Chronic Pain

Background -/- Innovative neurosurgical treatments present a number of known risks, the natures and probabilities of which can be adequately communicated to patients via the standard procedures governing obtaining informed consent. However, due to their novelty, these treatments also come with unknown risks, which require an augmented approach to obtaining informed consent. -/- Objective -/- This paper aims to discuss and provide concrete procedural guidance on the ethical issues raised by serious unexpected complications of novel deep brain stimulation treatments. -/- (...) Approach -/- We illustrate our analysis using a case study of the unexpected development of recurrent stereotyped events in patients following the use of deep brain stimulation (DBS) to treat severe chronic pain. Examining these unexpected complications in light of medical ethical principles, we argue that serious complications of novel DBS treatments do not necessarily make it unethical to offer the intervention to eligible patients. However, the difficulty the clinician faces in determining whether the intervention is in the patient's best interests generates reasons to take extra steps to promote the autonomous decision making of these patients. -/- Conclusion and recommendations -/- We conclude with clinical recommendations, including details of an augmented consent process for novel DBS treatment. (shrink)

The coronavirus disease 2019 pandemic had a negative psychological impact on the population at scale, yet it is possible that vulnerable patient populations may experience a heavier burden with increased feelings of anxiety and distress. Cancer patients have to trade-off between the fear of exposing themselves to the virus and the need to continue life-saving medical procedures. The present study investigated the prevalence of generalized anxiety and post-traumatic stress symptoms in a population of Italian cancer patients and healthy participants in (...) the months following the COVID-19 outbreak. Using standardized measures of PTSS and generalized anxiety, we found that patients experienced higher levels of adverse mental health outcomes. Several variables were found to negatively affect PTSS and anxiety in this population, including the younger age of respondents, having children, and the impossibility to attend regular medical check-ups. These findings stress the importance of maintaining a clear and regular communication with patients throughout future waves of the pandemic and ensure continuity of care in this vulnerable population. Furthermore, this study indicates the need to establish psychological interventions aimed at patients with cancer, targeting especially younger generations who are more likely to experience adverse psychological outcomes. (shrink)

: Psychogenic pain is considered to be pain that has a psychological origin. In this paper, I provide a brief history of the ways in which such pain has been interpreted and classified, highlighting the problem that psychogenic pain is typically defined by excluding organic evidence that could account for the sufferer’s experience. This has led to ambiguous disease classifications, which challenges the authenticity of the patient’s suffering. Today psychogenic pain is no longer considered a valid diagnosis, because it is (...) deemed to stigmatize the patient by implying that their pain is imaginary. But such stigmatization continues in the modern approach to chronic pain. Addressing this issue requires us to understand the relationship between “emotional” and “physical” pain and acknowledge the reality of all suffering. Radden tackles these issues by showing that even though pain and suffering can be accompanied by mistaken beliefs, such experiences cannot be delusional. Keywords: Psychogenic Pain; Imaginary Pain; Chronic Pain; IASP; DSM Dolore psicogeno e dolore immaginario Riassunto: Con dolore psicogeno si intende un dolore di origine psicologica. In questo lavoro presento una breve storia delle interpretazioni e classificazioni di questa forma di sofferenza, evidenziando che queste si sono fondate perlopiù sull’esclusione di evidenze organiche a giustificazione dell’esperienza del sofferente. Ciò ha portato ad ambigue classificazioni di malattia che mettono in discussione l’autenticità della sofferenza del paziente. Oggi, quella di dolore psicogeno non è più considerata una diagnosi valida perché ritenuta stigmatizzante, implicando che il dolore del paziente sia immaginario. Ciononostante, la stigmatizzazione persiste nell’approccio odierno al dolore cronico. Affrontare questo problema comporta la comprensione della relazione tra dolore “emozionale” e dolore “fisico” ed il riconoscimento della realtà di tutte le forme di sofferenza. Nel suo lavoro, Radden esamina queste tematiche mostrando che, sebbene esperienze di dolore e sofferenza possano essere accompagnate da credenze errate, le esperienze stesse non possono essere illusorie. Parole chiave: Dolore psicogeno; dolore immaginario; dolore cronico; IASP; DSM. (shrink)

Over 100 million Americans suffer from chronic pain, which causes more disability than any other medical condition in the United States at a cost of $560–$635 billion per year. Opioid analgesics are frequently used to treat CP. However, long term use of opioids can cause brain changes such as opioid-induced hyperalgesia that, over time, increase pain sensation. Also, opioids fail to treat complex psychological factors that worsen pain-related disability, including beliefs about and emotional responses to pain. Cognitive behavioral therapy can (...) be efficacious for CP. However, CBT generally does not focus on important factors needed for long-term functional improvement, including attainment of personal goals and the psychological flexibility to choose responses to pain. Acceptance and Commitment Therapy has been recognized as an effective, non-pharmacologic treatment for a variety of CP conditions. However, little is known about the neurologic mechanisms underlying ACT. We conducted an ACT intervention in women with chronic musculoskeletal pain. Functional magnetic resonance imaging data were collected pre- and post-ACT, and changes in functional connectivity were measured using Network-Based Statistics. Behavioral outcomes were measured using validated assessments such as the Acceptance and Action Questionnaire, the Chronic Pain Acceptance Questionnaire, the Center for Epidemiologic Studies Depression Scale, and the NIH Toolbox Neuro-QoLTM scales. Results suggest that, following the 4-week ACT intervention, participants exhibited reductions in brain activation within and between key networks including self-reflection, emotion, and cognitive control. These changes in connectivity strength were correlated with changes in behavioral outcomes including decreased depression and pain interference, and increased participation in social roles. This study is one of the first to demonstrate that improved function across the DMN, SN, and FPN may drive the positive outcomes associated with ACT. This study contributes to the emerging evidence supporting the use of neurophysiological indices to characterize treatment effects of alternative and complementary mind-body therapies. (shrink)

Considerable heterogeneity among pediatric chronic pain patients may at least partially explain the variability seen in the response to behavioral therapies. The current study tested whether autistic traits and attention-deficit/hyperactivity disorder symptoms in a clinical sample of children and adolescents with chronic pain are associated with socioemotional and functional impairments and response to acceptance and commitment therapy treatment, which has increased psychological flexibility as its core target for coping with pain and pain-related distress. Children and adolescents aged 8–18 years were (...) recruited. Patients and their parents completed questionnaires pre- and post-ACT of 17 sessions. Correlational analyses and mixed-effects models were used to assess the role of autistic traits and ADHD symptoms in pretreatment functioning and ACT-treatment response. Outcome variables were degree to which pain interfered with daily activities, socioemotional functioning, psychological inflexibility, and pain intensity. Autistic traits and ADHD symptoms, pain frequency, and pain duration were measured at pretreatment only. Higher autistic traits were associated with greater pain interference, higher depression, and greater psychological inflexibility. Higher ADHD symptomatology was associated with greater pretreatment pain interference, lower emotional functioning, greater depression, and longer duration of pain. Across patients, all outcome variables, except for sleep disturbances and school functioning, significantly improved from pre- to post-ACT. Higher autistic traits were associated with greater pre- to post-ACT improvements in emotional functioning and sleep disturbance and non-significant improvements in pain interference. ADHD symptomatology was not associated with treatment outcome. The current results showed that neuropsychiatric symptoms in pediatric chronic pain patients are associated with lower functioning, particularly pain interfering with daily life and lower socioemotional functioning. The results suggest that not only pediatric chronic pain patients low in neuropsychiatric symptoms may benefit from ACT, but also those high in autism traits and ADHD symptoms. With the present results in mind, pediatric chronic pain patients higher in autistic traits may actually derive extra benefit from ACT. Future research could assess whether increased psychological flexibility, the core focus of ACT, enabled those higher in autism traits to cope relatively better with pain-related distress and thus to gain more from the treatment, as compared to those lower in autism traits. Moreover, to address specific effects of ACT, inclusion of an appropriate control group is key. (shrink)

BackgroundChronic pain has serious medical and social consequences and leads to economic burden that threatens the sustainability of healthcare services. Thus, optimized management of pain tools to support CP patients in adjusting to their condition and improving their quality of life is timely. Although acceptance and commitment therapy is considered an evidence-based psychological approach for CP, evidence for the efficacy of online-delivered ACT for CP is still scarce. At the same time, studies suggest that self-compassion mediates the change in disability (...) and psychopathological symptoms in ACT interventions for CP, although self-compassion is not a specific target in ACT. Thus, an explicit focus on self-compassion might increase the efficacy of ACT interventions for CP, although this hypothesis has not been tested. This study aims to develop an eHealth ACT and compassion-based self-management intervention for CP, the iACTwithPain, and to compare its efficacy in improving health outcomes to a similar ACT-only intervention and a medical TAU group.MethodsThe eHealth platform that will host the interventions will be developed using a flat design identity and will be interactive. The iACTwithPain intervention will comprise eight weekly self-management sessions and will be developed taking into consideration the psychological flexibility model applied to CP, with the addition of explicit compassion-based components. To analyze whether the iACTwithPain intervention will present superiority in improving CP’s impact and related health markers over the two other conditions, this study will follow an RCT design with three arms. CP patients will be recruited through direct contact with patient associations and healthcare services and a national press release in Portugal. Outcome measurement will be conducted at baseline, post-intervention and at 3- and 6-month follow-ups. The interventions’ acceptability will also be assessed.DiscussionThe iACTwithPain intervention is expected to improve CP patients’ psychosocial functioning, quality of life, and empowerment, by promoting adaptive disease management and regulation of pain-related internal experiences. Results will contribute to a better understanding on the pertinence of adding compassion elements to ACT for CP and to reach an optimized intervention for CP.Clinical Trial RegistrationThis trial has been registered at ClinicalTrials.Gov. The current manuscript comprises the first version of this clinical trial’s protocol. (shrink)

Background. Herpes zoster is a disease that mainly causes severe segmental neuralgia and vesicles after infection with herpes zoster virus. At the same time, more than 9 to 34 percent of patients have postherpetic neuralgia present with chronic pain for months or even years. Moxibustion has been used to treat herpes zoster and postherpetic neuralgia for many years; however, there has been no comprehensive study to evaluate the efficacy and safety of moxibustion in the treatment of herpes zoster and postherpetic (...) neuralgia. More studies evaluated the combined effects of acupuncture and moxibustion. Therefore, the purpose of this systematic review is to evaluate their efficacy and safety, so as to provide an evidence-based basis for the clinical application of moxibustion in the treatment of HZ and PHN. Method. The literature search was conducted in nine Chinese and English databases, and randomized controlled trials were pooled from their inceptions to June 2020. The included literature was screened, and data were extracted. RevMan 5.3 software and Stata software were used for statistical analysis. The primary outcome was the total effect. The secondary outcomes include VAS, NRS, and time of analgesia. Outcomes. From a total of 1957 identified studies, 31 were included in analysis. 31 RCTs contained the experimental sample of 1185 cases and the control sample of 1149 cases reported efficiency of different moxibustions in the treatment of herpes zoster, statistical heterogeneity inspection without heterogeneity. So, we used the fixed-effects model, merge effect quantity OR = 3.89, Z = 8.86, and it suggested sample merger analysis was statistically significant. Also, the moxibustion, compared to other methods in the treatment of herpes zoster and herpes zoster neuralgia efficiency, increased significantly. The VAS scales, WMD = 1.69, and the time of analgesia, WMD = 2.41, indicated that moxibustion surpassed others in the relief of pain. NRS was just reported in one study. It was not statistically significant. There was no significant difference in adverse effects OR = 0.61, Z = 1.56. Conclusion. Moxibustion has obvious advantages over other therapies in the treatment of HZ and PHN. However, due to the obvious publication bias, the interpretation of the results should be cautious, and more rigorous randomized controlled clinical studies should be included to further confirm the results in the future. (shrink)

ObjectiveThe novel coronavirus is linked to increases in emotional distress and may be particularly problematic for those with pre-existing mental and physical conditions, such as chronic pain and posttraumatic stress disorder. However, little empirical research has been published on resilience factors in these individuals. The present study aims to examine authenticity as a resilience factor among those with chronic pain and/or PTSD.MethodsPrior to the national response to the pandemic, participants were screened for pain-related disability and PTSD symptoms, and on the (...) basis of those responses were categorized into one of four groups: healthy, chronic pain only, PTSD only, or comorbid chronic pain and PTSD. During the CV-19 pandemic, participants responded again to the ODI and PCL-5, in addition to the Wood Authenticity Scale, Brief Pain Inventory, and items related to the CV-19 pandemic.ResultsA total of 110 participants, aged 42.19, completed the survey during the pandemic. The comorbid group endorsed higher levels of CV-19 Threat and Impact compared to all other groups. Authenticity moderated this relationship relevant to CV-19 Threat among those in the chronic pain only group, and not in any other group.ConclusionThe comorbid group endorsed higher levels of CV-19 Threat and Impact compared to all other groups. Importantly, greater authenticity was associated with less CV-19 Threat in the chronic pain only group, and not in any other group. The present study also highlights the importance of engaging authentically for those with chronic pain during the pandemic. (shrink)

A patient-centred approach has gained increasing interest in medicine and other health sciences. Whereas there are discussions about the meaning of a patient-centred approach and what the concept entails, little is known about how the patient as a person is understood in patient-centred care. This article investigates understandings of the patient as a self in patient-centred care through physiotherapy of patients with chronic muscle pain. The material consists of interviews with five Norwegian physiotherapists working in a rehabilitation clinic. Drawing on (...) Kristeva’s discussion of subjectivity in medical discourse, the study highlights two different treatment storylines that were closely entwined. One storyline focuses on open singular healing processes in which the treatment was based on openness to a search for meaning and sharing. In this storyline, the “person“ at the centre of care was not essentialised in terms of biological mechanisms, but rather considered as a vulnerable, irrational and moving self. By contrast, the second storyline focused on goal-oriented interventions aimed at restoring the patient to health. Here, the person in the centre of the treatment was shaped according to model narratives about “the successful patient”; the empowered, rational, choosing and self-managing individual. As such, the findings revealed two conflicting concepts of the individual patient inherent in patient-centred care. On the one hand, the patient is seen as being a person in constant movement, and on the other, they are captured by more standardised terms designed to focus on a more stable notion of outcome of illness. Therefore, our study suggests that the therapists’ will to recognise the individual in patient-centred care had a counterpart involving a marginalisation of the singular. (shrink)

In Nietzsche the autobiographical theme of disease has at its core the philosophical problem of pain. While he reflects daily on the actual condition of the ill person, Nietzsche oscillates the man like a pendulum. He defines him as ‘the most melancholic and most happy animal who suffers so profoundly that he must invent laughter’, as ‘the ill animal’ but also ‘the most courageous and most used to pain’. Nietzsche seems to be entertained no end by playing around with these (...) definitions, almost as if he is making fun of Aristotle. It is in fact these two later quotations from the Genealogy that go on to construct the tracks on which his reflections on badness and suffering will move, marking out the area in which the decisive ‘match’ of the health of humanity is discussed. The first displays a Nietzsche who is always tranchant and blazing in its ability to conjure up the humanity of humans in few words. The highlight of the determinate article is original and shows that man is a unique animal who can define himself as being ill. The second suggests the image of a human being who tolerates pain with courage, arriving, just thanks to this journey of pain, to embark on a voyage leading to internal transformation. Nietzsche’s lifelong illness was what prompted him to develop the philosophical problem of pain and its relationship with thought. Taking advantage of his condition as a constant sufferer, Nietzsche strived to understand which directions human thought is able to take whenever it is ‘subjected to the pressure of evil’. The first is a hypocritical direction, represented by man’s attempts to remove pain from his life. Nietzsche denounces all justifications made for the purpose of providing at all costs a meaning for suffering, and which converge with the modern welfare society that dares to fashion mankind ‘without evil’. The other direction, however, is that of those who are not afraid to listen to suffering. Reflecting on his own personal situation, Nietzsche outlines the traits of human beings who reach out towards the mystery of existence and, shaken by the experience of pain, come to abandon their certainties and adopt a more critical view of themselves. ‘Every man is a medical history’, recites a posthumous fragment. Certainly, Nietzsche himself is the first to notice ‘his own story is the story of an illness and also of a healing’ – and this is not only true for him but for everyone who experiences suffering up close. This experience of pain – so intimate that it seems difficult to express in words – does not cause one to be locked up inside of oneself but rather serves to introduce a discussion on one’s subjectivity and as an occasion for a moral adventure into the profundities of one’s existence. (shrink)

Research documents that many chronic non-malignant pain patients experience existential, spiritual and religious needs; however, research knowledge is missing on if and how physicians approach these needs. We conducted a systematic review to explore the extent to which physicians address these needs in their communication with chronic non-malignant pain patients and to explore the facilitators and challenges of this communication. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching Embase, Medline, Scopus and PsycINFO. The quality of (...) the included articles was assessed based on design-specific screening tools. We included four of 2337 screened articles and found the quality to be good. Physicians’ communication about existential, spiritual and religious needs was given low priority and depended on the patients’ own initiative, except when clinicians were interested in holistic care. Patient dissatisfaction with the physician’s attention to these needs was related to higher pain and depression. Physicians’ challenges for addressing these needs were their tendency to prioritize physiological aspects and close further elaboration of existential needs when addressed by the patients. The main facilitator was the individual physician’s willingness to listen with openness and empathy to the patients’ existential concerns. A tentative conclusion is that physicians rarely meet the existential, spiritual and religious needs of their chronic non-malignant pain patients. This might be due to higher priority of physical aspects, lack of time and a lack of knowledge about the importance of and training in the ability to address these needs. Further research is needed on physicians’ communication about existential, spiritual and religious needs and on their training in here. (shrink)

Receiving a diagnosis of cancer can be devastating. Cancer continues to be one of the most feared diagnoses, and experiencing pain is a major fear for people diagnosed with cancer. Cancer pain is complex in aetiology and can be acute or chronic and can be caused by various compression, ischaemic, neuropathic or inflammatory processes. Many people with cancer will experience excruciating pain, which is often underreported and undertreated. The reasons for this are complex and include various factors including fears and (...) beliefs held by patients. Cognitive factors are important modulators of pain and the appraisals, meanings and beliefs that people have in relation to illness, cancer, and pain, have implications in regard to help-seeking behaviours and the coping strategies people adopt. Cancer pain can impact a range of psycho-social factors across its course. Cancer pain relates to higher rates of psychological distress, anxiety and low mood, and the perception of pain intensity is, in turn, influenced by psychological factors. Cancer pain can negatively affect psychological health, and psycho-social factors can affect the pain experience. It has been suggested that people with a life-limiting illness experience ‘total pain’, and this can encompass psychological, social, practical, spiritual domains. Research demonstrates that cancer is predominantly an illness affecting older people, yet there is a higher risk of under-treated pain in this age group and there is a paucity of research into the subjective experiences of older people managing their cancer pain. Many older people are required to self-manage cancer pain at home as outpatients, due to drivers to keep people out of inpatient care, such as the high healthcare costs of inpatient treatment, and patients wanting to manage their illness, and die, at home. Our own research into this area found that the self-management of cancer pain involves a sequential and temporal process, which centres on perceptions of control. We describe how the older people in our study experienced a perceived loss of control, followed by a sense of gaining control over pain through various experience of certain internal and external factors. The assessment and treatment of physical pain should be done in combination with assessment and treatment of psycho-social and spiritual pain, and interventions for cancer pain need to focus on increasing positive affect and reducing helplessness. No person should suffer with poorly controlled pain and we argue for the need for further research in this area to ensure adequate treatment for all.Clinical Implications: Assessment and treatment of physical pain in people with cancer needs to be conducted in combination with assessment and treatment of psycho-social issues and spiritual pain. Psychological and behavioural approaches have strong evidence supporting their efficacy for reducing cancer pain. Interventions should target helplessness and focus on increasing positive affect through positive psychological states including fighting spirit and resilience. Person-centred interventions that focus on helping people with the search for meaning may help those with cancer pain derive positive benefits. (shrink)

Both patients and clinicians frequently report problems around communicating and assessing pain. Patients express dissatisfaction with their doctors and doctors often find exchanges with chronic pain patients difficult and frustrating. This chapter thus asks how we could improve pain communication and thereby enhance outcomes for chronic pain patients. We argue that improving matters will require a better appreciation of the complex meaning of pain terms and of the variability and flexibility in how individuals think about pain. We start by examining (...) the various accounts of the meaning of pain terms that have been suggested within philosophy and suggest that, while each of the accounts captures something important about our use of pain terms, none is completely satisfactory. We propose that pain terms should be viewed as communicating complex meanings, which may change across different communicative contexts, and this in turn suggests that we should view our ordinary thought about pain as similarly complex. We then sketch what a view taking seriously this variability in meaning and thought might look like, which we call the “polyeidic” view. According to this view, individuals tacitly occupy divergent stances across a range of different dimensions of pain, with one agent, for instance, thinking of pain in a much more “bodycentric” kind of way, while another thinks of pain in a much more "mindcentric” way. The polyeidic view attempts to expand the multidimensionality recognised in, e.g., biopsychosocial models in two directions: first, it holds that the standard triumvirate— dividing sensory/cognitive/affective factors— needs to be enriched in order to capture important distinctions within the social and psychological dimensions. Second, the polyeidic view attempts to explain why modulation of experience by these social and psychological factors is possible in the first place. It does so by arguing that because the folk concept of pain is complex, different weightings of the different parts of the concept can modulate pain experience in a variety of ways. Finally, we argue that adopting a polyeidic approach to the meaning of pain would have a range of measurable clinical outcomes. (shrink)

This chapter explores the personal experience of pain from its biological underpinnings to strategies people identified for managing this experience. The somatic experience of chronic pain describes the biological processes involved in pain and how this can become a chronic experience with psychological and social implications. The personal experience of pain is explored through a systematic review of research of qualitative experiences. We found that the experience of pain was similar despite its etiological underpinnings—whatever the biological cause there were similarities (...) in the personal experience. Participants in the studies identified five themes that described these personal experiences: body as obstacle; disrupted sense of self; invisible but real; unpredictability; and keeping going. This section of the chapter is followed by the findings of a systematic review of how older people learn to manage their pain experiences: “adjusting to the inevitable,” “doing it my way without medication” and “the importance of support in managing the struggle.” The chapter concludes by discussing some of the strategies that can be used to manage the self in pain: support for self-management, medication, exercise and psychological interventions.Clinical Implications: Many people manage their chronic pain by actively balancing the competing forces of hope and despair. There are similarities in this experience of chronic pain across a range of conditions which has implications for the development of pain management strategies and interventions that address the pain experience and not just the biological condition. Learning to manage the self in pain involves acceptance of pain as on-going and a part of who they are; keeping connected with others; keeping occupied through meaningful activities; getting meaningful support; and developing new meaning in life. Clinical interventions need to a focus on the person’s sense of self, strategies for maintaining hope, strategies that provide relief for the distress associated with pain; and providing people with a sense of control over their experiences both with the pain itself and in their encounters with the medical profession and the use of medication. (shrink)

Pellegrino and Thomasma have proposed a normative medical ethics founded on a conception of the end of medicine detached from any broader notion of the telos of human life. In this essay, I question whether such a narrow teleological account of medicine can be sustained, taking as a starting point Pellegrino and Thomasma’s own contention that the end of medicine projects itself onto the intermediate acts that aim at that end. In order to show how the final end of human (...) life similarly alters intermediate ends, such as the end of medicine, I describe Thomas Aquinas’s concept of pain and explain how his remedies for pain derive from his account of the telos of human life. In turn, this account has implications for the way in which physicians who accept such a telos would manage their patients’ pain. If a comprehensive telos for human life is necessary to make sense of even such a routine aspect of medical care, then medical ethicists may not be able to sidestep questions about the good life for human beings. (shrink)

When acute pain persists beyond the expected healing time following an injury, important neurological changes occur that allow pain to transition from adaptive to maladaptive. Spine pain has become an important global problem, with significant increases in prevalence, disability, and subsequent healthcare costs over the past several decades. Low back pain is now the number one cause of disability in the world. Because of the magnitude of the effect of low back pain, and especially chronic low back pain, it has (...) become imperative that we embrace the best available evidence and clinical sensibilities as we work with patients to find appropriate solutions. Intrinsic to the successful care of persons with spine pain is the acknowledgment that the experience of pain is a biopsychosocial one. There is no universal experience of pain and thus our solutions must accommodate variation in the meanings of pain. Experiential knowledge of spinal pain can be integrated with our understanding of spinal pain neurobiology in rehabilitation contexts to improve health outcomes. Ultimately, the rehabilitation of persons with spine pain exists at the intersection of the objective and subjective goals of care.Clinical Implications: Understanding the full biopsychosocial scope of spinal pain allows clinicians to strengthen their therapeutic alliance with patients, reinforce self-efficacy, identify patients at risk for poor outcomes and intervene early, stratify care appropriate to the individual’s needs, reduce or prevent pain chronification, reduce direct and indirect costs to patients and society, and improve overall quality of life. (shrink)

Pain imagery is “like having a picture in your head [of your pain] which may include things you can imagine seeing, hearing or feeling.” Pain imagery may offer a unique insight into a patient’s pain experience. This chapter summarises findings from international pain imagery research in women with endometriosis-associated pain. Endometriosis is a chronic inflammatory condition associated with debilitating pain that affects 5–10% of women of reproductive age worldwide. Our international research has found that pain imagery is experienced by around (...) half of women suffering from endometriosis-associated pain, and is associated with higher levels of catastrophising, depression, and anxiety. However, coping imagery is also reported, and prevalent, at 30%. Pain imagery in women with endometriosis falls into themes: sensory qualities of pain; loss of power or control; attack ; pathology or anatomy envisaged; past or future catastrophe; pain as an object; and abstract images. Imagery content may therefore reveal the meanings of pain or endometriosis to these women. This chapter explores pain imagery content and its personal significance to patients, both for women with endometriosis-associated pain and for patients with other chronic pain conditions. The chapter concludes by discussing the clinical application of imagery, with example patient cases to contextualise the practicalities and therapeutic potential of imagery techniques.Clinical Implications: Pain imagery was reported by half of women with endometriosis-associated pain in our international study and associated with higher levels of catastrophising, depression, and anxiety. Imagery content is extremely varied but can be categorised into themes, which may offer unique insights into each woman’s pain experience. Coping imagery was prevalent at 30%. We believe imagery techniques may be particularly helpful for women with endometriosis-associated pain and discuss these techniques, which should be of interest to professionals involved in pain management. (shrink)

Living with complex regional pain syndrome can be described as similar to living with any other chronic pain condition, but with extra complications. Many health professionals have never heard of the condition and it is even less known in the general community. There is a diversity of presentations, no objective medical test for diagnosis, and it remains a diagnosis of exclusion based on clinical signs and symptoms. The pathophysiology is not fully understood and there is no dedicated treatment. There are (...) only low-quality data supporting any treatment approach. Although there is no known cure it may go into remission. It may also reappear. The condition may occur spontaneously. Although the mechanisms are not well understood, it can spread to other parts of the body.This chapter is based on a PhD study entitled “Battling Complex Regional Pain Syndrome: A Phenomenological Study.” The aim is to describe and discuss the meaning of living with CRPS. Using a heuristic hermeneutic phenomenological approach to investigate the phenomenon of living with CRPS, 17 patients and four health professionals from 6 different countries were interviewed. Textual material from internet blogs and a book containing patient stories were also included as data sources. As the first author has been diagnosed with the condition, she was interviewed as well. Serving multiple purposes, the interview transcript was used as data while allowing for explication of preunderstandings and assumptions. This is an important step in phenomenological research. Findings revealed that living with CRPS is a daily battle. Within the battle analogy, readers can recognise aspects of the themes and relate to them on some level. Within this battle, there are many smaller, but important, fights. These fights are the themes which are:Dealing with an unknown enemy;Building an armoury against a moving target;Battles within the war;Developing battle plans with allies; andWarrior or prisoner of war.The enemy is CRPS. Patients are the soldiers or warriors fighting it. From fighting for a diagnosis and coping with strange symptoms and disbelief, patients struggle with a condition that has no known cure and constantly changes. They battle against moving a painful body part too much and causing a flare or moving it too little and losing use of it. They face judgement from others, including health professionals, who do not understand CRPS. Support can be difficult to find. Patients must become resilient and must rise to the challenge with a warrior like attitude. Those who don’t may feel like a prisoner of war.This chapter provides vignettes composed from patient interviews. The vignettes could facilitate a better understanding of lived experiences from the patients’ perspective.Clinical Implications: Health professionals have little understanding of the smaller battles faced by patients living with CRPS and patient goals do not necessarily correlate to those of the HP. It is anticipated that with better understanding of the lived experience, HPs will deliver more empathic patient focussed care. This could result in the clarification of realistic patient goals and needs as opposed to HP expectations of adherence and compliance to therapeutic interventions and could foster more collaborative and supportive self-management strategies for patients. (shrink)

Pellegrino and Thomasma have proposed a normative medical ethics founded on a conception of the end of medicine detached from any broader notion of the telos of human life. In this essay, I question whether such a narrow teleological account of medicine can be sustained, taking as a starting point Pellegrino and Thomasma’s own contention that the end of medicine projects itself onto the intermediate acts that aim at that end. In order to show how the final end of human (...) life similarly alters intermediate ends, such as the end of medicine, I describe Thomas Aquinas’s concept of pain and explain how his remedies for pain derive from his account of the telos of human life. In turn, this account has implications for the way in which physicians who accept such a telos would manage their patients’ pain. If a comprehensive telos for human life is necessary to make sense of even such a routine aspect of medical care, then medical ethicists may not be able to sidestep questions about the good life for human beings. (shrink)

This thesis is about the crisis in representation that accompanies the attempt to account for lived experience, with particular reference to bodily pain in social science. The diagnosis of this problem of experience identifies epistemology as an inappropriate means of knowing that initiates a translational paradox unable to satisfy the simultaneous demands of making lived experience familiar in representational form yet retaining the foreignness of the original experience at the same time. This problem of simultaneity is not a problem, however, (...) if it is built into a way of knowing, something that escapes epistemological conditions of possibility with its either/or of singularities. To know in such ‘double vision’, or fractionally, characterises post-epistemological thinking. This thesis draws on a relatively underdeveloped method for practicing a fractional means of knowing from post- actor-network theory, that of the pinboard, and explores how it might be usefully applied to the problem of experience. The thesis constitutes an experiment in producing a social science account of the lived experience of chronic pain using this method as an alternative to conventional epistemological techniques that initiate the problem of experience. Through initial theoretical discussion, followed by reflection on its practical application involving the construction of fractional accounts of lived experience for five participants experiencing chronic pain, the pinboard is developed as a technique that seeks to maintain ‘double vision’ whilst inherently resisting attempts to resolve the juxtaposition it makes visible, enacting and engaging in an ontological politics with conventional methods of social analysis. This includes discussion of how the method might be transported from methodological knowledge spaces to effectively intervene on such conventional methods. (shrink)

Experiential evidence shows that pain is associated with common meanings. These include a meaning of threat or danger, which is experienced as immediately distressing or unpleasant; cognitive meanings, which are focused on the long-term consequences of having chronic pain; and existential meanings such as hopelessness, which are more about the person with chronic pain than the pain itself. This interdisciplinary book - the second in the three-volume Meanings of Pain series edited by Dr Simon van Rysewyk - aims to better (...) understand pain by describing experiences of pain and the meanings these experiences hold for the people living through them. The lived experiences of pain described here involve various types of chronic pain, including spinal pain, labour pain, rheumatic pain, diabetic peripheral neuropathic pain, fibromyalgia, complex regional pain syndrome, endometriosis-associated pain, and cancer-related pain. Two chapters provide narrative descriptions of pain, recounted and interpreted by people with pain. Language is important to understanding the meaning of pain since it is the primary tool human beings use to manipulate meaning. As discussed in the book, linguistic meaning may hold clues to understanding some pain-related experiences, including the stigmatisation of people with pain, the dynamics of patient-clinician communication, and other issues, such as relationships between pain, public policy and the law, and attempts to develop a taxonomy of pain that is meaningful for patients. Clinical implications are described in each chapter. This book is intended for people with pain, their family members or caregivers, clinicians, researchers, advocates, and policy makers. (shrink)

In this article, we discuss the ethical dimensions for the prescribing behaviours of opioids for a chronic pain patient, a scenario commonly witnessed by many physicians. The opioid epidemic in the USA and Canada is well known, existing since the late 1990s, and individuals are suffering and dying as a result of the easy availability of prescription opioids. More recently, this problem has been seen outside of North America affecting individuals at similar rates in Australia and Europe. We argue that (...) physicians are also confronted with an ethical crisis where a capitalist-consumerist society is contributing to this opioid crisis in which societal, legal and business interests push physicians to overprescribe opioids. Individual physicians often find themselves unequipped and unsupported in attempts to curb the prescribing of opioid medications and balance competing goals of alleviating pain against the judicious use of pain medications. Physicians, individually and as a community, must reclaim the ethical mantle of our profession, through a more nuanced understanding of autonomy and beneficence. Furthermore, physicians and the medical community at large have a fiduciary duty to patients and society to play a more active role in curbing the widespread distribution of opioids in our communities. (shrink)

Pain is an intensely subjective experience and one that is difficult for healthcare professionals to treat. Chronic pain, often diffuse, cyclical and involving many systems of the body, is often not well treated in a medical system that relies on discrete symptoms, identifiable causes, external pathogens and physician specialisation. Pain has its own problems specific to Somali diaspora populations, where chronic pain is prevalent but often undertreated, and where Somali patients face barriers of access to medicine. This study, conducted in (...) partnership with a Somali women’s health centre, seeks to understand Somali women’s use of informal and formal networks of healthcare. Drawing from qualitative interviews with Somali, refugee women, this article identifies four emerging frameworks through which participants experience chronic pain: pain as a symptom of exile; pain and the strength to bear pain as issues of faith; medicine as powerful, curative and fluid; medical discrimination and exclusion. (shrink)