE NE uptakeuptake((TCAsTCAs, , TramadolTramadol, , DuloxetineDuloxetine, , VenlafaxineVenlafaxine))

BlockageBlockageofof voltage voltage dependantdependantNa Na channelschannels((TCAsTCAs, , LamotrigineLamotrigine , , CarbamazepineCarbamazepine, , oxcarbazepineoxcarbazepine))

Modulation Modulation ofof NMDA NMDA receptorsreceptorsandand/or glutamate/or glutamaterelease release ((TCAsTCAs, , LamotrigineLamotrigine ))

BlockageBlockageofof voltage voltage gatedgatedCaCa channelchannelsubunitsubunit((TCAsTCAs, , GabapentinGabapentin, , PregabalinPregabalin))

Modulation Modulation ofof opioidsopioids receptorsreceptors((opioidsopioids))

CANNABINOIDSCANNABINOIDS

Inhibition Inhibition ofof voltage voltage gatedgatedNa Na channelschannelsLocal Local anesthesicsanesthesics((LidocaineLidocaine, , lidocainelidocaine 5% gel 5% gel andand patch)patch)

Inhibition Inhibition ofof CaCa channelchannel functionfunction + + reductionreduction in in membrane membrane excitabilityexcitabilityTetrazoleTetrazole

Modulation Modulation ofof alphaalpha--2 2 adrenoreceptoradrenoreceptorClonidineClonidine ((creamcream / / transdermaltransdermal patch)patch)

Blocage Blocage ofof adenosineadenosineuptakeuptakeTCAsTCAs ((amitritylineamitrityline 2% + 2% + kkéétaminetamine 1%) (1%) (DoxepinDoxepin 3%)3%)

TRPV1 TRPV1 receptorreceptor agonistagonist ((CapsaicinCapsaicin0.025%0.025%--0.075%)0.075%)(gel / (gel / creamcream ) ) CapsaicinCapsaicindermaldermal patch 8%)patch 8%)

Amitriptyline 2-7 %

Clonidine 0,05-0,2 %

Gabapentine 4-6 %

Baclofène 2-5 %

Ibuprofène 2,5-10%

Cyclobenzaprine 1%

Lidocaine gel 2 %

Lidocaine onguent 5 %

Lidocaïne 10%/kétamine1% (autres [[[[ ]]]] selon condition)

Nitroglycérine 0,2-0,8 % + Lidocaine 10 % ou Morphine 0,2-0,5 %

Kétamine 1 à 10% (+ Morphine 0,2-0,5%)(+ Hydromorphone 0,04-0,1%)

Diltiazem 2%

Nabilone topique(Cannabinoïdes)

Misoprostol 0,0024%- 0,015%

FIBROMYALGIAFIBROMYALGIA

CENTRALCENTRALSENSITIZATIONSENSITIZATION

FIBROMYALGIEFIBROMYALGIE IBSIBS

CRPSCRPS VULVODYNIAVULVODYNIA

PTSDPTSD

THE DESCENDING PAIN CONTROLTHE DESCENDING PAIN CONTROLSYSTEM SHOULD BE ACCESSIBLESYSTEM SHOULD BE ACCESSIBLEBY BOTH BY BOTH BEHAVIORALBEHAVIORAL AND AND PHARMACOLOGICALPHARMACOLOGICAL TREATMENTSTREATMENTS

CAN DESCENDING PAIN CONTROLCAN DESCENDING PAIN CONTROLIMPROVE WITH PRACTICE ?IMPROVE WITH PRACTICE ?

PREDICTIVE OF POSTPREDICTIVE OF POST --OP PAIN ???OP PAIN ???POSTPOST--HYSTERECTOMY ?HYSTERECTOMY ?

WhatWhat about about thethe descendingdescendingpain controlpain controlsystemsystemin in womenwomenwithwith a a historyhistory ofofphysicalphysical / / sexualsexualabuse ???abuse ???

SLEEP DISORDERSSLEEP DISORDERS

FMFMIBSIBSCRPSCRPS

QUESTIONNAIREQUESTIONNAIRE

PHYSICAL/SEXUALPHYSICAL/SEXUALABUSES ANDABUSES AND

PELVIPELVI --PERINEALPERINEALPAINPAIN

SexualSexualabuse abuse historyhistory: : PrevalencePrevalence, , HealthHealth effectseffects,,MediatorsMediators, , andand PsychologicalPsychologicaltreatmenttreatment..Jane Jane LessermanLessermanPsychomaticPsychomaticMedicineMedicine 67: 90667: 906--915 (2005915 (2005))

LongLong--termterm effectseffectsofof childhoodchildhood abuse on abuse on thethe qualityquality ofoflifelife andand healthhealth ofof olderolder peoplepeople: : ResultsResultsfromfrom thethedepressiondepressionandand earlyearly preventionprevention ofof suicide in suicide in generalgeneralpractivepractive projectproject..Brian Draper et Brian Draper et alal..GeriatrGeriatr Soc 56: 262Soc 56: 262--271, 2008271, 2008

SexualSexualabuse abuse andand lifetimelifetime diagnosisdiagnosisofof somaticsomaticdisordersdisordersA A systematicsystematicreviewreview andand metameta--analysisanalysisMollyMolly L. ParasL. ParasJamaJama August 5, 2009August 5, 2009--Vol 302 # 5Vol 302 # 5

A comparaison A comparaison ofof chronicchronic pain patients pain patients andand controlscontrolson on traumatictraumatic eventseventsin in childhoodchildhood..Richard T. Richard T. GoldbgergGoldbgerg et et alal..DisabilityDisability andand rehabilitationrehabilitation ,2000: Vol 22 No. 17, 756,2000: Vol 22 No. 17, 756--763763

ChildhoodChildhood sexualsexualabuse abuse isis associatedassociatedwithwith physicalphysicalillnessillnessburdenburden andand functioningfunctioning in in psychiatricpsychiatric patientspatients50 50 yearsyearsofof age age andand olderolder..Nancy L Nancy L talbottalbot et et alal..PsychosomPsychosomMedMed 2009 May; 71(4): 4172009 May; 71(4): 417--422422

ChildhoodChildhood trauma, trauma, attachmentattachment, , andand abuse by multipleabuse by multiplepartnerspartners..Pamela C. AlexanderPamela C. AlexanderPsychologicalPsychologicalTrauma: Trauma: TherapyTherapy, , researchresearchandand policypolicy. 2009. Vol 1 # 1, 78. 2009. Vol 1 # 1, 78--8888

ChronicChronic pain syndromes pain syndromes andand theirtheir relation to relation to childhoodchildhoodabuse abuse andand stressfulstressful lifelife eventsevents..Astrid Lampe et Astrid Lampe et alalJournal Journal ofof PaychosomaticPaychosomaticResearchResearch54 (2003) 36154 (2003) 361--367367

WE MUST STOP TO PRETENDWE MUST STOP TO PRETEND

THE PHENOMENA DOES EXISTTHE PHENOMENA DOES EXIST

Évaluation complète musculo-squelettiqueMobilisation des tissus mous interne (vaginal-rectal) et externeRelâchement myofascialManipulation articulaireTraitement des trigger pointsStimulation électriqueExercices thérapeutiquesEntraînement de la musculature pelvi-périnéaleUltra-son thérapeutiqueTENSDilatation vaginaleEMG de surfaceBiofeedbackMichel GuérineauElizabeth Rummer / Stéphanie Prendergast (San Francisco)« Headache in the pelvis »Stimulation du nerf tibial postérieur

INTERVENTION THÉRAPEUTIQUEINTERVENTION THÉRAPEUTIQUE

PUDENDAL NEURALGIAPUDENDAL NEURALGIA

TherapeuticTherapeutic targetstargetsMultiple types of Multiple types of medicationmedicationTopicalTopical creamscreams

STATE OF THE ART 2009STATE OF THE ART 2009

PelvicPelvic floorfloor reeducationreeducation

INFILTRATIONSINFILTRATIONS

DECOMPRESSIONDECOMPRESSIONCHIRURGICALECHIRURGICALE

NEUROMODULATION PUDENDALENEUROMODULATION PUDENDALE

BOTOXBOTOX

PharmacologicalPharmacologicalapproachapproach

Those Those whowho do do notnotrespondrespondto to conventionalconventionaltherapiestherapiesusuallyusually havehavea a severeseverehistoryhistory ofofsexualsexualabuseabuse

PTSD COMPLEXPTSD COMPLEX

PSYCHOPSYCHO--NEURONEURO--IMMUNOLOGYIMMUNOLOGY

STRESSSTRESS

HYPOTHALAMUSHYPOTHALAMUS

CRF

LOCUS CERULEUSLOCUS CERULEUS

NENE

AUTONOMOUS NERVOUS SYSTEMAUTONOMOUS NERVOUS SYSTEM

ALLOSTATIC LOADALLOSTATIC LOAD

The price the The price the body pays for wear of body pays for wear of tear tear on on its systemsits systems, , secondarysecondaryto to chronic psychological chronic psychological stress. stress. PhysiologicalPhysiologicalarousal arousal and the and the persistent release of stress hormonespersistent release of stress hormonesor or ««mediatorsmediators»», , sleep deprivationsleep deprivation, , poor dietpoor diet, , and otherand otherhealthhealth--damaging behaviors can result from damaging behaviors can result from feelingfeeling««stressed stressed outout»» with resultant psysiological with resultant psysiological changes. changes. ItItisis possible possible that that stress stress induced disturbances induced disturbances of endocrineof endocrineand neurological systems underlie the ultimate and neurological systems underlie the ultimate expressionexpressionof of diseasedisease

CAN WE HELP THEMCAN WE HELP THEM

FOCUSINGFOCUSING

EugeneEugeneGendlinGendlin PermitsPermits awarenessawarenessof of emotionsemotions..TransformTransform a vague a vague internalinternalsensation sensation intointo a a physicalphysicalsensationsensation

SUGGESTIONSSUGGESTIONS

METAPHORESMETAPHORES

ERICKSONIANERICKSONIANHYPNOSEHYPNOSE

A new A new wayway of of treatingtreating informationsinformationsPermitsPermits thethe spontaneousspontaneousemergenceemergenceof new associations, new of new associations, new emotionsemotions,,awarenessawareness

ART THERAPY

PSYCHOBIOLOGIC TRANSDUCTIONPSYCHOBIOLOGIC TRANSDUCTION

HypnoseHypnoseEMDREMDRBriefBrief therapytherapy

A.A. WeitzenhofferWeitzenhofferB.B. M.H M.H EricksonEricksonC.C. F. ShapiroF. ShapiroD.D. E.L.RossiE.L.Rossi

COMPLEX REGIONALCOMPLEX REGIONALPAIN SYNDROMEPAIN SYNDROME

A NEUROPATHIC (?) PAIN A NEUROPATHIC (?) PAIN DISORDER ASSOCIATED WITHDISORDER ASSOCIATED WITHSIGNIFICANT AUTONOMICSIGNIFICANT AUTONOMICINVOLVEMENTINVOLVEMENT

A A completecompletefunctionalfunctional losslossof of cutaneouscutaneoussympatheticsympatheticvasoconstrictorvasoconstrictoractivityactivityin an in an earlyearly stage, stage, withwith recoveryrecovery. This . This autonomicautonomic dysfunctiondysfunction originatesoriginates in in thethe CNSCNS

A spinal component to A spinal component to microcirculatorymicrocirculatory abnomalitiesabnomalitieswhichwhich appearedappearedto to manifestmanifestitselfitself throughthrough a neural a neural antidromicantidromic mechanismmechanism

A positive feedback circuit, A positive feedback circuit, consistingconsistingofof primaryprimary afferentafferent neuronneuron, spinal , spinal cordcordneuronsneurons, , sympatheticsympatheticneuronsneurons, , andand a a pathologicpathologic synpatheticsynpatheticcouplingcoupling

SNS SNS andand vascularvascular abnormalitiesabnormalities

ExageratedExageratedregionalregional inflammation inflammation responseresponse

ImpairmentImpairment ofof highhigh--energyenergyphosphate phosphate metabolismmetabolism

AbnormalAbnormal oxidativeoxidative stressstress

AfterAfter a partial nerve a partial nerve lesionlesion, excessive , excessive antidromicantidromic activation activation ofof undamagedundamagedafferentafferent C C fibersfibers andand neuropeptide release, neuropeptide release, leadingleading toto acute vasodilatation acute vasodilatation withinwithinthethe innervation innervation territoryterritory ofof thethe affectedaffectednerve has been nerve has been demonstrateddemonstrated

FrequentFrequent presencepresenceofof humanhuman lymphocyte antigenlymphocyte antigen--DQ1DQ1

AutoimmuneAutoimmune diseasedisease

Cortical changesCortical changesOngoingOngoing pain pain altersalters somatosensorysomatosensoryprocessingprocessingCortical Cortical hyperexcitabilityhyperexcitabilityCortical Cortical reorganizationreorganization

**********

CouplingCoupling betweenbetweenthethe sympatheticsympatheticandand afferentafferent neuronsneurons

BRADYKININBRADYKININ

NANA

SUBSTANCE PSUBSTANCE P

SKIN TEMPERATURESKIN TEMPERATURESUDOMOTOR FUNCTION TESTINGSUDOMOTOR FUNCTION TESTINGELECTRODIAGNOSTIC STUDIESELECTRODIAGNOSTIC STUDIESQUANTITATIVE SENSORY TESTINGQUANTITATIVE SENSORY TESTINGLASER DOPPLER IMAGING LASER DOPPLER IMAGING (Test skin (Test skin autonomicautonomic reflexesreflexes))

ShouldShould wewe test test somesomeofof ourour patients patients withwithpain an pain an autonomicautonomic manifestationsmanifestations

In In somesomecases cases pelvipelvi--perinealperineal pain pain seemsseemsto to bebe out out ofof proportion to identifiable causesproportion to identifiable causesofof pain. pain. ((AllodyniaAllodynia , , hyperpathyhyperpathy)) Variations Variations in skin in skin colorcolor andand temperaturetemperature andand abnormalabnormalsweatingsweatinghashasalsoalsobeenbeendescribeddescribed

CRPS OF THE PELVIC FLOORCRPS OF THE PELVIC FLOOR

GANGLION IMPAR BLOCKGANGLION IMPAR BLOCK

SympatheticSympatheticbloc bloc atat thethelevellevel ofof L2L2

ICICPerinealPerineal painpainIBSIBS

DESENSITIZATIONDESENSITIZATION

TheoreticallyTheoretically basedbasedon on thethe abilityability ofof bodybody’’ sstissues to tissues to adaptadapt in in responseresponseto to demanddemand

SufficientSufficient intensityintensity andand durationduration to to provideprovideadequateadequateinput to change input to change thethe abnormalabnormalCNS CNS activityactivity

SELFSELF--REGULATIONREGULATION

InnateInnate abilityability to to learnlearn to to modifymodify andand modumodu--latelate ««autonomicautonomic»» responseresponseto to reachreach aahealthierhealthier homeostatichomeostaticstatestate

TechnonologyTechnonologyassistedassistedselfself--modulationmodulation::NeuromotorNeuromotor + + otherother learninglearning withwith BFBBFB

TryTry to to reducereducethethe perception perception ofof pain viapain viamodification modification ofof thethe autonomicautonomic componentscomponents

HeartHeart beat Skin beat Skin temperaturetemperatureRespiratoryRespiratory rate rate SweatSweatresponseresponseType Type ofof breathingbreathing VasospasmVasospasmBloodBlood pressure Vasodilatationpressure VasodilatationBrainBrain wavewavepatterns patterns MuscularMuscular spasmsspasmsElectroElectro--dermaldermal responseresponse

REFLECTIONS, IMAGERY, ANDREFLECTIONS, IMAGERY, ANDILLUSIONS: THE PAST, PRESENTILLUSIONS: THE PAST, PRESENTAND FUTURE OF TRAINING THE AND FUTURE OF TRAINING THE BRAIN IN COMPLEX REGIONALBRAIN IN COMPLEX REGIONALPAIN SYNDROMEPAIN SYNDROME

Dr G. Dr G. LorimerLorimer MoseleyMoseley

GRADED MOTOR IMAGERY (MIRROR THERAPY)GRADED MOTOR IMAGERY (MIRROR THERAPY)

InducingInducing thethe illusion illusion thatthat thethe affectedaffected limblimb isissmallersmaller thanthan itit reallyreally isis reducesreducesthethe pain pain andandswellingswelling causedcausedby by movementmovementofof thethe limblimb

IMPLICATIONS IN PELVIIMPLICATIONS IN PELVI --PERINEAL PAIN !!!!!PERINEAL PAIN !!!!!

«« AUTONOMIC NERVOUS SYSTEMAUTONOMIC NERVOUS SYSTEMDYSFUNCTION DYSFUNCTION »»

Wilfrid Wilfrid JJäänignig

THE SYNPATHETICTHE SYNPATHETICNERVOUS SYSTEMNERVOUS SYSTEMAND BODY PROTECTION,AND BODY PROTECTION,INFLAMMATION, PAIN,INFLAMMATION, PAIN,AND HYPERALGESIAAND HYPERALGESIA

IBS & AUTONOMIC NERVOUS SYSTEMIBS & AUTONOMIC NERVOUS SYSTEM

PSYCHOLOGY PSYCHOLOGY ANDAND

CHRONIC PAINCHRONIC PAIN

THE EFFECT OF PERSONNALITY ON CENTRALTHE EFFECT OF PERSONNALITY ON CENTRALPAIN PROCESSINGPAIN PROCESSING

RESILIENCERESILIENCE

PAIN ACCEPTANCEPAIN ACCEPTANCE

CATASTROPHYSINGCATASTROPHYSING

HYPERVIGILENCEHYPERVIGILENCE

TraumaticTraumatic lifelife eventseventsscreeningscreeningquestionnairequestionnaireTrauma Trauma scalescaleofof DavidsonDavidsonResilienceResiliencescalescaleChronicChronic pain pain acceptanceacceptancequestionnairequestionnaireFearFear avoidanceavoidancebeliefsbeliefsquestionnairequestionnairePain Pain andand catastrophysingcatastrophysingscalescalePain vigilance Pain vigilance andand awarenessawarenessquestionnairequestionnaireHospitalHospital anxietyanxiety andand depressiondepressionscalescalePain Pain intensityintensity questionnairequestionnaireTheThe impairmentimpairment andand functionningfunctionning inventoryinventoryDisabilityDisability andand functioningfunctioning inventoryinventory

AND WHAT ABOUT THEAND WHAT ABOUT THE

SUFFERINGSUFFERING

OF THESE PATIENTSOF THESE PATIENTS

WHAT ABOUTWHAT ABOUT ……....

MOTIVATIONAL ENHANCEMENTMOTIVATIONAL ENHANCEMENTTHERAPYTHERAPY

OPTIMISM INTERVENTIONOPTIMISM INTERVENTION

SOMATOSENSORY LANGUAGESOMATOSENSORY LANGUAGEWhereWhere isis thethe pain ?pain ?How How isis thethe sensation sensation perceivedperceived??WhatWhat cancan I do to I do to makemake thethe pain stop ?pain stop ?

LIMBIC LANGUAGELIMBIC LANGUAGEWhatWhat pain pain meansmeansto me ?to me ?How How isis thethe pain pain changingchanging thethe lifelife I I hadhadbeforebefore thethe pain ?pain ?WhatWhat cancan I do to I do to recoverrecover mymy lifelife ??

IN CONCLUSIONIN CONCLUSION

OverlapOverlap ofof patient patient andand healthyhealthy populationspopulations……..HowHow do do youyou becomebecomea a chronicchronic patientspatients……....

VisceroViscero--somaticsomaticsensitivitysensitivityPeripheralPeripheral andand central central sensitizationsensitizationLimbicLimbic systemsystemresponsivenessresponsivenessAutonomicAutonomic nervousnervoussystemsystemactivityactivity

Neurocognitive Neurocognitive factorsfactorsSelectiveSelectiveattention to attention to bodilybodily sensationssensationsCatastrophysingCatastrophysingSymptomsSymptomsrelatedrelated worriesworriesIllnessIllness behaviorbehaviorPsychologicalPsychologicalstressorsstressors

GreaterGreater prevalenceprevalencein in womenwomen

HistoryHistory ofof adverse adverse earlyearly lifelife eventseventsandand stressstresssensitivitysensitivity

ComorbidityComorbidity withwith disordersdisorders ofof moodmood andand affectaffect

ResponseResponseto to centrallycentrally actingacting therapiestherapies((DuloxetineDuloxetine MilnacipranMilnacipran , , TCaTCa, SSRI), SSRI)

EvidenceEvidencefor for alteredaltered pain perception pain perception andand processingprocessing

HypersensitivityHypersensitivity to to experimentalexperimental stimulistimuli

CompromisedCompromiseddiffuse diffuse noxiousnoxious inhibitoryinhibitorycontrol ( DNIC) control ( DNIC) (FM, IBS, (FM, IBS, VulvodyniaVulvodynia, CRPS), CRPS)

EvidenceEvidencefromfrom brainbrain imagingimaging studiesstudiesofofalteredaltered pain pain processingprocessingandand modulationmodulation

EvidenceEvidenceofof structural structural brainbrain abnormalitiesabnormalities(Changes in (Changes in greygrey mattermatter densitydensity or cortical or cortical thicknessthicknessin FM, IBS,in FM, IBS,headacheheadache))

EvidenceEvidenceofof alteredaltered neurocognitive neurocognitive functionfunction(FM, (FM, lowlow backback pain, IBS,PTSD)pain, IBS,PTSD)

EvidenceEvidenceofof increasedincreasedactivityactivity in central arousalin central arousalcircuits circuits andand sympatheticsympatheticnervousnervoussystemsystemactivityactivity((EnhanceEnhancestress stress responsivenessresponsiveness) ( FM, IBS, TMJD, PTSD)) ( FM, IBS, TMJD, PTSD)

EvidenceEvidenceofof commoncommongeneticgeneticsusceptibilitysusceptibility(Pain amplification (Pain amplification andand psychologicalpsychologicaldistressdistress))

WHEREWHEREARE WEARE WESTANDINGSTANDINGNOW !!!!!NOW !!!!!

FunctionalFunctional pain syndromes pain syndromes shouldshould notnotbebe individualizedindividualized

WeWe shouldshould stop stop treatingtreating justjust thethe ««organorgan»»((endend--organorgan--specificspecificsyndrome) BUT syndrome) BUT wewemust must integrateintegrate thethe pain syndromepain syndrome

PeripheralPeripheral ««organicorganic»» etiologyetiology ofof symptomssymptomsare possible but a more are possible but a more integratedintegrated psychopsycho--sociosocio--neurobiologicneurobiologic approachapproach isis mandatorymandatory

•• Alain Alain WatierWatier mdmd, LMCC, FRCP, LMCC, FRCP•• ProfessorProfessorofof GastroenterologyGastroenterology•• DirectorDirector ofof PelvicPelvic FloorFloor UnitUnit•• PelvicPelvic FloorFloor reeducationreeducation(Lyon)(Lyon)•• FacultFacultéé de mde méédecine et des Sciences de la Santdecine et des Sciences de la Santéé

de lde l’’ UniversitUniversitéé de Sherbrookede Sherbrooke•• CHUSCHUS--HôtelHôtel--DieuDieu•• 580 580 BowenBowenSud Sherbrooke QuSud Sherbrooke Quéébec Canada J1G2E8bec Canada J1G2E8•• 819819--346346--1110 1110 awatier@abacom.comawatier@abacom.com