{"id":2042,"date":"2020-10-10T15:03:12","date_gmt":"2020-10-10T14:03:12","guid":{"rendered":"http:\/\/mmcup.se\/?page_id=2042"},"modified":"2022-11-20T15:35:16","modified_gmt":"2022-11-20T14:35:16","slug":"kapitel-7-smarta-hos-vuxna-med-ryggmargsbrack","status":"publish","type":"page","link":"https:\/\/mmcup.se\/?page_id=2042","title":{"rendered":"Kapitel 7 &#8211; Sm\u00e4rta hos vuxna med ryggm\u00e4rgsbr\u00e5ck"},"content":{"rendered":"\n<figure class=\"wp-block-image size-full\"><a href=\"http:\/\/mmcup.se\/wp-content\/uploads\/2022\/11\/Kap-7-Smarta.pdf\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" width=\"32\" height=\"32\" src=\"https:\/\/i0.wp.com\/mmcup.se\/wp-content\/uploads\/2022\/11\/PDF_ikon-2.png?resize=32%2C32&#038;ssl=1\" alt=\"\" class=\"wp-image-3259\"\/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\">Evidens vad g\u00e4ller sm\u00e4rta och behandling av vuxna med MMC \u00e4r bristf\u00e4llig. F\u00f6rekomst av sm\u00e4rta rapporteras hos mellan 28% och 90%.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\">En skada i nervsystemet d\u00e4r k\u00e4nseln \u00e4r f\u00f6r\u00e4ndrad\/nedsatt inneb\u00e4r att sm\u00e4rtans ursprungliga funktion som larmsystem f\u00f6r att skydda, varna vid p\u00e5g\u00e5ende v\u00e4vnadsskada \u00e4r satt ur spel. Detta b\u00f6r beaktas i all kontakt med patienter med ryggm\u00e4rgsbr\u00e5ck. Personens beskrivning av k\u00e4nselupplevelsen p\u00e5verkas av att k\u00e4nself\u00f6rm\u00e5gan alltid varit annorlunda.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\">T\u00e4nk utanf\u00f6r boxen! En femurfraktur kan till exempel misstolkas som en inflammation, d\u00e5 patienten inte k\u00e4nner n\u00e5gon sm\u00e4rta.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\">Vid anv\u00e4ndning av manuell rullstol och vid annan f\u00f6rflyttning med hj\u00e4lp av armstyrka uts\u00e4tts nacke och axlar f\u00f6r \u00f6kad belastning. Nociceptiv sm\u00e4rtproblematik fr\u00e5n dessa omr\u00e5den och tidig artrosutveckling \u00e4r d\u00e4rf\u00f6r vanligare \u00e4n hos \u00f6vriga befolkningen. Nedsatt b\u00e5lbalans och skolios \u00f6kar f\u00f6rmodligen belastningen ytterligare. Felst\u00e4llning i framf\u00f6rallt h\u00f6fter, men \u00e4ven i andra leder kan i vuxen \u00e5lder \u00f6ka risken f\u00f6r att drabbas av l\u00e5ngvarig sm\u00e4rta.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\">Nytillkommen sm\u00e4rta som kan misst\u00e4nkas vara neuropatisk och f\u00f6rs\u00e4mrad sensibilitet kan vara tecken p\u00e5 fj\u00e4ttrad ryggm\u00e4rgssyndrom.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\">Shuntdysfunktion kan ge b\u00e5de f\u00f6rh\u00f6jt intrakraniellt tryck och syringomyeli som kan ge sm\u00e4rta. Huvudv\u00e4rk kan vara enda symptom av en tryck\u00f6kning. Observera att sp\u00e4nningshuvudv\u00e4rk \u00e4r mycket vanlig i denna patientgrupp p.g.a. den l\u00e5ngvariga \u00f6verbelastningen av nacke\/axlar.<\/p>\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\"><strong>Utredning<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\">Personer med ryggm\u00e4rgsbr\u00e5ck har oftast sv\u00e5rt att ber\u00e4tta fritt. Konkreta fr\u00e5gor beh\u00f6vs.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\"><em>Fr\u00e5ga alltid<\/em><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Brukar du ha ont?<\/li>\n\n\n\n<li>Var g\u00f6r det ont?<\/li>\n\n\n\n<li>Hur l\u00e4nge har det k\u00e4nts s\u00e5?<\/li>\n\n\n\n<li>I vilka situationer kommer sm\u00e4rtan?<\/li>\n\n\n\n<li>Hur p\u00e5verkar sm\u00e4rtan din vardag?<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\">Unders\u00f6kning av r\u00f6relseapparaten \u00e4r alltid n\u00f6dv\u00e4ndig f\u00f6r att kunna v\u00e4rdera sm\u00e4rtor. Sensorik vad g\u00e4ller ber\u00f6ring, v\u00e4rme kyla och stick pr\u00f6vas i sm\u00e4rtande omr\u00e5de, (pensel , kall o varm metallrulle samt n\u00e5l). En hyper- eller hyposensibilitet av minst 2 kvaliteter skall f\u00f6religga vid neuropatisk sm\u00e4rta. Bed\u00f6mningen kompliceras om en f\u00f6r\u00e4ndrad k\u00e4nsel f\u00f6religger sedan f\u00f6dseln. J\u00e4mf\u00f6r aktuell situation med tidigare svar p\u00e5 fr\u00e5gor i MMCUP 3.1 fysioterapi och 7.2 liten genomg\u00e5ng.<\/p>\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\"><strong>Prevention<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\">Regelbunden uppf\u00f6ljning hos fysioterapeut rekommenderas f\u00f6r att tidigt uppt\u00e4cka och f\u00f6rebygga sm\u00e4rtor p.g.a. \u00f6verbelastning av r\u00f6relseorganen. Anv\u00e4ndning av g\u00e5nghj\u00e4lpmedel samt elrullstol vid l\u00e4ngre transporter kan vara ett f\u00f6rebyggande alternativ. Detta g\u00e4ller \u00e4ven personer som g\u00e5r med st\u00f6d.<\/p>\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\"><strong>Behandling<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\"><em>Fysioterapi <\/em>\u00e4r f\u00f6rstahandsbehandling vid l\u00e5ngvarig sm\u00e4rta. Viktigt att t\u00e4nka p\u00e5 \u00e4r att anv\u00e4ndning av TENS \u00e4r kontraindicerad p\u00e5 k\u00e4nselst\u00f6rda omr\u00e5den \u2013 kan provocera ist\u00e4llet f\u00f6r att lindra sm\u00e4rtan.<br><em>Kognitiv beteendeterapi <\/em>har god evidens vid l\u00e5ngvarig sm\u00e4rta, men studier och klinisk erfarenhet avseende personer med ryggm\u00e4rgsbr\u00e5ck saknas.<br><em>Sm\u00e4rtrehabiliteringsprogram i grupp <\/em>Konklusiva resultat avseende patienter med ryggm\u00e4rgs- br\u00e5ck saknas.<br><em>Farmakologisk behandling. <\/em>V\u00e4lj l\u00e4kemedel utifr\u00e5n om sm\u00e4rtan bed\u00f6ms vara nociceptiv eller neurogen. Viktigt att g\u00f6ra en cost\/benefit-analys av varje farmakologisk \u00e5tg\u00e4rd. Beakta f\u00f6rv\u00e4ntad behandlingstid.<\/p>\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\"><strong>Nociceptiv sm\u00e4rta&nbsp;<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>NSAID \u00e4r f\u00f6rstahandsval vid en inflammatorisk utl\u00f6st sm\u00e4rta.<\/li>\n\n\n\n<li>Behandling med NSAID p\u00e5verkar koagulationssystemet. L\u00e5ngtidsbehandling inneb\u00e4r en \u00f6kad risk f\u00f6r tromboser f\u00f6r en stillasittande patient.<\/li>\n\n\n\n<li>Paracetamol kan pr\u00f6vas och \u00e4r relativt ofarligt om det ej \u00f6verdoseras.<\/li>\n\n\n\n<li>Morfinpreparat fungerar, men rekommenderas inte vid l\u00e5ngtidsbehandling p\u00e5 grund av toleransutveckling. Det \u00e4r viktigt att tidsbegr\u00e4nsad anv\u00e4ndning ej utesluts, d\u00e5 dessa medel \u00e4r \u00f6verl\u00e4gset effektivast vid nociceptiv sm\u00e4rta.<\/li>\n<\/ul>\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\"><strong>Neuropatisk sm\u00e4rta<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Om sm\u00e4rtan bed\u00f6ms neuropatisk har NSAID eller Paracetamol ingen effekt.<\/li>\n\n\n\n<li>Gabapentinoider: Gabapentin och Pregabalin. Behandling inneb\u00e4r en st\u00e5ende medicinering. L\u00e4gsta effektiva dygns dos av Gabapentin \u00e4r 1200 mg (400 mg x 3) Pregabalin 150 mg (75 mg x 2). Gabapentin kan vara s\u00f6mnst\u00f6rande.<\/li>\n\n\n\n<li>NSRI-preparat\n<ul class=\"wp-block-list\">\n<li>Duloxetin ger effekt hos ungef\u00e4r 70% b\u00f6r ges tv\u00e5 g\u00e5nger dagligen, kan kombineras med Gabapentinonider.<\/li>\n\n\n\n<li>Venlafaxin har pr\u00f6vats och kan ge effekt.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Tricykliska antidepressiva\n<ul class=\"wp-block-list\">\n<li>Mest studerat \u00e4r Amitryptilin vilket har anv\u00e4nt sedan 60-talet och fungerar hos c:a 30% med neuropatisk sm\u00e4rta i doser 50-75 mg\/dygn<\/li>\n\n\n\n<li>10 mg Amitryptilin p\u00e5 kv\u00e4llen kan f\u00f6rb\u00e4ttra s\u00f6mnen.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Opioider\n<ul class=\"wp-block-list\">\n<li>Vissa opioider har effekt p\u00e5 neuropatisk sm\u00e4rta. ( Metadon, Oxikodon, Tramadol, Tapentadol)<\/li>\n\n\n\n<li>Beakta dock att dessa preparat f\u00e5r s\u00e4mre effekt vid l\u00e5ngvarig behandling (dos- toleransutveckling) och risk finns f\u00f6r en beroendeproblematik, samt opioidrelaterad f\u00f6rstoppning.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:18px\"><strong><em>Kom ih\u00e5g<\/em>!<\/strong><br>Vid utprovning av l\u00e4kemedel mot neuropatisk sm\u00e4rta \u00e4r en l\u00e5ngsam dostitrering under 1-2 veckor att rekommendera f\u00f6r att minska biverkningar och \u00f6ka acceptansen. F\u00f6rv\u00e4ntad effekt uppkommer ej innan l\u00e4gsta effektiva dos uppn\u00e5tts. Testa ett preparat i taget och utv\u00e4rdera.<\/p>\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\"><strong>Rekommendationer<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Fr\u00e5ga om sm\u00e4rtor vid varje bes\u00f6k och g\u00f6r en noggrann sm\u00e4rtanalys om sm\u00e4rtan \u00e4r nociceptiv eller neuropatisk.<\/li>\n\n\n\n<li>Unders\u00f6k \u201dhands on\u201d.<\/li>\n\n\n\n<li>S\u00e4tt in behandling \u00e4ven i v\u00e4ntan p\u00e5 utredning och ev. operativ \u00e5tg\u00e4rd.<\/li>\n\n\n\n<li>Var frikostig med utredning, bilddiagnostik (MRT hj\u00e4rna-spinalkanal) och med att konsultera specialist eftersom sm\u00e4rttillst\u00e5nd vid ryggm\u00e4rgsbr\u00e5ck \u00e4r sv\u00e5rv\u00e4rderade.<\/li>\n<\/ul>\n\n\n\n<p class=\"has-medium-font-size wp-block-paragraph\"><strong>Referenser<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Mir\u00f3, Jordi, et al. &#8221;Defining mild, moderate, and severe pain in young people with physical disabilities.&#8221; <em>Disability and rehabilitation <\/em>39.11 (2017): 1131-1135.<\/li>\n\n\n\n<li>Adigo, Am\u00e9gninou Mawuko Yao, et al. &#8221;Can atlas spina bifida-occulta be a cause of cervicogenic headaches?.&#8221; <em>SpringerPlus<\/em>4.1 (2015): 605.<\/li>\n\n\n\n<li>Kanda, Shotaro, et al. &#8221;An unusual presentation of adult tethered cord syndrome associated with severe chest and upper back pain.&#8221; <em>Case reports in orthopedics <\/em>2015 (2015).<\/li>\n\n\n\n<li>Robbins, J. Will, et al. &#8221;Perineal pain secondary to tethered cord syndrome: retrospective review of single institution experience.&#8221; <em>Child&#8217;s Nervous System <\/em>31.11 (2015): 2141-2144.<\/li>\n\n\n\n<li>Wagner, Robert, et al. &#8221;Perception of secondary conditions in adults with spina bifida and impact on daily life.&#8221; <em>Disability and health journal <\/em>8.4 (2015): 492-498.<\/li>\n\n\n\n<li>Ferrero, G., et al. &#8221;Risk factors for shoulder pain in patients with spinal cord injury: a multicenter study.&#8221; <em>Musculoskeletal surgery<\/em>99.1 (2015): 53-56.<\/li>\n\n\n\n<li>Garg, Kanwaljeet, et al. &#8221;Management of adult tethered cord syndrome: our experience and review of literature.&#8221; <em>Neurology India <\/em>62.2 (2014): 137.<\/li>\n\n\n\n<li>Crytzer, Theresa M., Brad E. Dicianno, and Roohi Kapoor. &#8221;Physical activity, exercise, and health-related measures of fitness in adults with spina bifida: a review of the literature.&#8221; <em>PM&amp;R <\/em>5.12 (2013): 1051- 1062.<\/li>\n\n\n\n<li>Werhagen, L., et al. &#8221;Medical complication in adults with spina bifida.&#8221; <em>Clinical neurology and neurosurgery <\/em>115.8 (2013): 1226-1229.<\/li>\n\n\n\n<li>Werhagen, Lars, Claes Hultling, and Kristian Borg. &#8221;Pain, especially neuropathic pain, in adults with spina bifida, and its relation to age, neurological level, completeness, gender and<\/li>\n\n\n\n<li>hydrocephalus.&#8221; <em>Journal of rehabilitation medicine <\/em>42.4 (2010): 374-376.<\/li>\n\n\n\n<li>Yildirim, Necmiye Un, Esra Comert, and Nuriye Ozengin. &#8221;Shoulder pain: a comparison of wheelchair basketball players with trunk control and without trunk control.&#8221; <em>Journal of back and musculoskeletal rehabilitation <\/em>23.2 (2010): 55-61.<\/li>\n\n\n\n<li>Hansson, \u201d<a rel=\"noreferrer noopener\" href=\"https:\/\/lakartidningen.se\/Functions\/OldArticleView.aspx?articleId=10347\" target=\"_blank\">Antidepressiva, antiepileptika och opioider kan lindra<em>.<\/em><\/a><em>\u201d L\u00e4kartidningen <\/em>2008-09-23 nr 39.<a href=\"http:\/\/www.lakartidningen.se\/Functions\/OldArticleView.aspx?articleId=10347\"> <\/a><\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"wp-block-paragraph\" style=\"font-size:16px\">Patrik Ugge, \u00f6verl\u00e4kare, Neuro- och Rehabiliteringsmedicinska kliniken, Universitetssjukhuset \u00d6rebro<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">2018-07-01<\/p>\n<div class=\"pdfprnt-buttons pdfprnt-buttons-page pdfprnt-bottom-left\"><a href=\"https:\/\/mmcup.se\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F2042&print=print\" class=\"pdfprnt-button pdfprnt-button-print\" target=\"_blank\" ><img data-recalc-dims=\"1\" decoding=\"async\" src=\"https:\/\/i0.wp.com\/mmcup.se\/wp-content\/plugins\/pdf-print\/images\/print.png?ssl=1\" alt=\"image_print\" title=\"Print Content\" \/><span class=\"pdfprnt-button-title pdfprnt-button-print-title\">Skriv ut sida<\/span><\/a><\/div>","protected":false},"excerpt":{"rendered":"<p>Evidens vad g\u00e4ller sm\u00e4rta och behandling av vuxna med MMC \u00e4r bristf\u00e4llig. F\u00f6rekomst av sm\u00e4rta rapporteras hos mellan 28% och 90%. En skada i nervsystemet d\u00e4r k\u00e4nseln \u00e4r f\u00f6r\u00e4ndrad\/nedsatt inneb\u00e4r att sm\u00e4rtans ursprungliga funktion som larmsystem f\u00f6r att skydda, varna vid p\u00e5g\u00e5ende v\u00e4vnadsskada \u00e4r satt ur spel. Detta b\u00f6r beaktas i all kontakt med patienter [&hellip;]<\/p>\n","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"default","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-2042","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/mmcup.se\/index.php?rest_route=\/wp\/v2\/pages\/2042","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mmcup.se\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mmcup.se\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mmcup.se\/index.php?rest_route=\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/mmcup.se\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2042"}],"version-history":[{"count":12,"href":"https:\/\/mmcup.se\/index.php?rest_route=\/wp\/v2\/pages\/2042\/revisions"}],"predecessor-version":[{"id":3262,"href":"https:\/\/mmcup.se\/index.php?rest_route=\/wp\/v2\/pages\/2042\/revisions\/3262"}],"wp:attachment":[{"href":"https:\/\/mmcup.se\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2042"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}