[Chronic pain and the social context]. / Douleurs chroniques en contexte : du côté du social.

The chronic pain complaint is still poorly accepted in the community and even sometimes in the health care system. It may trigger reactions of disbelief, suspicion or rejection. The legitimization and validation of the patient's suffering is a priority in order for him/her to feel believed and understood and improve his/her commitment to the treatment proposal. The social consequences of chronic pain include various limitations, a reduction of activities, of personal and professional ties leading to social exclusion amplifying the painful experience. Exploring his/her social context during the consultation often helps the patient to re-establish significant links. It leads to wider therapeutic approaches focusing on the strengthening of social support, with documented benefits on pain experience, mood and quality of life.

La plainte douloureuse chronique reste souvent mal acceptée dans le champ social et parfois même dans le système de soins. Elle peut rencontrer de l'incrédulité, de la suspicion et du rejet. Sa légitimation est prioritaire afin de donner au patient le sentiment d'être cru et entendu et d'améliorer son engagement dans un projet thérapeutique partagé. Les conséquences sociales de la douleur chronique comprennent des limitations diverses et une modification des activités et des liens personnels et professionnels qui peuvent mener à des situations d'exclusion sociale amplifiant l'expérience douloureuse. L'exploration du contexte permet d'aider le patient à renouer des liens et d'orienter les approches thérapeutiques vers un renforcement du soutien social dont les bénéfices sur le vécu douloureux, l'humeur et la qualité de vie sont documentés.

[On some links between pain and emotions]. / De quelques liens entre douleurs et emotions.

The entanglement between pain and emotions is increasingly recognized. Emotions can predispose to pain and contribute to its chronicisation but also to its relief. The placebo effect is a witness to the moderating influences of cognitions and emotions on pain. An awareness of these influences is of interest to patients as it can widen their therapeutic perspectives. Chronic refractory pain has often been linked to a history of abuse, neglect and psychological trauma whose neuropsychological and affective traces can predispose to painful complaints. The treatment approach requires strong commitment and empathy on the part of the therapist in order to help patients reconnect with their own history and their emotions.

L'intrication entre douleurs et émotions est de mieux en mieux reconnue. Les émotions représentent des facteurs de vulnérabilité et de persistance de la douleur autant que des alliées de son soulagement. L'effet placebo est un témoin des influences modératrices des cognitions et émotions sur la douleur. L'utilisation de ces influences peut être présentée aux patients comme un élargissement des possibilités thérapeutiques. Il arrive que les douleurs chroniques rebelles soient les indices de la persistance d'une souffrance liée à des expériences traumatiques, de maltraitance ou d'abandon infantile, dont les traces neuropsychologiques et affectives prédisposent aux plaintes douloureuses. La prise en charge nécessite un engagement empathique et attentif du thérapeute pour permettre aux patients de renouer avec leur histoire et leurs émotions.

Bedside or not bedside: Evaluation of patient satisfaction in intensive medical rehabilitation wards.

BACKGROUND: Concerns that bedside presentation (BsP) rounds could make patients uncomfortable led many residency programs to move daily rounds outside the patients' room (OsPR). We performed a prospective quasi-experimental controlled study measuring the effect of these two approaches on patient satisfaction. METHODS: Patient satisfaction was measured using the Picker questionnaire (PiQ). Results are expressed in problematic percentage scores scaled from 0 = best-100 = worst. During three months, 3 wards of a 6 ward medical rehabilitation division implemented BsP and 3 control wards kept their usual organization of rounds. In total, 90 patients of each group were included in the study and completed the PiQ. RESULTS: Socio-clinical characteristics were similar in both groups: mean age = 67 years (SD = 13), mean Charlson comorbidity index = 8.6 (2.4); mean length of stay = 22 days (12). During their stay, patients in the BsP units had a mean of 14.3 (8) BsP rounds and 0.5 (0.8) OsPR; control patients had a mean of 0.9 (0.7) BsP and 14.8 (7.3) OsPR (p<0.0001). Patients in BsP units reported lower problematic scores regarding coordination of care (39% vs 45%, p = 0.029), involvement of family/friends (29 vs 41%, p = 0.006) and continuity/transition (44% vs 54%, p = 0.020); two questions of the PiQ had worse scores in the BsP: trust in nurses (46.7% vs 30 %, p = 0.021) and recommendation of the institution (61.1% vs 44.4%. p = 0.025). No worsening in dimensions such as respect for patient preferences was seen. CONCLUSIONS: BsP rounds influenced the patient-healthcare professionals' encounter. These rounds were associated with improved patient satisfaction with care, particularly regarding interprofessional collaboration and discharge planning.

Health status and quality of life: results from a national survey in a community-dwelling sample of elderly people.

PURPOSE: To investigate the relation between age and HRQoL indicators in a community-dwelling population aged 65 years and older. METHODS: Data were collected within a sample stratified by age (65-69; 70-74; 75-79; 80-84; 85-89; 90 years and above) and sex and randomly selected in the population records in Switzerland. The EQ-5D was used to assess HRQoL. Analyses were conducted on the entire available sample (N = 3,073) and on the subsample with no missing data in the EQ-5D (N = 2,888), considering age, gender, education and region. RESULTS: Results of multiple regression analyses showed different age-related patterns across the EQ-5D. The proportion of respondents reporting no problems ranged from 51 % in the 65- to 69-year age group to 20 % in the 90 years and above age group. Odds ratio (OR) for Mobility problems increased from 2.04 in the 75- to 79-year age group to 13.34 in the 90 years and above age group; OR for Usual Activities increased from 1.76 to 11.68 and from 1.55 to 2.32 for Pain/Discomfort; OR for Self-Care increased from 5.26 in the 80- to 84-year age group to 30.36 in the 90 years and above age group. Problems with Self-Care remained low, increasing from 6.22 % in the 80- to 84-year age group to 26.21 % in the oldest age group. The magnitude of the gender, region and education effects was much lower than that of age. CONCLUSION: HRQoL is globally preserved in older adults in Switzerland, even if substantial impairment is reported in very old age affecting mainly functional health dimensions. Anxiety/Depression and Pain/Discomfort did not appear to be affected by age; high rates of difficulties were reported for Pain/Discomfort but not for Anxiety/Depression.

Assessing the affective load in the narratives of women suffering from fibromyalgia: the clinicians' appraisal.

OBJECTIVE: Fibromyalgia is characterized by chronic widespread pain and various associated symptoms, including psychological distress. This study presents a secondary analysis of the interviews of patients with fibromyalgia to appraise the affective load of the patient narratives as assessed by independent clinicians. SETTING AND PARTICIPANTS: Three clinicians, an internist, a psychiatrist and a psychologist, who were experienced in chronic pain reviewed the interview transcripts of 56 women eliciting their views regarding fibromyalgia onset. A Clinical Global Impression (CGI) scale was used (0 = no affective load to 5 = maximum affective load) to provide a subjective appraisal of the intensity of the affective impact, as suggested in the transcripts and from the clinician perspectives. RESULTS: The mean affective load was 3.6 (SD = ±1), indicating the perception of a high affective load in the clinicians. Values indicating a high or very high affective load (≥4 points on the CGI scale) were more frequent than those in the lower range [23 narratives (41%) vs. 3 (5%)]. The inter-rater agreement of the affective load of the narratives was high (K > 0.85). These results of the clinician perspectives parallel those of the patient narratives, emphasizing disruptive circumstances, psychological distress and hopelessness surrounding symptom onset. CONCLUSION: The affective load in the narratives of these patients with fibromyalgia was high and had a negative undertone when considered from the clinicians' perspective. This study highlights the importance of considering the affective resonance in the context of therapeutic relationships that are often emotionally laden and highly challenging for the clinician.

Primary attributions in women suffering fibromyalgia emphasize the perception of a disruptive onset for a long-lasting pain problem.

OBJECTIVE: Fibromyalgia (FM) is a chronic musculoskeletal pain disorder characterized by widespread pain. This study focuses on patients' attributions of illness and of symptom onset. METHODS: Semi-structured interviews were conducted with 56 women to elicit patients' views on what triggered their FM. The transcripts of the interviews were analyzed using a classical indexing technique to identify key themes. Content analysis was performed by two independent coders. RESULTS: Primary causal attributions fell into five categories: psychological problems (28 respondents); somatic concerns (N=12); violence/abuse during childhood (N=7), gynaecological/obstetrical problems (N=6), and fatigue (N=3). Patients' attributions were internal and external in the same proportions, more frequently unstable than stable, and more often described uncontrollable than controllable. Participants expressed decrements in self-esteem and feelings such as self-blame or despair; global perceptions of persistent pain and long-lasting problems, evoking chronicity and hopelessness; and low perceived control over their lives as well as beliefs that nothing can be done, thus increasing a feeling of guilt and vulnerability. Patients' narratives emphasized disruptive circumstances surrounding symptom onset. CONCLUSION: Attributions often referred to the psychological dimension of the events surrounding FM onset, even though some of them also had a clear somatic dimension. Many narratives mentioned successive disruptive events and suggested an increasing loss of control. Addressing these illness representations may contribute to tailor the treatment and to help patients gain self-coherency by providing means to understand pain onset but also to guide future behaviours, particularly in terms of adjustment and help-seeking.