Le rôle des représentations de la maladie et de la douleur dans la relation patient-thérapeute

Résumé  La rencontre entre patient et thérapeute dans la relation de soins met en présence non seulement deux individus, mais aussi deux systèmes de pensée. Elle suppose donc l'articulation de deux types de savoirs, profane d'une part et scientifique d'autre part. La clarification et la prise en compte des représentations du patient à propos de l'atteinte dont il souffre constitue un enjeu important de la relation. Il en va de même des attentes du thérapeute par rapport à ce qu'il considère comme un comportement douloureux adéquat, par exemple. Faute de la prise en compte des modèles de référence explicites et implicites tant du patient que du thérapeute, la relation peut déboucher sur des malentendus, des réactions d'agressivité, d'anxiété, et conduire à une rupture de cette relation.

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Summary  The patient-therapist relationship involves not only two individuals, but also two systems of thinking. It calls forth lay knowledge on the one hand and scientific knowledge on the other hand. The patient's representations about his pain and suffering may play an important role in the patient-health care provider relationship and thus need to be clarified and taken into account. This need also holds true where the therapist's expectations are concerned, for example with regard to what is considered as an adequate pain behavior. Failing to take into account the explicit and implicit models of both the patient and the therapist may lead to misunderstandings, aggressive behaviors, anxious reactions, and thus hamper or even disrupt the patient-therapist relationship.

     

THE INTRODUCTION OF PATIENT-CONTROLLED ANALGESIA INTO AN ISOLATED RURAL HOSPITAL

This study investigated the feasibility of using patient-controlled analgesia (PCA) effectively in a small 70 bed isolated rural hospital. The tirst 50 patients to use a Bard PCA 1, in the Port Lincoln Hospital, South Australia, were studied. The patients consumed morphine at a mean rate of 1.24 mg/h and used PCA for a mean of 48 h. Thirty-eight per cent of patients required treatment for nausea and other complications which is similar to the rate of those in other published series. Visual analogue pain scores showed excellent pain control, generally without evidence of oversedation; however, there was one episode of respiratory depression. Seventy-eight per cent of patients reported that their pain was relieved most or all of the time. The study demonstrated that a PCA service provided by nursing staff, the GP anaesthetist and rural surgeons is feasible in an isolated rural hospital.     

AAEM minimonograph #43: Neuromuscular problems in the performing arts

Over the past 10–15 years, there has been increasing interest in the health problems of performing artists. In this review, I will discuss the major playing-related disorders seen in instrumental musicians. Among the 672 instrumentalists evaluated, the major diagnoses identified included musculoskeletal disorders in 64%, peripheral nerve problems in 22.5%. and focal dystonia in 7%. Sixty percent of instrumentalists were female although males predominate in the group with focal dystonia. The average age of those evaluated was 32 years. Among musculoskeletal disorders overuse syndrome is the most common. Frequent peripheral nerve disorders include thoracic outlet syndrome, carpal tunnel syndrome, and ulnar neuropathy. A characteristic distribution of symptoms and signs is identified for each instrument group. Electrodiagnostic studies are an important part of the evaluation of these disorders. With carefully designed treatment, the majority of instrumental musicians can be returned to full and pain-free playing activities. The success rate is highest in some entrapment neuropathies but remains low in focal dystonia. © 1994 John Wiley & Sons, Inc.     

Preoperative infiltration of the surgical area enhances postoperative analgesia of a combined low–dose epidural bupivacaine and morphine regimen after upper abdominal surgery

In a randomized, blinded trial we assessed the value of adding preoperative infiltration of the surgical area with bupivacaine to a low dose epidural regimen for postoperative pain treatment. Forty–nine patients scheduled for major upper abdominal surgery during combined thoracic epidural (bupivacaine + morphine) and general anaesthesia were studied. Postoperative analgesia was epidural bupivacaine 10 mg hr^-1 + morphine 0.2 mg hr^-1 for 72 h. The patients randomly received preoperative infiltration of the surgical area with bupivacaine 0.25%, 40 ml (group I); or no infiltration (group II). Pain was evaluated at rest, during cough and during mobilization six and eight h after start of surgery, and at 8 a.m. and 4 p.m. on the following days until 72 h after start of surgery. The sensory level of analgesia was evaluated by pin prick. We found no difference between the two groups during rest and cough. However, during mobilization group I had lower pain scores compared to group II ( P < 0.05). There was a significant reduction in the need for supplemental intramuscular morphine in the treatment group compared to the control group ( P <0.05). Thus an enhanced analgesic effect was demonstrated by adding preoperative infiltration of the surgical area with local anaesthetic to a low dose epidural bupivacaine/morphine regimen after upper abdominal surgery.     

国产鼻喷鲑鱼降钙素治疗骨质疏松性疼痛的疗效观察

目的观察国产鼻喷鲑鱼降钙素治疗骨质疏松性疼痛的疗效。方法采用随机分组对照设计。选择骨质疏松患者53例,随机分为两组,治疗组(30例)给予鼻喷鲑鱼降钙素,20u/次,1次/天,8周为1个疗程,停药后继续观察3周。对照组(23例)口服钙尔奇D片,1片/次,1次/天,共8周;采用国际惯用分级标准对疼痛予以评估。结果治疗组患者的疼痛明显改善,其总有效率为95%;在停药后缓解疼痛的作用仍可维持4周以上,Ⅲ度骨质疏松患者的治疗效果较Ⅰ度和Ⅱ度患者的效果差;对照组症状未见明显改善。结论用国产鼻喷鲑鱼降钙素治疗骨质疏松性骨痛,可明显缓解患者的疼痛症状。     

Vulvodynia: evolution of classification and management

The aim of this article is to make the reader familiar with the history and current status of vulvodynia. The account is presented as a historical survey, from the seventies to the nineties. It explains how and why the term came to be defined, and how some sub-groups – in particular dysaesthetic vulvodynia and vulval vestibulitis – have been identified and described. Their management is discussed. The importance of distinguishing these conditions from those which are variants of normal is stressed.
It is noted that these sub-groups have much in common, so that a degree of convergence or overlap has come to be recognised. In parallel with this, ideas concerning aetiology and optimal management have been clarified and are explored.
Appreciation of the present state of affairs, and of how it has been arrived at, will help to improve management. It will also facilitate the collection of data, which in turn may lead to further research and understanding of vulvodynia.     

Single visit root canal treatment: incidence of postoperative pain using three different instrumentation techniques

A clinical study was carried out on nonvital maxillary central incisors to evaluate the incidence of postoperative pain following single-visit root canal treatment using three different instrumentation techniques. Ninety teeth from 78 patients whose ages ranged from 14 to 63 years were selected and divided into three groups. Each group (30 teeth) was prepared by a different coronal-to-apical technique using different instrument movement depending upon the technique employed: modified double-flared, crown-downpressureless and balanced force techniques. No difference was observed in the incidence of postoperative pain among the groups.     

Transfer of lumbosacral load to iliac bones and legs Part 1: Biomechanics of self-bracing of the sacroiliac joints and its significance for treatment and exercise

This study deals primarily with the stability of the base of the spine. The sacroiliac joints are vulnerable to shear loading on account of their predominantly flat surfaces. This raises the question of what mechanisms are brought into action to prevent dislocation of the sacroiliac joints when they are loaded by the weight of the upper part of the body and by trunk muscle forces. First a model is introduced to compare load transfer in joints with spherical and with flat joint surfaces. Next we consider a biomechanical model for the equilibrium of the sacrum under load, describing a self-bracing effect that protects the sacroiliac joints against shear according to ‘the sacroiliac joint compression theory’, which has been demonstrated in vitro. The model shows joint stability by the application of bending moments and the configuration of the pelvic arch. The model includes a large number of muscles (e.g. the gluteus maximus and piriformis muscles), ligaments (e.g. the sacrotuberous, sacrospinal, and dorsal and interosseous sacroiliac ligaments) as well as the coarse texture and the ridges and grooves of the joint surfaces.     

Stimulation of nerve growth factor and substance P expression in the iris–trigeminal axis of diabetic rats—involvement of oxidative stress and effects of aldose reductase inhibition

In rats with streptozotocin-induced diabetes, we measured increased (by 61%; P<0.05) mRNA for nerve growth factor (NGF) in the iris together with increased (by 82%; P<0.05) mRNA for preprotachykinin (the substance P precursor) in the trigeminal ganglion, suggesting that increased NGF was driving increased substance P gene expression. In other diabetic rats, these changes were prevented by treatment with either an antioxidant (butylated hydroxytoluene; 1% by diet) or an aldose reductase inhibitor (ARI) (sorbinil; 25 mg/kg/day p.o.) and the sorbinil treatment was associated with significant inhibition of polyol pathway intermediates in both lens and sciatic nerve. This suggests that polyol pathway activity in the lens may translate to oxidative stress-driving stimulation of NGF gene expression in the iris. The change is selective for NGF, because expression of the analogous neurotrophin, neurotrophin-3 (NT-3), was unaltered in the same irises. These changes suggest that oxidative stress and/or inflammation can drive up NGF expression in diabetes—a mechanism that might participate in iritis.