Um dos sintomas mais prevalentes em pessoas que vivem com HIV / AIDS é a dor (1-12). Na África do Sul, onde mais de dez por cento da população vivem com HIV / AIDS (13), há necessidade de um tratamento efetivo da dor (14). Em particular, é necessário encontrar intervenções eficazes para a gestão da dor para as pessoas que vivem nas zonas rurais, as áreas pobres em recursos, e em especial para as mulheres, uma vez que as mulheres experimentam um manejo da dor mais precário quando comparado aos homens (4,15-20). Além disso, as mulheres geralmente carregam o ônus de ser “chefes da casa” nessas comunidades rurais uma vez que os homens, que tradicionalmente desempenhavam esse papel, muitas vezes se afastam para áreas urbanas (21,22).

As evidências atuais indicam eficácia limitada da administração farmacológica de dor em pessoas com HIV (23). Além da terapia farmacológica (6,23,24), as intervenções existentes para o manejo da dor incluem educação (25-28), intervenções de auto-manejo (29-31), terapia cognitivo-comportamental (TCC) (32,33), exercícios físicos (34-37). O programa ‘Positive Living’ (PL ) (38,39) é baseado na teoria da auto-eficácia e na terapia cognitivo comportamental (TCC) (40). Esse programa foi desenvolvido e testado para uso em mulheres amaXhosa que vivem em um ambiente urbano (39). Considerando os recursos limitados disponíveis na África do Sul (6,23-39), desenvolvemos um estudo para mulheres amaXhosa que vivem em áreas urbanas e tem diagnóstico de HIV / AIDS com objetivo de se verificar o efeito do programa PL.

Pesquisas anteriores sobre o programa PL sugeriram que a relação terapêutica que se desenvolveu entre os participantes do estudo e os pesquisadores pode ter um efeito positivo sobre a dor (39). O desenvolvimento da relação terapêutica parece ser importante para os resultados de saúde, incluindo a redução da dor (41,42). Essas melhorias nos sintomas foram anteriormente consideradas como efeito placebo, mas agora o efeito significativo é reconhecido como sendo devido à percepção do paciente sobre o cuidado (43). Os efeitos podem resultar em alterações fisiológicas, como a liberação de opióides endógenos e alterações neurofisiológicas , mesmo na ausência de medicação analgésica (44-46).

Realizamos um estudo para determinar a eficácia do programa PL combinado com a relação terapêutica em comparação com a relação terapêutica sozinha em mulheres amaXhosa de zonas rurais. O grupo de intervenção recebeu o programa PL (por 6 semanas) combinado com uma relação terapêutica, enquanto o grupo de relacionamento terapêutico recebeu apenas a relação terapêutica. O assistente de pesquisa conduziu a coleta de dados, foi cegado quanto à alocação de grupo e foi treinado para desenvolver uma relação terapêutica com todos os participantes através de estratégias de comunicação (47-51). Nossos resultados indicaram que a intensidade e a interferência da dor foram significativamente reduzidas em todos os participantes ao longo das 24 semanas do estudo e não houve diferenças significativas entre os grupos para esses desfechos primários.

Esta pesquisa destaca que a relação terapêutica é uma intervenção ativa. Os profissionais de saúde precisam reconhecê-la como parte do tratamento. Isso significa que a formação de profissionais de saúde em estratégias de comunicação conhecidas por melhorar a relação terapêutica deve ocorrer para proporcionar um tratamento de dor eficaz e adequado entre as mulheres amaXhosa de zonas rurais que vivem com HIV / AIDS (47-51). Embora nossos resultados não sejam generalizáveis para além das mulheres amaXhosa de zonas rurais, eles aumentam a necessidade de novas pesquisas sobre a relação terapêutica e seu efeito na dor em outros grupos de pessoas vivendo com HIV / AIDS e pessoas com outras síndromes dolorosas.

Texto escrito como parte de um estudo maior realizado por pesquisadores da University of Cape Town sob orientação das professoras Romy Parker e Antonia Wadley, e em colaboração com Cameron Reardon, Sarah Cameron e Dershnee Devan. A Fundação Nacional de Pesquisa Thuthuka Grant e uma Sociedade Sul-Africana de Fisioterapia promoveram financeiramente esse estudo.

 

ENGLISH VERSION

Handle with care: the therapeutic relationship and its effect on pain

One of the most prevalent symptoms in people living with HIV/AIDS (PLWHA) is pain and yet, it is largely undermanaged^{1–9 1,10–12}. In the Eastern Cape of South Africa, where over ten percent of the population are living with HIV/AIDS¹³, there is a need for effective pain management¹⁴. In particular finding effective pain management interventions for people living in the rural, resource poor areas of the Eastern Cape is pressing and even more so for women as women experience poorer management of pain than men^4,15–20. Additionally, women commonly carry the burden of being heads of the home in these rural communities, as men, who traditionally performed this role, often move away to the urban areas^21,22.

Current evidence indicates limited efficacy of pharmacological management for pain in PLWHA^6,23. Apart from pharmacological therapy^6,23,24, existing interventions for managing pain include education^25–28, self-management interventions^29–31, cognitive behavioural therapy (CBT)^32,33, physical exercise^34–37, and a peer-led exercise and education group intervention, the ‘Positive Living’ (PL) programme^38,39. The PL programme, based on the self-efficacy theory and CBT⁴⁰, was developed and tested for use in amaXhosa women living in an urban setting³⁹. Considering the efficacy and acceptability for urban amaXhosa women living with HIV/AIDS and the limited resources available in the Eastern Cape of South Africa^6,23–39, we set out to study the effect of the PL programme in the Eastern Cape in rural amaXhosa women.

Previous research on the PL programme suggested that the therapeutic relationship which developed between study participants and the researchers may have had a positive effect on their pain³⁹. Fostering the therapeutic relationship appears to be important for health outcomes, including pain reduction^41,42. These improvements in symptoms were previously dismissed as a placebo effect but it is now acknowledged to be due to the patient’s perception of care, or meaning effect ⁴³. The meaning effect may result in physiological changes, such as a release of endogenous opioids and neurophysiological changes, even in the absence of analgesic medication^44–46.

We conducted a study to determine the efficacy of the PL programme combined with a therapeutic relationship in comparison to the therapeutic relationship alone in rural amaXhosa women LWHA. The Positive Living group received the PL programme (which ran for 6 weeks) combined with a therapeutic relationship whilst the therapeutic relationship group received the therapeutic relationship only. The research assistant conducted the data collection, was blinded as to group allocation and was trained to develop a therapeutic relationship with all the participants through communication strategies^47–51. Our results indicated that pain severity and pain interference were significantly reduced in all the participants over the 24 weeks of the study and there were no significant differences between groups for these primary outcomes.

This research highlights that the therapeutic relationship is an active intervention. Health care professionals need to recognise it – as a treatment. This means that training health care professionals in communication strategies known to enhance the therapeutic relationship should take place to provide effective and adequate pain management amongst rural amaXhosa women living with HIV/AIDS^47–51. While our results are not generalisable beyond rural amaXhosa women in the Eastern Cape, they raise the need for further research into the therapeutic relationship and its effect on pain in other groups of people living with HIV/AIDS and people with other pain syndromes.

*This was done as part of a larger study by researchers at the University of Cape Town with principal investigators, Associate Professor Romy Parker and Dr Antonia Wadley, and in collaboration with Cameron Reardon, Sarah Cameron and Dershnee Devan. The National Research Foundation Thuthuka Grant and a South African Society of Physiotherapy education grant financially supported this study.

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Kirsty Jackson

Fisioterapeuta – University of Cape Town