La communication de

la douleur sans mots

Prof. Anne-Sylvie Ramelet

Journée Recherche du Domaine

Santé HES-SO

25 Novembre 2015

Institut universitaire de formation et de

recherche en soins – IUFRS

Le phénomène de la douleur

« L’homme » de René Descartes (1644)

l'introduction de l'anesthésie à l'éther

(1798-1848)

Gate Theory (1965)

Neuromatrice (Melzack, 2001)

Définition de la douleur An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment.

Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life.

Nociception

“an actually or potentially tissue

damaging event transduced and

encoded by nociceptors” and

may lead to “nociceptive pain”

Nociception is necessary to pain

perception, but it will not always

lead to a conscious experience

Personnes non-communicantes

= personnes vulnérables

cause d

e do

uleu

r Expérience Expression

Evaluation

Jugement Action

Personne Professionnels de la santé

Biologique Socioculturel

Développement Expérience Contexte

Adapté de : Pain Assessment as a Social Transaction: Beyond the "Gold Standard". Schiavenato, Martin; PhD, RN; Craig, Kenneth Clinical Journal of Pain. 26(8):667-676, October 2010. DOI : 10.1097/AJP.0b013e3181e72507

Consensus Outcome Observable Facteurs Cliniques

Copyright © 2015 PAIN. Published by Lippincott Williams & Wilkins. 8

Social communication model of pain Craig, Kenneth D. PAIN. 156(7):1198-1199, July 2015.

•Distinction between historical and current biological and social determinants: (a) Intrapersonal: people bring dispositions to react based on their biological, psychological, and social histories. (b) Current setting: the immediate social and physical environment within which pain is suffered has a powerful impact on both the person in pain and potential caregivers. •Social determinants of pain are explicitly acknowledged in human and animals

Darwin believed it…

“that the chief expressive actions, exhibited by man and by the lower animals, are now innate or inherited,--that is, have not been learnt by the individual,--is admitted by every one... infants scream from pain directly after birth, and all their features then assume the same form as during subsequent years. the inheritance of most of our expressive actions explains the fact that those born blind display them… we can thus also understand the fact that the young and the old of widely different races, both with man and animals, express the same state of mind by the same movements.”

The Expression of Emotion in Man and Animals, 1872

Kenneth Craig© Putting the Social in the Biopsychosocial Model of Pain Nov 2009

Principes d’évaluation de la douleur

1. Solliciter une auto-évaluation si possible

2. Identifier les causes de douleurs possibles

3. Observer le comportement

4. Hetéro-évaluation (proxy reporting): Utiliser des

instruments validés pour la population considérée

5. Test à l’analgésie

Herr K et al. Pain management nursing : 2011;12(4):230-50.

La douleur chez l’enfant

Précis clinique et opératoire de CHIRURGIE INFANTILE, Masson, 1925, pages 1-4

« En règle générale, il ne faut point opérer un enfant sans l’avoir anesthésié. Nous devons en effet d’abord éviter à l’enfant la douleur ; mais il nous faut aussi abolir ses réflexes de défense s’il s’agit d’un nourrisson. Bien plus, si chez un très jeune enfant, non encore conscient, la douleur n’est pas perçue comme telle, il n’est point prouvé néanmoins qu’elle ne puisse déterminer des réflexes généraux redoutables. Cette règle d’ailleurs souffrira des exceptions en particulier, il est inutile et probablement désavantageux de recourir à l’anesthésie pour opérer les nouveau-nés dans les deux ou trois premiers jours de leur vie, surtout s’il s’agit d’intervention rapides. »

Fitzgerald M and Walker SM (2008) Infant pain management: a developmental neurobiological approach Nat Clin Pract Neurol doi:10.1038/ncpneuro0984

Figure 1 Key sites of developmental transition in infant pain pathways

(1) innervation périphérique: sensitivité élevée

(2) Corne dorsale: réorganisation des voies sensorielles

(3) Réflexe nociceptif: diffus et peu fiable

(4) Hyperalgie primaire (5) Contrôle peu fiable des voies

descendantes via le tronc cérébral

(6) ? développement du réseau intra cortex

(7) ? Activation du cortex somatosensoriel.

ESPNIC consensus statement on pain, sedation,

withdrawal and delirium assessment in critically ill infants

and children

Recommendations for pain assessment in

critically ill infants and children *:

Critères de Herr et al.

Instruments validés: COMFORT, PICU-

MAPS, FLACC

La douleur chez les personnes

intubées, sédatées

Chanques, G et al.(2009).. Intensive

Care Medicine.

Gelinas et al. (2006). American

Journal of Critical Care

La douleur chez les personnes

cérébro-lésées

Figure 1. Cerebral activation in patients in a vegetative state/unresponsive wakefulness syndrome (VS/UWS) and in a minimally

conscious state (MCS) compared with healthy control subjects. (A) Yellow/red areas illustrate brain regions that are activated during

...

Caroline Schnakers, Nathan Zasler

Assessment and Management of Pain in Patients With Disorders of Consciousness

PM&R, Volume 7, Issue 11, Supplement, 2015, S270–S277

http://dx.doi.org/10.1016/j.pmrj.2015.09.016

Decoding executive function in one behaviorally nonresponsive patient.

Lorina Naci et al. PNAS 2014;111:14277-14282

©2014 by National Academy of Sciences

1. Revue de la litérature

2. Résultats étude pilote

3. Interviews 18 cliniciens

4. Validité de contenu 10 cliniciens and 4

scientifiques

5. observations de 116 patients cérébrolésés

6. 2 ICUs 2 hôpitaux universitaires CH romande

Figure 1. Behavioral and physiological items observation tool.

Marie-José Roulin, Anne-Sylvie Ramelet

Generating and Selecting Pain Indicators for

Brain-Injured Critical Care Patients

Pain Management Nursing, Volume 16, Issue 3, 2015, 221–232

http://dx.doi.org/10.1016/j.pmn.2014.06.003

47 items générés Réduits à 33 items Fermeture des yeux(58.6%), movements des yeux (57.8%), asynchonie ventilatoire(55.2%), froncements (50%).

© 2014 by Lippincott Williams & Wilkins. ??diteur Lippincott Williams & Wilkins, Inc. 2

TABLE 6 Detecting Pain in Traumatic Brain-injured Patients With Different Levels of Consciousness During Common Procedures in the ICU: Typical or Atypical Behaviors?. Arbour, Caroline; RN, PhD; Choiniere, Manon; Topolovec-Vranic, Jane; Loiselle, Carmen; RN, PhD; Puntillo, Kathleen; RN, PhD; FAAN, FCCM; Gelinas, Celine; RN, PhD Clinical Journal of Pain. 30(11):960-969, November 2014. DOI : 10.1097/AJP.0000000000000061

TABLE 6 Most Common Neutral Behaviors and Pain Behaviors Exhibited During Turning by Participants With Different LOC at Initial and Second Data Collections

La douleur chez les personnes avec

démence

Figure 1. Functional MRI of pain-related activity in Alzheimer's diseaseRegions showing substantially greater pain-related activity in

the Alzheimer's disease patient group compared with healthy controls for the contrast between moderate pain and innocuous pre...

Thomas Hadjistavropoulos, Keela Herr, Kenneth M Prkachin, Kenneth D Craig, Stephen J Gibson, Albert Lukas, Jonathan H

Smith Pain assessment in elderly adults with dementia

null, Volume 13, Issue 12, 2014, 1216–1227

http://dx.doi.org/10.1016/S1474-4422(14)70103-6

Figure 2. Components of pain assessment in non-verbal adultsPain assessment in non-verbal adults necessitates the use of

behavioural recordings, which should be interpreted with regard to contextual variables and in light of the individual's general state of

h...

Thomas Hadjistavropoulos, Keela Herr, Kenneth M Prkachin, Kenneth D Craig, Stephen J Gibson, Albert Lukas, Jonathan H

Smith Pain assessment in elderly adults with dementia

null, Volume 13, Issue 12, 2014, 1216–1227

http://dx.doi.org/10.1016/S1474-4422(14)70103-6

Conclusion

• Vulnérabilité des personnes non-

communicantes

• En pratique, observations de

comportements prévalent

• Instruments disponibles et validés

MERCI

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