Livsstilsændringer

ved kroniske

smerter

Svetlana Solgaard Nielsen,

Ergoterapeut, kandidat i ergoterapi

ERGO 18, 6-7. NOVEMBER 2018 1

Hvad er ergoterapiens potentiale på

smerteområdet? Hvilken relevans har

ergoterapi for patienterne?

1. Evidens om ergoterapi til kroniske non-maligne smerter

2. Livstilsorienteret tilgang i behandlingen af kronisk smerteproblematik

3. Planlægning af en ergoterapeutisk livstilsorienteret intervention

ERGO 18, 6-7. NOVEMBER 2018 2

Definitioner

International Association for the Study of Pain (IASP, http://www.iasp-

pain.org):

“Pain is an unpleasant sensory and emotional experience associated with actual or

potential tissue damage, or described in terms of such damage”

Andre betegnelser:

”Kropslig udtryk for sorg” (Spinoza)

”Kompleks lidelse uden behandlingskur” (Sidall & Cousins, 2004)

…

ERGO 18, 6-7. NOVEMBER 2018 3

Behandlingen af kroniske smerter

Det danske forbrug af opioider er i dag det højeste i Norden

(Sundhedsstyrelsen, 2016; The International Narcotics Control Board, 2017)

Det biopsykosociale syn på kroniske smerter

Multidisciplinær behandling

Effektiv ved kroniske smerter af forskellig ætiologi og komplekse tilstande

(Scascighini et al., 2008; Sundhedsstyrelsen. NKR til generaliserede smerter i

bevægeapparatet,https://sundhedsstyrelsen.dk/~/media/82268C6BAF19461399C4FC8D1647D

CC0.ashx)

Multimodal behandling

Kognitiv adfærdsterapi (CBT) betragtes som det mest effektive koncept for brug i

multi- og interdisciplinære sammenhænge

(Gatchel & Okifuji, 2006; Turk et al., 2008)

Ikke-farmakologiske behandlingsmuligheder

ERGO 18, 6-7. NOVEMBER 2018 4

Kronisk smerte påvirker de daglige aktiviteter

ERGO 18, 6-7. NOVEMBER 2018 5

(Breivik et al., 2006)

Eksempler på påvirkning fra kroniske smerter

På aktivitetsudøvelsen (Aegler & Satink, 2009; Larson, 2004):

”Stop and go”, afbrudt aktivitetsudøvelse – ringe tilfredshed

Ventetid ved pauser, krav til selektiv og delt opmærksomhed

Aktivitetsafslutning

På aktivitetsdeltagelse (Mathews 2013; Præfontaine & Rochette, 2014):

Stillesiddende livsstil

Isolation

På aktivitetsidentitet (Henare et al., 2003; Robinson et.al., 2011a; van Huet,

Innes & Stancliff, 2013):

Tab af vaner og rutiner

Tab af roller

Lavere selvværd og selv-kompetence

ERGO 18, 6-7. NOVEMBER 2018 6

Hvad er ergoterapiens potentiale på

smerteområdet?

ERGO 18, 6-7. NOVEMBER 2018 7

Ergoterapiens fokusområder i

behandlingen af kroniske smerter

Aktivitetsbaseret og aktivitetsfokuseret tilgang

Klient-centreret målarbejde

Graduering af aktivitetskrav

Energibesparende teknikker

Pacing

Afspænding og stresshåndtering

Vejledning om arbejdsstillinger og arbejdsbevægelser

Ergonomisk vurdering af omgivelserne i hjemmet og på arbejdet

Råd og vejledning om hjælpemidler

(Marcus, 2000; Robinson et al., 2011a; van Huet et al., 2013).

ERGO 18, 6-7. NOVEMBER 2018 8

Brug for viden om effekten af ergoterapi

på smerteområdet

Risiko for yderligere stigmatisering af mennesker med kronisk

smerteproblematik (Robinson, 2011a; Robinson, 2011b)

At arbejde evidensbaseret

At være med uden at miste ekspertisen

At kende evidens der allerede findes, fx rehabilitering på arbejdspladsen som

eksempel (Snodgrass, 2011; von der Heyde, 2011)

At skabe evidens som ikke findes endnu: at undgå ”silo-tænkning” og tænke

holistisk (Prefontaine & Rochette, 2013)

ERGO 18, 6-7. NOVEMBER 2018 9

Livsstilsorienteret ergoterapi ved

kroniske smerter

Kroniske smertepatienter oplever behov for ergoterapi især i forhold til sin

livsstil og aktivitetsdeltagelse (Müllersdorf, 2002)

Fælles mekanismer i udviklingen af kroniske tilstande

Hjernens plasticitet (Marcus et al., 2000):

Sensoriske, perceptuelle og neurofysiologiske forandringer

Spredning af det smertende område

Reversibilitet

ERGO 18, 6-7. NOVEMBER 2018 10

Livstilsfaktorer med betydning for

kronisk smertetilstand

ERGO 18, 6-7. NOVEMBER 2018 11

(van Hecke, Torrance & Smith, 2013)

Ergoterapeutiske interventioner med fokus på

modificerbare livstilsfaktorer blandt voksne

med kroniske non-maligne smerter

Review af publikationer som beskriver og evaluerer ergoterapeutiske

interventioner med fokus på livsstil blandt voksne med kroniske non-maligne

smerter

Formål: at identificere evidensen om indflydelsen af ergoterapi på

modificerbare livsstilsfaktorer, for at informere udviklingen af en

ergoterapeutisk livsstilsorienteret intervention

Litteratursøgning i fem videnskabelige databaser, referencesøgning og manuel

søgning af studier som beskriver den ergoterapeutiske indsats til en bred

målgruppe, hvis hverdag er påvirket i væsentlig grad af kroniske smerter

Fem systematiske reviews og en kritisk vurdering identificeret

Diagnoser: gigt, fibromyalgia og uspecificerede kroniske smerter

ERGO 18, 6-7. NOVEMBER 2018 12

Fund - kort opsummeret

Overordnet var der mangel på studier om livstilsorienteret ergoterapi

Dokumentation for ergoterapeuternes arbejde med modificerbare

livstilsfaktorer som overvægt, rygning, alkoholindtag, søvn og ernæring

mangler især

Ofte var konklusioner baseret på outcomes der kunne have været af potentiel

relevans for ergoterapi, men ingen krav om, at ergoterapeuter var involveret

i interventionsprocessen

Få eller ingen interventioner i de inkluderede reviews var aktivitetsbaserede

ERGO 18, 6-7. NOVEMBER 2018 13

Lifestyle Redesign®

”… holistic approach that gives most attention to occupation, the activities

with which people “occupy” themselves and are the building blocks of

lifestyle (e.g. productive activity, social activity, and physical activity)”

(http://chan.usc.edu/academics/continuing-education/life-management-series)

Life Management series

Chronic Pain and Headache Management

Weight Management, Diabetes and Related Co-morbid Conditions

Biopsychosocial Dimensions of Creating Life Balance

Autism Spectrum Disorders

Multiple Sclerosis

Stress

ERGO 18, 6-7. NOVEMBER 2018 14

Livstilsorienteret indsats forbedrer

livskvalitet, selvtillid og funktion

Lifestyle Redesign® for Chronic Pain Management: A Retrospective Clinical

Efficacy Study (Uyeshiro & Collins, 2017)

Kvantitative signifikante effekter af den livstilsorienterede ergoterapeutiske

tilgang anvendt til kronisk smerteproblematik

Forskerne bag studiet vil inspirere ergoterapeuter fra alle praksisområder som

kommer i berøring med kronisk smerte, evt. som sekundær problematik

Studiets resultater fortæller stakeholdere og beslutningstagere om relevansen af

aktivitetsfokuseret tilgang til personer med kroniske smerter, også hvor smerte

ikke nødvendigvis er en primær diagnose

ERGO 18, 6-7. NOVEMBER 2018 15

Livstilsorienteret ergoterapi anvendt til

danske smertepatienter

Lifestyle-oriented occupational therapy intervention for patients with chronic

non-malignant pain – A randomized controlled trial

(Ergoterapeutisk livsstilsintervention til patienter med kroniske non-maligne

smerter - et randomiseret kontrolleret forsøg)

ERGO 18, 6-7. NOVEMBER 2018 16

Projektpræsentation

Formål: at undersøge den ekstra effekt af en ergoterapeutisk

livsstilsbehandling integreret i den nuværende behandling for kroniske

smertepatienter

Projektet udføres i 2019-2021 i et samarbejde mellem Tværfagligt

smertecenter, Næstved sygehus, og Afdelingen for Fysioterapi og Ergoterapi

(Næstved, Slagelse og Ringsted Sygehuse)

I det kliniske forsøg vil i alt 228 ambulante smertepatienter bliver fordelt ved

lodtrækning i en behandlings- og en kontrolgruppe

ERGO 18, 6-7. NOVEMBER 2018 17

Inklusions- og eksklusionskriterier

Inklusionskriterier: alder 18<65 år, kronisk smerte ≥ 3 mdr. ved opstart

Eksklusionskriterier: Akutte/ subakutte smerter; cancer-relaterede smerter;

ustabil indtag af smertestillende medicin (1 md. før opstart); opioid indtag

>30 mg/dg.; hovedpine/ migræne; aktuel depression, misbrug af alkohol eller

stoffer; alvorlige psychiatriske diagnose (fx skizofreni, skizoaffektive

forstyrrelser eller psykoser); beskedne skriftlige og mundtlige kundskaber i

dansk der forhindrer gennemførelse af de planlagte undersøgelser, samt

deltagelse I andre programmer for personer med kroniske smerter

ERGO 18, 6-7. NOVEMBER 2018 18

Endpoints

Patienterne bliver undersøgt ved opstart, samt 12, 24 og 52 uger efter opstart

Efter 1 år forventes patienter, der modtager den ergoterapeutiske

livsstilsbehandling i tillæg til nuværende behandling, at opleve signifikante

større forbedringer sammenlignet med patienter, der alene modtager den

nuværende behandling.

ERGO 18, 6-7. NOVEMBER 2018 19

Abstract Introduction: About 20-30% of the Danish population suffer from chronic non-malignant

pain. Current evidence suggests that a bio-psychosocial treatment delivered by multidisciplinary teams is the most effective treatment of chronic non-malignant pain. However, evidence is still missing on the optimal multimodal treatment combination as well as the additional effect of specific treatment modalities.

Methods: This two-arm RCT conducted at the Multidisciplinary Pain Center, Zealand, Denmark will randomize 228 patients with chronic non-malignant pain (1:1 allocation ratio) to either a lifestyle-oriented intervention added to the current multimodal treatment, or the current multimodal treatment only. Quality of life (EQ-5D-5L) will be the primary outcome. Occupational performance, balance and participation in meaningful everyday activities, pain self-efficacy and lifestyle-related parameters will be evaluated as secondary outcomes.

Analysis: The differences in change in the primary and secondary outcomes between the groups from baseline to 12, 24 and 52 weeks will be analysed by repeated measures mixed model.

Ethics and dissemination: The study will be ethically approved at The Regional Committee on Health Research Ethics in Region Zealand (Denmark) and The Danish Data Protection Agency. The results will be reported in peer-reviewed journals and presented at conferences.

ERGO 18, 6-7. NOVEMBER 2018 20

Flow chart

ERGO 18, 6-7. NOVEMBER 2018 21

Primary outcome

Differences in self-reported health-related QoL (scored by EQ-5D-5L Index)

will be the primary outcome for the study. The patients will evaluate their

subjective health state in domains Mobility, Self-care, Usual activities, Pain/

Discomfort and Anxiety/ Depression on a 5-point Likert scale from 1= having

no problems, having slight problems, having moderate problems, having

severe problems and 5= being unable to do/having extreme problems. The

outcome measure will allow a later cost-effectiveness analysis.

ERGO 18, 6-7. NOVEMBER 2018 22

Secondary outcome

A. Self-reported Occupational Performance and satisfaction (COPM), observed

Motor and Process Skills (AMPS), self-reported Occupational balance (OBQ)

and Pain Self-efficacy (PSEQ) to investigate meaningful everyday activities,

participation and coping capacity;

B. Physical wake-time activity (actigraphs); BMI (weight and height scale),

waist circumference (measuring tape), blood pressure (sphygmomanometer)

(35), and blood sugar (glucometer) will be measured by verified methods, to

evaluate lifestyle-associated conditions and risks.

ERGO 18, 6-7. NOVEMBER 2018 23

Intervention group

Twelve sessions: combination of group sessions of 2 hours and individual sessions of 1 hour, both led by occupational therapists

The groups will be composed of 8-10 participants

Each group session will include relaxation and simple physical exercises suitable for practicing at home

The individual sessions will be planned in cooperation with every individual patient according to the actual needs, and executed either at-home, or home-close environments

Cooperation with the multidisciplinary team at the MPC and inter-sectoral units will be provided according to the patient’s needs and on interdisciplinary basis

Subsequently, the intervention group will continue with the regular treatment

The control group will receive the regular multimodal treatment at MPC, without the OT component

ERGO 18, 6-7. NOVEMBER 2018 24

Individual sessions at home

Individual goal setting

Executing ADL routines in self-care, leisure and productivity

Applied energy and time management

Ergonomics at home

Social relations

Family and relatives involvement

ERGO 18, 6-7. NOVEMBER 2018 25

Group sessions

Introduction

Meaningful activity and its impact on health

Occupational balance and value-based activity choice

Identification of Values, Roles, Interests and Habits

ADL, I-ADL and activity levels on day- and week-basis

At each group session:

Assistive devices advise

Simple physical activity indoor or outdoor

ERGO 18, 6-7. NOVEMBER 2018 26

Group sessions topics Self-care

Movement and well-being

Eating routines and enjoying meals

Sleep routines

Energy and fatique management

Time management

Stress management

Risk behavior

Pain rescue plan

Social activities and leisure

Socialization

Pleasurable activities

Transportation and exploring the environments

Productivity

Household management

Ergonomics at home and workplace

ERGO 18, 6-7. NOVEMBER 2018 27

Multidisciplinary and cross-sectional co-

operation (optional)

Multidisciplinary Pain Centre, Naestved

Exercise program (physical therapist)

Social-worker advise

Psychologist consultation

Physician consultation

Municipal social, health and activity facilities

Social-worker advise

Stop-smoking program

Local activity centres

ERGO 18, 6-7. NOVEMBER 2018 28

Patienterne om livsstil

Smertepatienter har ikke overskud til at tænke på sundhed hver dag

Men man kan ikke sætte livet på pause pga. smerter

Livsstilsændringer skal der til for at stå stærkere mod udfordringerne

ERGO 18, 6-7. NOVEMBER 2018 29

Afrundning

Ergoterapi kan sikre et holistisk tilgang i behandlingen af kroniske non-

maligne smertepatienter

Flere studier vil styrke evidensgrundlaget

Projektet vil skabe viden om anvendelsen af den livstilsorienterede tilgang på

smerteområdet i Denmark

Tak, fordi I lyttede!

Svetlana Solgaard Nielsen, ssolgaard@health.sdu.dk

ERGO 18, 6-7. NOVEMBER 2018 30

Referencer1. Breivik H, et al. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal

of Pain. 2006;10:287–333.

2. Clark, F. A., Blanchard, J., Sleight, A., Cogan, A., Florindez, L., Gleason, S., . . . Vigen, C. (2015). Lifestyle

Redesign®: The intervention tested in the USC Well Elderly Studies, Second Edition. Bethesda, MD: AOTA Press.

3. Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of

comprehensive pain programs for chronic nonmalignant pain. J Pain. 2006;7(11):779-93.

4. Gatchel RJ, et al. Interdisciplinary Chronic Pain Management: Past, Present, and Future. Am Psychol.

2014;69(2):119-30.

5. Henare D. 'It just isn't me anymore' moving forward to a new identity. New Zealand Journal of Occupational Therapy.

2003;50(1):4-10

6. Larson EA. The time of our lives: The experience of temporality in occupation. Can J Occup Ther. 2004;71:24-34.

7. Marcus DA. Treatment of nonmalignant chronic pain. Am Fam Physician. 2000;61(5):1331-8, 1345-6

8. Mathews M. Neurosurg Clin N Am. 2014;25:803–808

9. Prefontaine A, Rochette A. A literature review on chronic pain: the daily overcoming of a complex problem. British

Journal of Occupational Therapy. 2013;76(6):280-286.

10. Robinson K, Kennedy N, Harmon D. The Issue Is—Is Occupational Therapy Adequately Meeting the Needs of People

With Chronic Pain? AJOT, 2011a;65:106-113.

11. Robinson K, Kennedy N, Harmon D. Review of occupational therapy for people with chronic pain. AJOT, 2011b;58:74-

81.

ERGO 18, 6-7. NOVEMBER 2018 31

Referencer (fortsat)

12. Scascighini L, et al. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Journal of Rheumatology. 2008;47:670–678.

13. Sidall PJ, Cousins MJ. Persistent Pain as a Disease entity: Implications for Clinical Management. Anaesthethic Analgesia, 2004; 99: 510-520.

14. Snodgrass J. Effective occupational therapy interventions in the rehabilitation of individuals with work-related low back injuries and illnesses: A systematic review. AJOT. 2011;65:37–43.

15. Sundhedsstyrelsen. Kortlægning af opioidforbruget i Danmark. Sundhedsstyrelsen, 2016. (https://www.sst.dk/da/nyheder/2016/~/media/69913B827BAA4850A9A70E0CF76CB305.ashx.)

16. The_International_Narcotics_Control_Board. Narcotic Drugs - Estimated World Requirements for 2017, Statistics for 2015. INCB, New York, US, 2016. (https://www.incb.org/documents/Narcotic-Drugs/Technical-Publications/2016/Narcotic_Drugs_Publication_2016.pdf.)

17. Turk DC, et.al. Psychological approaches in the treatment of chronic pain patients - when pills, scalpels, and needles are not enough. Can J Psychiatry. 2008;53(4):213-23.

18. Uyeshiro SA, Collins CER. Lifestyle Redesign® for Chronic Pain Management: A Retrospective Clinical Efficacy Study. Am J Occup Ther. 2017;71(4):7104190040p1-7104190040p7.

19. van Hecke O, Torrance N, Smith B. Chronic pain epidemiology – where do lifestyle factors fit in? British Journal of Pain. 2013;7(4):209–217.

20. Van Huet H, Innes E, Stancliff R. Occupational therapists perspectives of factors influencing chronic pain management. Australian Occupational Therapy Journal. 2013;60:56-65

21. Von der Heyde R. Occupational Therapy Interventions for Shoulder Conditions: A Systematic Review. AJOT. 2011;65:16-23.

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