Dinu C.eficacitatea Diferentiala

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Revista European a Durerii (2002), 6:1-16

Eficacitatea diferenial a interveniilor psihologice pentru reducerea durerii

osteoartritice: comparaie ntre hipnoza Ericksonian i relaxarea Jacobson

Marie Claire Gray, Pierre Phillipot i Oliver Luminet

Universitatea din Paris, departamentul de psihologie

Acest studiu investigheaz eficacitatea hipnozei Ericksoniene i a relaxrii Jacobson n

reducerea durerii din osteoartrit. Participanii care aveau dureri din aceast cauz au fost

repartizai la ntmplare ntr-unul din urmtoarele grupuri: (a) hipnoz (tratamentstandardizat cu 8 edine de hipnoterapie), (b) relaxare (tratament standardizat cu 8

edine de relaxare Jacobson), (c) grupul de control (respectiv lista de ateptare). n

ansamblu rezultatele arat c n cele dou grupuri experimentale nivelul durerii

subiective a fost mai sczut dect n grupul de control i c nivelul durerii subiective a

diminuat n timp. A fost observat de asemenea efectul tratamentului n timp, aparent

efectele fiind mai rapide n cazul utilizrii hipnoterapiei. Rezultatele indic de asemenea

faptul c hipnoza i relaxarea sunt eficace n reducerea cantitii de analgezice folosite de

participani. i nu n cele din urm, rezultatele acestui studiu sugereaz c diferenele

individuale n ce privete imageria modereaz efectul tratamentului psihologic la

urmrirea peste 6 luni, dar nu i dac msurtorile sunt efectuate mai devreme (respectiv

la 4 sptmni dup tratament, la 8 sptmni dup tratament i la 3 luni). Rezultatele

sunt interpretate n termeni de procese psihologice care se afl la baza hipnozei, i a

implicaiilor lor n tratamentul psihologic al durerii.

2002 European Federation of Chapters of the Association for the Study of Pain

Cuvinte cheie: hipnoz, relaxare, imagerie mental, osteoartrit, persoane vrtsnice,

durere


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INTRODUCERE

Osteoartrita (OA) este considerat o boal destul de comun, mai ales n rndul populaiei

vrstnice. Aceast patologie se definete prin eroziunea cartilajelor, mrirea oaselor i

apariia de excrescene, care adesea duc la dizabilitate pe termen lung. Principalul

simptom al bolii este durerea. Pe msura creterii expectanei d evia crete i numrul

de persoane care sufer de afeciuni articulare i n mod special OA. n ciuda prevalenei

crescute a OA, nu exist pn la ora actual un tratament specific al acestei boli. Terapiile

medicamentoase pentru persoanele vrstnice care sufer de OA sunt destul de limitate

datorit efectelor lor secundare. La fel i interveniile chirugicale au multiple riscuri i

sunt de obicei rezervate ca ultim linie de tratament pentru durerea extrem de sever

(Turner i Keefe, 1999).O abordare n tratamentul OA sunt tehnicile psihologice care au drept scop

diminuarea durerii subiective. Se cunoate la ora actual faptul c durerea are

componente psihologice care se refer la calitatea ei, intesnitate i caracteristicile sale

spaio-temporale referitor la senzaie, n timp ce procesele afective i motivaionale se

refer la valenele sale negative i aversiune (Melzack i Wall, 1965, 1988, Melzack i

Casey, 1968, Price, 1988). n plus, activitatea cognitiv, care include variabilele sociale i

psihologice referitoare la acea situaie moduleaz aceste procese, n timp ce rspunsurileautonome i comportamentale sunt concepute ca fiind procese rezultante care pot produce

o modulare a feed-back-ului. Aceste consideraii au condus la o perspectiv

biopsihosocial asupra durerii i interveniilor psihologice (Craig, 1994, Fernandez i

Turk, 1992, Arena i Blanchard, 1999).

Interveniile psihologice au aplicaii interesante n OA. S-a artat faptul c adulii

vrstnici care au OA a genunchiului difer considerabil n ce privete utilizarea i

eficacitatea perceput a strategiilor de coping la durere i c aceste strategii sunt legate de

durere i dizabilitate (Keefe i colab, 1987). Percepia durerii poate fi modificat prin

folosirea interveniilor cognitiv- comportamentale (CBT) care au drept scop

mbuntirea auto-eficienei n managementul durerii i dizabilitii (Brandura, 1991).

Aceste intrevenii implic relaxarea, pacing-ul, stabilirea scopurilor, imageria,

restructurarea cognitiv, rezolvarea de probleme i schimbarea stilului de via. Ele s-au


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dovedit a fi eficace n reducerea percepiei durerii i dizabilitatii psihologic n

comparaie cu condiiile standard de ngrijire paliativ. Rezultatele sunt de obicei de

durat i persist cteva luni dup finalizarea tratamentului (Basler, 1989, Keefe i colab.,

1990).

Studiile efectuate asupra efectului programelor educaionale n OA (programe de

auto-management al OA) arat c exist i n acest caz efecte semnificative n ce privete

managementul simptomatic. Aceste tehnici au de asemenea scopul de mbuntire a

auto-eficienei. Ele sunt similare cu CBT, dei funrizeaz informaii mai formale

participanilor (despre artrit, exerciii, managementul durerii, depresie, nutriie,

comunicarea cu medicii i familia) (Barlow i colab, 1997, 1988, 1999). Un studiu

comparativ al eficacitii CBT i programelor educaionale arta c exist o mai mare

eficacitate a CBT (Keefe i colab, 1990), n timp ce programele educaionale par s numai fie eficace dup un an (Calfas i colab, 1994). Aceste observaii sunt doar

preliminare i este nevoie ca studiile s fie repetate.

n consecin, este clar c interveniile psihologice afecteaz nivelul durerii la

pacienii cu OA i c aceste intervenii sunt eficace n tratamentul OA. Oricum,

cercetrile existente nu au stabilit nc dac toate componentele acestor intrevenii sunt

necesare pentru ca interveniile s fie eficace sau dac eficacitatea lor se datoreaz

anumitor componente specifice. Studiile viitoare trebuie s stabileasc care suntingredientele interveniilor eficace.

n plus, anumite tipuri de interveie s-au dovedit a fi eficace pentru reducerea

durerii n alte afeciuni, dar ele nu au fost nc testate pentru OA. De exemplu, este

surprinztor faptul c eficacitatea hipnozei n OA nu a fost studiat pentru tratamentul

durerii, n ciuda dovezilor evidente din clinic i cercetare care arat c hipnoza

acioneaz asupra durerii. ntr-adevr, cercetrile fundamentale au artat c hipnoza este

eficient ca tehnic cognitiv de producere a analgeziei (Hilgard, 1975, Hilgard i

Hilgard, 1975, Sheehan i Perry, 1976, Girodo i Wood, 1979, Spanos i colab, 1984,

1985, 1990, Tripp i Marks, 1986, Stam i colab, 1984, Elton i colab, 1988, Zeltzer i

colab, 1989, Baker i Kirsch, 1993, Chaves, 1999, Yachariae i Bjering, 1994,

Montogomery i colab, 2000) i pentru modificarea percepiei durerii, respectiv hipo- i

hiperlagie (Meier i colab, 1993), precum i n creterea sau descreterea pragului durerii


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(Arendt, Nielsen, 1990), precum i n diferenierea dimensiunilor durerii (Houle i colab,

1988, Malone i colab, 1989, Price, 1996, price i Barber, 1987, Rainville i colab, 1999).

Mai mult, Kiernan i colab, 1995, raporteaz c hipnoza are un efect psihologic msurabil

n modificarea nivelului durerii. Aceasta sugeeraz c rapoartele subiective pot reflecta

consecinele fizice ale unor intervenii eficace. Oricum, bazele biologice ale proceselor

hipnotice rmn nc contestate (Wagestaff, 1999) i sunt necesare studii ulterioare.

Eficacitatea hipnozei n reducerea durerii a fost de asemenea testat n cercetarea

clinic. n plus fa de numeraoasele rapoarte de caz care indic eficacitatea hipnozei

pentru reducerea durerii (Barber i colab, 1996, Covino i Frankel, 1998, Chaves, 1999),

mai multe studii clinice controlate au fost realizate utiliznd hipnoza pentru controlarea

durerii. Studiile clinice din stomatologie (Stam i colab, 1084, Enquist i Fisher, 1997), n

tratamentul arsurilor (Wakemann i Kaplan, 1978, Patterson i colab, 1989, 1992,Patterson i Ptacek, 1997), n chirurgie (lambert, 1996, Faymonville i colab, 1997,

Maurer i colab, 1999) i radiologie (Lang i colab, 1996), au indicat c aceast tehnic

este eficace att n durerea cronic ct i n cea acut. De asemenea hipnoza este eficient

n tratamentul durerii cronice din migren (Anderson i colab, a975, Ter Kuile i colab,

1994, 1995, 1996, Emerson i Trexler, 1999, Spinhoven, 2000), n colonul iritabil

(Galowski i Blanchard, 1998), n tumori (Spiegel i Bloom, 1983, Syriayia i colab,

1992, liossi i Hatira, 1999), n artrita reumatoid (Geissner i colab, 1994, Horton imitzdorf, 1994), durerile de spate (Burte i colab, 1994), fibromialgie (Haanen i colab,

1991) i boala coronarian /Weinstein i Au, 1991). Oricum, nu s-a dovedit mc c

hipnoza ar fi mai eficace dect alte tehnici psihologice. Dou meta-analize recente nu

arat diferene semnificative ntre analgezia sugerat i strategiile de management ale

durerii prin tehnici non-hipnotice, ca de exemplu relaxarea, instruciunile motivaionale

centrate pe sarcina, CBT, training-ul autogen i meditaia (Chaves i Dworkin, 1997,

Montogomery i colab, 2000), chiar dac unele studii clinice indic faptul c hipnoza ar

putea fi mai eficient dect relaxarea n cazul durerilor acute din arsuri (Patterson i

Ptacek, 1997) i pentru durerile cronice severe cum sunt cele din artrita reumatoid

(Horton i Mitzdorf, 1994, Geissner i colab, 1994) i fribromialgie (Haanen i colab,

1991). Dificultatea n diferenierea eficacitii analgeziei sugerate n comparaie cu alte

tratamente non-hipnotice poate fi explicat prin faptul c cele mai multe tehnici (hipnoza,


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imageria ghidat, trainingul autogen, meditaia) au componente de relaxare. n

consecin, se nate ntrebarea dac toate tehnicile eficace sunt de fapt varaiiuni ale

relaxarii sau dac toate aceste tehnici posed un alt ingredient activ, respectiv altul dect

relaxarea. Tehnicile pot fi diferite ca denumire sau fundal teoretic dar pot fi foarte

similare n practic. Acesta este cazul, de exemplu, pentru hipnoz i imageria ghidta.

Distincia ntre cele dou a fost realizat iniial ca i consecin a dezbaterilor asupra

rolului atribuit imageriei mentale n procesele hipnotice (Spanos i Barber, 1972, Barber,

1972, Wilson i Barber, 1982). Mai mult, eficacitatea relaxrii nsi pentru diminuarea

durerii n OA nu a fost evaluat separat n studiile anterioare (Calfas i colab, 1994,

Keefe i colab, 1990, barlow i colab, 1997, 1998, 1999), ci a fost inclus n programe

globale care aveau derpt scop reducerea durerii. Aceast stare de fapt face neecsar

realizarea rapid de studii controlate care s determine gradul de specificitate aldiferitelor tehnici psihologice descrise.

Un alt factor important n stabilirea eficacitii interveniilor clinice trebuie s

determine dac exist diferene individuale n ce privete rspunsul la interveia

respectiv. Aceast ntrebare pare n mod particular relevant pentru relaxare i hipnoz

deoarece exista mari variaii individuale n ce privete caapcitatea de imagerie (Denis,

1991, Lang, 1979, 1980, McKleive, 1995) i deoarece cercetrile din domeniul

susceptibilitii hipnotice au artat c rspunsul hipnotic se coreleaz cu factorii deimagerie (pentru o tercere n revist vezi Nadon i colab, 1987). Este interesant c dei s-

a demonstrat clar c relaxarea nu duce la creterea rspunsului hipnotic (Hilgard, 1965,

Council, 1999), Delmonte, 1981, a artat c susceptibilitatea hipnotic poate fi activat la

persoanele care mediteaz sau sunt relaxate, n aceast stare ei fiind caapbili s rspund

la sugestiile hipnotice.

Principalul scop al acestui studiu este de a investiga dac tratamentul controlat

prin hipnoz este eficace n reducerea durerii din OA. n plus studiul a fost astfel realizat

nct s clarifice impactul rspunsului terapeutic la relaxare i procesele de imagerie care

sunt active n hipnoz. ntr-adevr ipoteza naostr este aceea c relaxarea, mai ales dac

este folosit ca inducie hipnotic, joac un rol important n rspunsul terapeutic. Cu acest

scop au fost create trei grupuri experimentale: un grup de control aflat pe lista de

ateptare, un grup n care se aplic un tratament standardizat de 8 edine de relaxare i


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un grup n care se aplic tratamentul standradizat de 8 edine de hipnoz. Aceast

structur permite separarea efectelor care sunt specifice relaxrii de acelea care sunt

specifice hipnozei.

Studiul de fa se adreseaz de asemenea eficactii hipnozei, modificate de

susceptibilitatea hipnotic individual i imageria mental. Pentru a evalua diferenele

individuale privitoare la imagerie i capcitile hipnotice am utilizat dou teste, unul acre

evaluaez abilitatea hipnotic de a rspunde la sugestiile hipnotice, i cel de-al doilea,

care msoar dou componente ale imageriei mentale.

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