Randi Abrahamsen, DDS PhD

23rd. November 2018

The Beauty of Healing

in Chronic Pain

11th International Congress

of Medical Hypnosis

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

IASP 1994

Background

Pain

Pain Experience

Tracey and Mantyh, Neuron 2007

Brain activity

Possitionemmissontomoghrafi (PET)

Functionel magnetic resonance (fMRI)

Electroencephalography (EEG)

Rainville et al 2000

PET

Pain mechanism

Tracey and Mantyh, Neuron 2007

Background Previous eksperimental studies of pain mechanism

Tracey and Mantyh, Neuron 2007

Rainville et al. 1997, 2002 Marquet et al. 1999

Faymonville et al. 2000,2003 Derbyshire et al. 2004 Schulz-Stübner 2004

Raji et al 2005

Background Previous eksperimental studies of pain mechanism

Tracey and Mantyh, Neuron 2007

Healthy subjects High hypnotic suggestibility No facial painstimulation

Effect of hypnosis on brain activity

Patients and behavioral outcome

19 TMD patients with myofascial pain

(1 man and 18 women)

Pain intensity (NRS)

Pain unpleasantness (NRS)

Hypnotic susceptibility Harvard Group Scale of Hypnotic Susceptibility (0-12)

Effect of hypnosis on brain activity

Hypnosis training

1 hour hypnosis training prior to fMRI:

1. Progressive musclerelaxation

2. Autobiographic safeplace

3. Gloveanalgesia (2 buckets with hot and cold water) combined with autobiographic memory of analgesia.

4. Transferring analgesia to test region

5. Posthypnotic cues for fMRI session

No training in hyperalgesia

3 different experimental conditions with

identical pain stimulation:

Baseline

Control

Hypnotic

hyper-

algesia

Hypnotic

analgesia

A GE Signa HDx 3T scanner (General Electric, Milwaukee, WI,

USA) gradient-Echo EPI, acceleration resolution 128 x 128

pixels, field-of-view 240 mm, slice thickness 3.5 mm, and 39

slices per volume.

Effect of hypnosis on brain activity. Material and Methods

Experimental design

Pain stimulation 30 seconds- 30 seconds off Repeated in 5 cycles

Randomised hypnotic conditons.

Pain

Control Hyperalgesia Hypnotic analgesia

NR

S

(0

- 1

0)

0

2

4

6

8

10

Modulation of pin-prick stimulation in control, hypnotically induced hyperalgesia, and hypnotic analgesia.

Control Hyperalgesia Hypnotic analgesia

0

2

4

6

8

10

Unpleasantness

Effect of hypnosis on brain activity. Results

Pain intensity and unpleasantness

*** **

** **

Time effects ***(P=0.001)** (P<0.01) Abrahamsen et al. Pain 2010

Control Hypnotic analgesia

Control-control.off hyponotic analgesia- hyponitic analgesia. off

Effect of hypnosis on brain activity. Results

Brain activity during hypnotic analgesia

Abrahamsen et al. Pain 2010

Control

Hypnotic analgesia

Effect of hypnosis on brain activity. Results

Brain activity during hypnotic analgesia

Abrahamsen et al. Pain 2010

Eksperimentelle studier af hypnoses

smertelindrende effekt

Tracey and Mantyh, Neuron 2007

Brainstem reflexes

Diffences in brain activity Physically induced pain Hypnotically inducered pain Imagined pain

Derbyshire 2004

N=7

Difference in brain activity between patients

with high and low pain score

Derbyshire 2004

Person with lowest painscore

Person with highest painscore

Person with highest painscore

Catastrophizing

Catastorphizing related to anticipation

interpretation of pain

Automatic circuits nucl. claudatus og

lentiformes

Tracey and Mantyh, Neuron 2007

Anxiety

Tracey and Mantyh, Neuron 2007

Acquired brain injury

Lindeløv et al. 2017

From: Improving working memory performance in brain-injured patients using hypnotic suggestion Brain. 2017;140(4):1100-1106. doi:10.1093/brain/awx001

Brain | © The Author (2017). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For

Permissions, please email: journals.permissions@oup.com

From: Improving working memory performance in brain-injured patients using hypnotic suggestion Brain. 2017;140(4):1100-1106. doi:10.1093/brain/awx001

Brain | © The Author (2017). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For

Permissions, please email: journals.permissions@oup.com

Chronic pain

19% af the European population

have pain >5 (pain scale 0-10)

Breivik et al. 2006

56%

44%

Age: 41-60 years Average 50 years

40% insufficient paincontrol sideeffects

Pain and traumatic events

Often relation between pain and mental stress /traumatic events (divorce, workloads and

-shifts, severe disease and death in close family)

Reduced activity at work and at home

Reduced participation in social life

Poor sleep

Less exercise

Large consumption of painkillers-many side effects

Increased use of health care system

Depression

How can we use this for chronic pain

Somatosensory cortex

Function of Somatosensory cortex S1,S2 : information about nociception: pain intensity, pain area, pain quality

Suggestions to alter pain:reduce area, intensity, change pain quality

Chudler & Bonia 2001 May 2007

Anterior cingulate cortex (ACC)

Part of the limbic system: affective part of the pain- the meaning of the pain

Suggestions to change the meaning of pain, amnesia

Craig 2008, Rainville 2002

Insula

Insula: superior monitoring central, risk evaluation

Suggestions on safety and comfort

Craig 2008,

Præfrontal korteks (PFL)

PFL: Pain memory, meaning of pain, activity

Suggestions to change pain memories (meaning) change of activity (age regression- progression)

The brain is amazing

The brain does what you train it to do!

Clinical studies

PIOP persistent ideophatic pain

Temporomandibular disorders

• RDC/TMD

• Coping stategies

• SCL

Inclusion

•VAS pain intensity

•Medication

•Sleep

After treatment

• VAS pain intensity

• RDC/TMD

• Coping strategies

• SCL

• Medication

• Sleep

• Hypnotic susceptibility

4 individual sessions of hypnosis (6 PIOP)

CD with hypnosis for training

1 week

Hypnosis

Control

Baseline

4 individual sessions of relaxation (6 PIOP) I CD with relaxation for training

Effect of hypnosis in PIOP and TMD patients

Experimental design

Effect of hypnosis in PIOP and TMD patients Material and methods

Primary Outcome

Average daily pain intensity

scored 3 times daily on

a Visual Analogue Scale (VAS)

(0-10)

1 Hypnosis Progressive relaxation

Guided imaginary to a safe comfortable place

Hypnotic suggestions of:

Feelings of success, calm, peace of mind, and inner strengths

Changing pain perception

Feeling of anesthesia

Stress coping

Refraiming of psychological trauma

2. Control Progressive relaxation

Guided imaginary to a safe comfortable place

Effect of hypnosis in PIOP and TMD patients Material and methods

Intervention

Effect of hypnosis in PIOP patients. Results

Daily pain intensity

Hypnosis (N=22)

Control (N=19)

Time effects ***(P >0.001)** (P<0.01) * P<0.05) Group difference # # (P<0.01) ###(P<0.001)

Study 2 Effect of hypnosis in TMD patients. Results

Daily pain intensity N

RS

pain

(0 -

10

)

0

2

4

6

8

10 Hypnosis (N=20)

Control (N=20)

# # #

* * *

* * * * * *

Time effects (P >0.001) # Group difference (P = 0.024)

baseline week1 week 2 week 4

-10

0

10

20

30

40

50

60

70

% r

ed

uc

tio

n in

pa

in s

co

res

hypnosis gruppe

control gruppe

Effect on hypnosis on chronic orofacial pain

% Reduction in daily score

Case

Accident on skies 17 years old male Previously attempted treatment: Painkillers even opiods Chiropractor: manipulation Physiotherapy: massage, ultrasound, Acupuncture, excercise Dentist: Splint Treatment at a pain clinic All of it is virtually without effect. Daily pain at 7-8

Treatment with hypnosis

Pain free days

Several pain free days

Average pain Worst pain

Follow up

Telefonfollow up 2 months later: Feeling Ok

no more treatment needed – uses selfhypnosis. Started to study again

1 year later: Still doing well

Acknowledgement All the patients who participated in the study Department of Clinical Oral Physiology Professor Peter Svensson, DDS, PhD, Dr.Odont. Associate Professor Lene Baad-Hansen, DDS, PhD Sara Baram, dental research student Bente Haugsted, research assistent Eduardo Castrillon, DDS, PhD Elin Norbud, Anni Stagstup, secretaries Karina Bendixen, DDS PhD student Faramarz Jadidi, medical engineer, PhD student

Psychooncology Research Unit, Aarhus University Hospital Professor Bobby Zachariae, MSc, MD Sci, Cand Psych, Dr Med,

Center of Functionally Integrative Neuroscience Associate professor Andreas Roepstorff , cand. scient., cand. phil., PhD Professor Leif Østergaard MD, MSc, PhD, DMSc Physicist Ryan Sangill MSc Research Radiographer Dora Zeidler RT, PgD in MR Sanne Lodahl PhD Martin Dietz PhD

Danish Dental Association Vi FAB (Danish Ministry of the Interior) Aarhus University Research Foundation

European Society of Hypnosis

Research project for clinicians

Patients: Consent Symptomdiary and medication MYMOP before and after Dissociative scale

Clinicians: Time registration

Interested ?? please contact Peter Naish: peter.naish@open.ac.uk Randi Abrahamsen: randiabrahamsen@hotmail.com

Thank you for your

attention