[Interest of a biopsychosocial approach in the management of a patient with chronic pain : a narrative review]. / Intérêt d'une approche biopsychosociale dans la prise en charge d'un patient souffrant de douleurs chroniques : une revue narrative.

Pain is generally perceived as a sensory, emotional and cognitive aggression by the patient who suffers from it and as the enemy that must be defeated by the physician. It may become chronic, and the passage from the acute phase to the chronic phase cannot be explained in a single way. Indeed, multiple factors come into play: biological, psychological and socio-professional. The patient's quality of life then deteriorates and places him/her in a vicious cycle of pain. The assessment of the different components of pain (sensory, emotional, cognitive and behavioural) and its maintenance factors allow for the implementation of therapeutic strategies, both physical and psychological, adapted to every patient. Due to the complexity of chronic pain management, a multidisciplinary strategy is being developed, with a global approach according to the biopsychosocial perspective, including non-pharmacological approaches, with the objective of allowing the patient to be autonomous in the management of his/her symptoms.

La douleur est généralement perçue comme une agression sensorielle, émotionnelle et cognitive par le patient qui en souffre, et comme l'ennemi que le médecin doit vaincre. Elle peut se chroniciser, et le passage de la phase aiguë à la phase chronique ne peut s'expliquer d'une façon unique. En effet, de multiples facteurs biologiques, psychologiques et socio-professionnels entrent en jeu. La qualité de vie du patient se dégrade alors et le place dans un véritable cercle vicieux de la douleur. L'évaluation des différentes composantes de la douleur (sensorielle, émotionnelle, cognitive et comportementale) et de ses facteurs de maintien permet de mettre en place des stratégies thérapeutiques, aussi bien sur le plan physique que psychologique, adaptées à chaque patient. Du fait de la complexité de la prise en charge de la douleur chronique, se développe une méthode pluridisciplinaire, dans une perspective d'approche globale selon le modèle biopsychosocial, incluant également des approches non médicamenteuses avec comme objectif, notamment, de permettre au patient une autonomie dans la gestion de sa symptomatologie.

[Well-being center in CHU of Liege : interest for oncological patients and their families]. / Centre de bien-être au CHU de Liège : intérêt pour les patients oncologiques et leurs proches.

Although conventional medicine has made considerable progress in the treatment of cancer, this disease remains a distressing experience for patients who may feel they are losing control of their live. In response to this need for autonomy over their therapeutic choices and their health, some patients turn to complementary and alternative medicine. Some oncology care centres therefore complete their offer of care by providing patients with a well-being centre where activities focusing on the well-being and comfort of the person are offered. In order to ensure that the needs of people are met, a survey was carried out among 82 patients attending the oncology day hospital and the radiotherapy department. The results enabled us to establish an action plan in line with the patients' wishes with a view to creating a well-being centre named OASIS, which will be located in the heart of the Arsène Burny Cancer Institute at the CHU of Liège. The different activities organised around psycho/corporal and bodily/psychological axes are presented in this article.

Bien que la médecine conventionnelle ait réalisé des progrès considérables dans la prise en charge du cancer, cette maladie reste une épreuve difficile pour les patients qui peuvent éprouver un sentiment de perte de contrôle sur leur vie. En réponse à ce besoin d'autonomie vis-à-vis de leurs choix thérapeutiques, certains patients se tournent vers les médecines complémentaires et alternatives . Certains centres de soins oncologiques mettent ainsi à disposition des patients un centre de bien-être où sont proposés différents types d'activités centrées sur le bien-être et le confort de la personne. Afin de rencontrer au mieux les besoins des utilisateurs, une enquête a été réalisée auprès de 82 patients fréquentant l'hôpital de jour oncologique ou le service de radiothérapie. Les résultats nous ont permis d'établir un plan d'action en phase avec les souhaits des patients, dans l'optique de créer un centre de bien-être situé au coeur de l'Institut de Cancérologie Arsène Burny au CHU de Liège et baptisé centre OASIS. Les différentes activités organisées autour d'axes psychocorporel et corporel/psychologique sont présentées dans cet article.

Randomized controlled trial of a group intervention combining self-hypnosis and self-care: secondary results on self-esteem, emotional distress and regulation, and mindfulness in post-treatment cancer patients.

PURPOSE: Cancer patients often report low self-esteem and high emotional distress. Two factors seem particularly linked to these symptoms: emotion regulation strategies and mindfulness. The interest of hypnosis and self-care to relieve these symptoms is not well documented. Our randomized controlled trial aimed at assessing the effect of a group intervention combining self-hypnosis and self-care on self-esteem, emotional distress, emotion regulation, and mindfulness abilities of post-treatment cancer patients, as well as investigating the links between these variables. METHODS: One hundred and four patients who had suffered from cancer were randomized into the intervention group (N = 52) and the wait-list control group (N = 52). They had to answer questionnaires before (T1) and after the intervention (T2). Nine men were excluded from the analyses, leading to a final sample of 95 women with cancer. Group-by-time changes were assessed with MANOVA, and associations with self-esteem and emotional distress were investigated with hierarchical linear regression models. RESULTS: Participants in the intervention group (mean age = 51.65; SD = 12.54) reported better self-esteem, lower emotional distress, a decreased use of maladaptive emotion regulation strategies, and more mindfulness abilities after the intervention, compared to the WLCG. This increase in mindfulness explained 33% of the improvement of self-esteem and 41.6% of the decrease of emotional distress in the intervention group. Self-esteem and emotional distress also predicted each other. CONCLUSION: Our study showed the efficacy of our hypnosis-based intervention to improve all the investigated variables. Mindfulness predicted the improvement of self-esteem and emotional distress. The primary impact of our intervention on mindfulness abilities seems to explain, at least in part, its efficacy. Registration: ClinicalTrials.gov (NCT03144154). Retrospectively registered on the 1st of May, 2017.

Hypnosis for cingulate-mediated analgesia and disease treatment.

Hypnosis is a technique that induces changes in perceptual experience through response to specific suggestions. By means of functional neuroimaging, a large body of clinical and experimental studies has shown that hypnotic processes modify internal (self-awareness) as well as external (environmental awareness) brain networks. Objective quantifications of this kind permit the characterization of cerebral changes after hypnotic induction and its uses in the clinical setting. Hypnosedation is one such application, as it combines hypnosis with local anesthesia in patients undergoing surgery. The power of this technique lies in the avoidance of general anesthesia and its potential complications that emerge during and after surgery. Hypnosedation is associated with improved intraoperative comfort and reduced perioperative anxiety and pain. It ensures a faster recovery of the patient and diminishes the intraoperative requirements for sedative or analgesic drugs. Mechanisms underlying the modulation of pain perception under hypnotic conditions involve cortical and subcortical areas, mainly the anterior cingulate and prefrontal cortices as well as the basal ganglia and thalami. In that respect, hypnosis-induced analgesia is an effective and highly cost-effective alternative to sedation during surgery and symptom management.

Efficacy of a hypnosis-based intervention to improve well-being during cancer: a comparison between prostate and breast cancer patients.

BACKGROUND: Prostate and breast cancer can have a lot of negative consequences such as fatigue, sleep difficulties and emotional distress, which decrease quality of life. Group interventions showed benefits to emotional distress and fatigue, but most of these studies focus on breast cancer patients. However, it is important to test if an effective intervention for breast cancer patients could also have benefits for prostate cancer patients. METHODS: Our controlled study aimed to compare the efficacy of a self-hypnosis/self-care group intervention to improve emotional distress, sleep difficulties, fatigue and quality of life of breast and prostate cancer patients. 25 men with prostate cancer and 68 women with breast cancer participated and were evaluated before (T0) and after (T1) the intervention. RESULTS: After the intervention, the breast cancer group showed positive effects for anxiety, depression, fatigue, sleep difficulties, and global health status, whereas there was no effect in the prostate cancer group. We showed that women suffered from higher difficulties prior to the intervention and that their oncological treatments were different in comparison to men. CONCLUSION: The differences in the efficacy of the intervention could be explained by the baseline differences. As men in our sample reported few distress, fatigue or sleep problems, it is likely that they did not improve on these dimensions. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02569294 and NCT03423927 ). Retrospectively registered in October 2015 and February 2018 respectively.

[How I treat? complex regional pain syndrome]. / Comment je traite ... le syndrome douloureux régional complexe (SDRC).

Complex regional pain syndrome (CRPS), formerly known as algoneurodystrophy, is a painful condition of a part of the body, associated with vasomotor, motor and trophic dysfunctions that can occur after trauma. The epidemiology, diagnostic criteria and advances in physiopathology of CRPS will be briefly described. Then the different therapeutic approaches available today will be clarified.

Le syndrome douloureux régional complexe (SDRC), anciennement connu sous le nom d'algoneurodystrophie, est un état douloureux d'une région du corps, souvent un membre, associé à des troubles vasomoteurs, moteurs et trophiques, qui peut survenir après un traumatisme. Nous décrivons brièvement l'épidémiologie, les critères diagnostiques et les avancées dans la physiopathologie. Nous explicitons ensuite les différents schémas thérapeutiques disponibles actuellement.

Efficacy and cost-effectiveness: A study of different treatment approaches in a tertiary pain centre.

BACKGROUND: Chronic pain is considered to be a complex phenomenon, involving an interrelation of biological, psychosocial and sociocultural factors. Currently, no single treatment or therapy can address all aspects of this pathology. In our expert tertiary pain centre, we decide to assess the effectiveness of four treatments for chronic pain classically proposed in our daily clinical work: physiotherapy; psycho-education; physiotherapy combined with psycho-education; and self-hypnosis/self-care learning. METHODS: This study included 527 chronic pain patients, with a mean duration of pain of 10 years. Patients were allocated either to one of the four pre-cited treatment groups or to the control group. Pain intensity, quality of life, pain interference, anxiety and depression were assessed before and after treatment. RESULTS: This study revealed a significant positive effect on pain interference and anxiety in patients included in the physiotherapy combined with psycho-education group, after 20 sessions spread over 9 months of treatment. The most prominent results were obtained for patients allocated to the self-hypnosis/self-care group, although they received only six sessions over a 9-month period. These patients showed significant benefits in the areas of pain intensity, pain interference, anxiety, depression and quality of life. CONCLUSIONS: This clinical report demonstrates the relevance of biopsychosocial approaches in the improvement of pain and psychological factors in chronic pain patients. The study further reveals the larger impact of self-hypnosis/self-care learning treatment, in addition to a cost-effectiveness benefit of this treatment comparative to other interventions.

Neurophysiology of hypnosis.

We here review behavioral, neuroimaging and electrophysiological studies of hypnosis as a state, as well as hypnosis as a tool to modulate brain responses to painful stimulations. Studies have shown that hypnotic processes modify internal (self awareness) as well as external (environmental awareness) brain networks. Brain mechanisms underlying the modulation of pain perception under hypnotic conditions involve cortical as well as subcortical areas including anterior cingulate and prefrontal cortices, basal ganglia and thalami. Combined with local anesthesia and conscious sedation in patients undergoing surgery, hypnosis is associated with improved peri- and postoperative comfort of patients and surgeons. Finally, hypnosis can be considered as a useful analogue for simulating conversion and dissociation symptoms in healthy subjects, permitting better characterization of these challenging disorders by producing clinically similar experiences.

[Swallowing in disorders of consciousness]. / Déglutition et états de conscience altérée.

INTRODUCTION: Interest in studying swallowing disorders in patients with altered consciousness has increased over the past decade. Swallowing deficit is frequently encountered in severe brain-injured patients. STATE OF ART: Results of studies have highlighted different factors such as the delay between the injury and the treatment and the level of consciousness of these patients, as well as the presence or not of tracheotomy, which will determine the feasibility of resuming oral feeding. Nowadays, very few valid and sensitive scales can be used to assess swallowing deficit in patients with disorders of consciousness. The Facial Oral Tract Therapy (FOTT) scale is an inter-professional multidisciplinary approach offering a structured way to evaluate and treat patients with swallowing disorders. In contrast with other scales, patients do not have to follow verbal instructions for the FOTT. PERSPECTIVES: This paper presents a review of existing literature on the assessment and management of swallowing disorders in patients with altered state of consciousness, and a description of the FOTT method. CONCLUSION: The FOTT seems to be an interesting assessment and rehabilitation tool for patients with disorders of consciousness. However, clinical studies are needed to confirm the validity and sensitivity of this technique.

Hypnotic modulation of resting state fMRI default mode and extrinsic network connectivity.

Resting state fMRI (functional magnetic resonance imaging) acquisitions are characterized by low-frequency spontaneous activity in a default mode network (encompassing medial brain areas and linked to self-related processes) and an anticorrelated "extrinsic" system (encompassing lateral frontoparietal areas and modulated via external sensory stimulation). In order to better determine the functional contribution of these networks to conscious awareness, we here sought to transiently modulate their relationship by means of hypnosis. We used independent component analysis (ICA) on resting state fMRI acquisitions during normal wakefulness, under hypnotic state, and during a control condition of autobiographical mental imagery. As compared to mental imagery, hypnosis-induced modulation of resting state fMRI networks resulted in a reduced "extrinsic" lateral frontoparietal cortical connectivity, possibly reflecting a decreased sensory awareness. The default mode network showed an increased connectivity in bilateral angular and middle frontal gyri, whereas its posterior midline and parahippocampal structures decreased their connectivity during hypnosis, supposedly related to an altered "self" awareness and posthypnotic amnesia. In our view, fMRI resting state studies of physiological (e.g., sleep or hypnosis), pharmacological (e.g., sedation or anesthesia), and pathological modulation (e.g., coma or related states) of "intrinsic" default mode and anticorrelated "extrinsic" sensory networks, and their interaction with other cerebral networks, will further improve our understanding of the neural correlates of subjective awareness.

Pain and non-pain processing during hypnosis: a thulium-YAG event-related fMRI study.

The neural mechanisms underlying the antinociceptive effects of hypnosis still remain unclear. Using a parametric single-trial thulium-YAG laser fMRI paradigm, we assessed changes in brain activation and connectivity related to the hypnotic state as compared to normal wakefulness in 13 healthy volunteers. Behaviorally, a difference in subjective ratings was found between normal wakefulness and hypnotic state for both non-painful and painful intensity-matched stimuli applied to the left hand. In normal wakefulness, non-painful range stimuli activated brainstem, contralateral primary somatosensory (S1) and bilateral insular cortices. Painful stimuli activated additional areas encompassing thalamus, bilateral striatum, anterior cingulate (ACC), premotor and dorsolateral prefrontal cortices. In hypnosis, intensity-matched stimuli in both the non-painful and painful range failed to elicit any cerebral activation. The interaction analysis identified that contralateral thalamus, bilateral striatum and ACC activated more in normal wakefulness compared to hypnosis during painful versus non-painful stimulation. Finally, we demonstrated hypnosis-related increases in functional connectivity between S1 and distant anterior insular and prefrontal cortices, possibly reflecting top-down modulation.

Organ procurement after euthanasia: Belgian experience.

Euthanasia was legalized in Belgium in 2002 for adults under strict conditions. The patient must be in a medically futile condition and of constant and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident. Between 2005 and 2007, 4 patients (3 in Antwerp and 1 in Liège) expressed their will for organ donation after their request for euthanasia was granted. Patients were aged 43 to 50 years and had a debilitating neurologic disease, either after severe cerebrovascular accident or primary progressive multiple sclerosis. Ethical boards requested complete written scenario with informed consent of donor and relatives, clear separation between euthanasia and organ procurement procedure, and all procedures to be performed by senior staff members and nursing staff on a voluntary basis. The euthanasia procedure was performed by three independent physicians in the operating room. After clinical diagnosis of cardiac death, organ procurement was performed by femoral vessel cannulation or quick laparotomy. In 2 patients, the liver, both kidneys, and pancreatic islets (one case) were procured and transplanted; in the other 2 patients, there was additional lung procurement and transplantation. Transplant centers were informed of the nature of the case and the elements of organ procurement. There was primary function of all organs. The involved physicians and transplant teams had the well-discussed opinion that this strong request for organ donation after euthanasia could not be waived. A clear separation between the euthanasia request, the euthanasia procedure, and the organ procurement procedure is necessary.

[Transdermal buprenorphine: a current overview of pharmacological and clinical data]. / La buprénorphine transdermique. L'état actuel dans les domaines clinique et pharmacologique.

Our understanding of the pathophysiologic mechanisms of chronic pain progresses; the complexity of the problem justifies our need for new molecules and new ways of administration that will help to further optimise and better individualize our pharmacologic therapies. Whereas acute pain can be considered an alarm signal, chronic pain constitutes, per se, a syndrome that requires a meticulous selection of the analgesic drug(s). Since pain is permanent, the continuous administration of the analgesic is recommended rather than an on demand administration. Transdermic modes of administration are of value for the treatment of chronic pain because they allow a progressive delivery of the active compound together with the maintenance of stable plasma levels of the drug. Buprenorphine is a semi-synthetic opioid that is available in the sublingual, injectable, or transdermic forms. The matrix patch of buprenorphine represents a major asset for the treatment of chronic pain, whether it be cancerous in origin, or not. Its efficacy and safety have been clearly demonstrated in randomised double blind trials as well as in post-marketing surveillance observations. Buprenorphine, administered as a transdermal therapeutic system, induces a dose-related pain relief, whatever the nature of the pain and the age of the patient. Buprenorphine also exerts an analgesic action on neuropathic pain. It differs from other opioids by its affinity as a partial agonist on mu and kappa receptors, and as a complete agonist of ORL-1 receptors. Therefore, transdermal buprenorphine will be useful to all physicians having to control severe pain by powerful opioids.

[Hypnosis and pain perception]. / Hypnose et perception de la douleur.

Improvement in functional neuroimaging allows researchers to disentangle the brain mechanisms involved in the pain modulation encountered during hypnosis. It has been shown that the anterior cingulate and prefrontal cortices are important in the modulation of incoming sensory and noxious input. Moreover, clinical studies in certain types of surgery (eg thyroidectomy, mastectomy and plastic surgery) have demonstrated that hypnosis may avoid general anesthesia.

[Pain assessment in non-communicative patients]. / Mesurer la douleur chez le patient non communicant.

Pain is a subjective experience. Its assessment is based on the subject's direct verbal report. This method of assessment is, however, impossible in patients who cannot communicate their feelings. In this context, indirect measurements such as behavioral observations or physiological measurements are needed. To facilitate the assessment of pain in non-communicative patients, numerous standardized behavioral scales have been developed. The aim of this review is to discuss the main validated pain scales employed in end-stage dementia, newborn and preverbal children, and severely brain damaged patients with a disorder of consciousness such as coma, the vegetative state or the minimally conscious state.

[Blink and you live: the locked-in syndrome]. / Le Locked-In Syndrome: la conscience emmurée.

INTRODUCTION: The Locked-In syndrome (LIS) is defined by: (i) the presence of sustained eye opening (bilateral ptosis should be ruled out as a complicating factor); (ii) preserved awareness; (iii) aphonia or hypophonia; (iv) quadriplegia or quadriparesis; and (v) a primary mode of communication that uses vertical or lateral eye movement or blinking. Acute ventral pontine lesions are its most common cause. Following such brainstem lesions patients may remain comatose for some time and then gradually awaken, remaining paralyzed and voiceless, superficially resembling the vegetative state. BACKGROUND: It has been shown that more than half of the time physicians fail to recognize early signs of awareness in LIS. Given appropriate medical care, life expectancy may be several decades but the chances of good motor recovery remain small. Eye-controlled computer technology now allows LIS patients to communicate and control their environment. Recent studies show that most LIS patients self-report meaningful quality of life and the demand for euthanasia is infrequent. CONCLUSION: Patients suffering from LIS should not be denied the right to die--and to die with dignity--but also they should not be denied the right to live--and to live with dignity and the best possible pain and symptom management and revalidation.

Revelations from the unconscious: studying residual brain function in coma and related states.

The purpose of our research is to contribute to a better understanding of the residual brain function of patients who survive an acute brain damage but remain in a coma, vegetative state, minimally conscious state or locked-in syndrome. The diagnosis, prognosis, therapy and medical management of these patients remain difficult. These studies are also of interest scientifically, as they help to elucidate the neural correlates of human consciousness. We here review our studies on bedside behavioral evaluation scales, electrophysiology and functional neuroimaging in these disorders of consciousness and conclude by discussing methodological and ethical issues and current concepts of the standards for care and quality of life in these challenging conditions.

[Indications for epidural steroids in back pain and in radiculopathy]. / Indications des corticoïdes par voie péridurale dans les douleurs rachidiennes et radiculaires.

Back pain is very frequent in western countries and it represents a very high social cost. The treatment is based on five modalities: medication, physiotherapy, invasive technics, rehabilitation programs and psycho-social approaches. Several treatments may be proposed simultaneously and introduced gradually. Steroid administration by epidural injection is frequently used in Belgium, even though no prospective randomised studies have shown a real benefit over the long term. The indications for epidural injection must be carefully chosen. These include subacute pain (less than six months) in the lower limbs despite a well observed medical treatment. Patients are invited to give informed consent; the technic must be performed in an appropriate environment by an experienced physician. The initial treatment of back pain is medical. This pathology is multifactorial and the relief of symptoms is often incomplete. The patient should be urged to feel responsible for and involved in his treatment.

[Cerebral functions in brain-damaged patients. What is meant by coma, vegetative state, minimally conscious state, locked-in syndrome and brain death?]. / Zerebrale Funktionen bei hirngeschädigten Patienten. Was bedeuten Koma, "vegetative state", "minimally conscious state", "Locked-in-Syndrom" und Hirntod?

Comatose, vegetative, minimally conscious or locked-in patients represent a problem in terms of diagnosis, prognosis, treatment and everyday management at the intensive care unit. The evaluation of possible cognitive functions in these patients is difficult because voluntary movements may be very small, inconsistent and easily exhausted. Functional neuroimaging cannot replace the clinical assessment of patients with altered states of consciousness. Nevertheless, it can describe objectively how deviant from normal the cerebral activity is and its regional distribution at rest and under various conditions of stimulation. The quantification of brain activity differentiates patients who sometimes only differ by a brief and incomplete blink of an eye. In the present paper, we will first try to define consciousness as it can be assessed at the patient's bedside. We then review the major clinical entities of altered states of consciousness encountered in the intensive care unit. Finally, we discuss the functional neuroanatomy of these conditions as assessed by positron emission tomography (PET) scanning.

Cerebral processing in the minimally conscious state.

We studied a patient in a minimally conscious state using PET and cognitive evoked potentials. Cerebral metabolism was below half of normal values. Auditory stimuli with emotional valence (infant cries and the patient's own name) induced a much more widespread activation than did meaningless noise; the activation pattern was comparable with that previously obtained in controls. Cognitive potentials showed preserved P300 responses to the patient's own name.