Douleurs en rhumatologie, aspects physiopathologiques, moyens d'évaluation, moyens thérapeutiques

Pain represents the most frequent reason for visiting a rhumatologist; over a half of chronic pains affect the muscular-skeletal apparatus. Conventionally, two physiopathological mechanisms are considered: pain due to excessive nociception (abnormal stimulation of peripheral nociceptors despite normal nervous system), and neuropathic pain (a lesion of the nervous system that generates painful sensations). This dichotomy doesn’t always reflect reality, and many pains are due to both (composite) mechanisms, especially in rhumatology. The first step of the medical management is to undertake complete assessment of a subjective symptom. In acute pains, the evaluation is based on standard general scales (visual analogue scale, verbal and numerical scales) that should be repeated for rapid adaptation of the treatment. In chronic pains, should they be a symptom of chronic disease or an autonomous pain, the assessment is complex, multidimensional, involving not only sensory-discriminative components, but also affective and emotional, cognitive, and behavioural components, and the familial and socio-professional context. Therapeutic management is based on the treatment of aetiological factors when possible, and also on symptomatic pain treatment: antalgesic agents, co-analgesic drugs, and non-pharmacological therapies. Antalgesic drugs are convenient for pains due to excessive nociception, where as most neuropathic or composite pains need combination with co-analgesics, what underlines that awareness of the neuropathic component is of utmost importance. In chronic pain, combination of drug therapy, non-pharmacological treatment and psychiatric management is often necessary. Rather than performing an overview of the whole rhumatologic therapy, this chapter intend to approach the pathophysiological mechanisms of pain, to highlight the importance of adequate assessment, to consider the symptomatic treatment of severe or persistent pain according to practical guidelines for antalgesic prescription, and finally to underline the importance of neuropathic pains in rhumatology, along with their specific management.