[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.

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.

Representations of symptom history in women with fibromyalgia vs chronic low back pain: a qualitative study.

OBJECTIVE: To compare fibromyalgia (FM) and chronic non-specific low back pain (LBP) patients' narratives about symptom onset. This investigation aimed to better understand how patients with FM relate to their pain problem and the physicians in charge of making the diagnosis. DESIGN: Qualitative study. SUBJECTS AND METHODS: We included 56 female patients with FM and 29 with LBP. Semi-structured interviews were conducted, eliciting patients' representations of symptom onset. Interviews were tape-recorded and transcribed, and content analysis was performed. RESULTS: Patients with FM and LBP were comparable for socio-demographic characteristics and pain duration. Content analysis identified five dimensions: psychological issues, somatic concerns, occupational problems, diagnostic issues, and issues related to chronicity. FM patients emphasized psychological issues, as single events and long-lasting distress. Regarding somatic concerns, gynecological events were prominent in FM while LBP patients emphasized accidents, awkward movements, and physical work conditions. Both groups expressed pessimistic views about pain evolution. FM patients reported diagnosis as an area of major uncertainty in an illness perceived as spreading all over the body. CONCLUSIONS: The narratives of patients with FM expressed high psychological loads and dramatic connotations and emphasized legitimacy issues. In contrast, patients with LBP stressed overload, wear and tear, and treatment inefficacy. The combination of chronicity and lack of specificity may render FM and LBP prone to raise skepticism in the therapists. Investigating and discussing patients' perceptions allows overcoming the apparent uniformity of patients' complaints. It contributes defining realistic and shared treatment goals and help therapists cope with pain chronicity.

Characteristics of elderly patients with fibromyalgia: a pilot retrospective study.

BACKGROUND AND AIMS: Very little informations are available about the characteristics of fibromyalgia (FM) in older patients. The objective of the study was to know better what are some of their specificities in order to tailor the management of elderly patients with FM. METHODS: Retrospective chart review of all patients with a diagnosis of FM addressed to the pain consultation of a geriatric hospital, have been analysed. RESULTS: Forty patients (38 women and 2 men) were included. Mean age at the moment of diagnosis of FM was 75±9.1 years. Patients were hospitalized with a mean of 6±5.2 years after onset of FM. Median pain intensity measured by a visual or numerical pain scale was 6 at rest and 9 during mobilisation. Seventeen patients were isolated at home because of pain. Symptoms associated with FM were depression (n=25), fatigue and poor sleep quality (n=24), anxiety (n=15), irritable bowel syndrome (n=10), restless leg syndrome (n=3) and tension-type headache (n=2). Traumatic events, such as the death of a relative or nursing home admission were frequent. Twenty-four patients were discharged home, 13 patients in a nursing home and 3 patients died during the hospitalisation. DISCUSSION: Although elderly patients with FM constituted a small proportion of elderly patient's addressed to a pain consultation, these patients have some particular features that must be taken into account. Further prospective studies should be conducted in this population.

Patients' views about causes and preferences for the management of cancer-related fatigue-a case for non-congruence with the physicians?

PURPOSE: Cancer-related fatigue (CRF) is frequently overlooked. Adherence to treatment guidelines may be related to the patient's views about illness. This study aimed at exploring patients' views about CRF and determining whether they are congruent with best practice treatments. METHODS: Data were collected in 160 consecutive patients hospitalized in a supportive care setting. Biological, clinical, and psychological variables were assessed using validated questionnaires. Patients were also asked to complete the Brief Fatigue Inventory (BFI) and a questionnaire investigating their main symptoms and views about CRF and its management. RESULTS: Patients were mainly men (60%); median age was 66 years. Various cancer diagnoses were represented; 17.5% had primary local diseases, 40% local recurrences, and 42.5% metastatic diseases. The majority of the patients experienced moderate or severe CRF (76.3%) on the BFI. Fatigue was the most frequently reported symptom (87.5%). Only anxiety, depression, and dimensions of quality of life were significantly related with CRF. Two thirds of the patients associated CRF with cancer-related morbidities. As for the best treatments, patients first stressed control of adverse effects. Over half of the patients were reluctant to report fatigue, mainly because they considered fatigue as an unavoidable side effect, but also because they feared a change towards less active/aggressive treatments. CONCLUSION: Patients mostly consider that CRF must be tolerated. Guidelines emphasize activity enhancement strategies as beneficial. The patients' preferences for rest rather than activity may be related to their high level of fatigue, which leads them to disregard activity as a possible treatment.