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Desciption d’un programme comportemental. Un centre de traitement de la douleur

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Douleur et Analgésie

Résumé

Les patients pris en charge par le INPUT, Pain Management Unit (Centre de gestion de la douleur) de l’hôpital St Thomas à Londres souffrent tous de douleur chronique, le plus souvent définie comme une douleur ayant duré six mois ou plus, bénigne, en majorité lombaire.

Les patients sont envoyés par leurs médecins traitants ou par divers spécialistes. Un médecin spécialiste de la douleur et un psychologue les interviewent alors afin de déterminer si le traitement leur est adapté selon un certain nombre de critères d’inclusion et d’exclusion basés sur le travail de Fordyce.

La douleur chronique a de larges répercussions dans de nombroux domaines comme la consommation de soins, la vie professionnelle, familiale et sociale ainsi que les niveaux de forme physique et émotionnelle. Toutes ces conséquences deviennent les cibles des différents aspects du programme.

En accordance avec les principes cognitivo-comportementaux du traitement de la douleur, tous les patients suivent le même programme, que l’étiologie de leur douleur soit connue ou pas. INPUT accueille environ 300 patients par an. Ceux-ci suivent l’un des trois programmes proposés: un programme en internat de quatre semaines, un programme en internat intensif de deux semaines ou un programme combiné alliant une semaine en internat et cinq sessions en externat étalées sur sept semaines. Tous les programmes sont organisés selon les principes cognitivo-comportementaux, tels que les renforcements des comportements d’adaptation à la douleur et l’extinction des comportements de douleur (pain behaviours), ou la remise en question des croyances par rapport à la douleur.

Les programmes consistent en un certain nombre de sessions de thérapie cognitive (animées par un(e) psychologue clinicien(ne)), d’exercises physiques (animées par un(e) kinésothérapeute), de relaxation (animées soit par un(e) psychologue soit par un(e) infirmier(ère) spécialisé(e)), d’éducation sur la douleur, ses mécanismes, ses traitements (animées par un médecin spécialiste de la douleur), de réduction de prise de médication (animées par un(e) infirmier(ère) spécialisé(e) et enfin des sessions de «pacing», de progrommation d’activités, d’organisation d’emploi du temps etc. (animées par un(e) ergothérapeute ou un(e) psychologue).

Ce type de programme s’est révélé très efficace pour la grande majorité des patients qui le suivent. Les travaux publiés dans ce domaine seront passés en revue brièvement. Quelques mots seront ajoutés concernant le problèmes du maintien à long terme des progrès effectués pendant le programme par les patients.

Summary

Patients treated at INPUT, a Pain Management Unit at St Thomas’ Hospital in London, are all suffering from chronic benign pain, which is commonly defined as pain lasting six months or more, mainly located in the lumbar region.

Patients are referred by their GP or by a specialist. A medical pain specialist and a psychologist interview all referred patients in order to ascertain whether the treatment is adapted to their complaints, following a number of inclusion and exclusion criteria based on Fordyce’s work.

Chronic pain has a wide-range of consequences in numerous areas, such as health care utilisation, professional, family and social life, as well as levels of physical and emotional health. The treatment aims at addressing each of these consequences. In accordance with cognitive and behavioural principles of treatment, all patients follow the same programme, whether or not the aetiology of their pain is known.

INPUT treats about 300 patients per years who follow one of the three available programmes: a four-week inpatients programme, a two-week intensive inpatient programme or a combined programme which includes one week as an inpatient followed by five sessions as an outpatient spread over a period of seven weeks.

Each programme follows cognitive-behavioural principles, such as reinforcement of adaptative behaviours, extinction of pain behaviours or challenging of pain-related thoughts. They consist of a number of cognitive therapy sessions (run by a clinical psychologist), exercise sessions (run by a physiotherapist), relaxation sessions (run either by a nurse specialist or a psychologist), educational sessions on pain, its mechanisms and treatments (run by a medical specialist), on reduction of medication intake (run by a nurse specialist) and lastly sessions on «pacing», activity planning etc. (run either by an occupational therapist or a psychologist).

This type of programme has proven very effective for the vast majority of patients. A brief review of the published studies is included. Lastly the issue of long term maintenance of treatment gains is evoked.

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    I. H. Richardson

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Richardson, I.H. Desciption d’un programme comportemental. Un centre de traitement de la douleur. Doul. et Analg. 12, 289–297 (1999). https://doi.org/10.1007/BF03008496

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