Meanings of Pain, Volume II: Common Forms of Pain and Language (2019, Springer)

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Meanings of Pain_Volume II_Cover

  • Provides a study of pain in which meaning is essential to the way pain is felt
  • Describes meanings of pain in patients with common forms of chronic pain
  • Discusses the importance of meaning in pain assessment, diagnosis, clinical language and medical stigmatisation

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.

“It is my opinion that this … work will stand as the definitive reference work in this field. I believe it will enrich the professional and personal lives of health care providers, researchers and people who have persistent pain and their family members. The combination of framework chapters with chapters devoted to analysing the lived experience of pain conditions gives the requisite breadth and depth to the subject.” – Dr Marc A. Russo, MBBS DA(UK) FANZCA FFPMANZCA, Newcastle, Australia, from the Foreword

Review the Table of Contents and buy now on Springer.

Meanings of Pain, Volume II, follows on from Meanings of Pain, Volume I, published in 2016 by Springer.

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Reasons for Investigator-Participation and Introspection in Pain Research

Reason 1: Historical Cases of Investigator-Participation in Pain Research

In the early twentieth century, scientists commonly viewed self-experimentation an essential part of medical research. Self-exposure to untested interventions was believed the most ethical way to assess human responses to those interventions, and to catalyse further research (Dresser 2013). Some of this research helped to found new scientific fields. Respiratory physiology was one such field, formed in the 1920s through self-experiments conducted by scientist John Haldane and colleagues. In 1984, physician Barry Marshall ingested Helicobacter pylori, which helped to establish the link between H. pylori and gastric pathology, and in 1992, self-experiments conducted by Mike Stroud and Ranulph Fiennes in Antarctica advanced understanding of nutrition in extreme conditions.

Self-experiments to study pain experience have been published by Sir Head (1920), Woollard and Carmichael (1933), Landau and Bishop (1953), Price (1972), Price et al. (1977), and Staud et al. (2001, 2008), to name only a few significant investigator-participants who studied pain. William Landau and George H. Bishop conducted standard psychophysical research on themselves to study the qualitative differences between “first pain” and “second pain” (i.e. “double pain”; later termed epicritic and protopathic pain) (Landau and Bishop 1953). Initially, Landau and Bishop identified through introspection the differential experiential qualities between first and second pain, followed by scientifically informed speculation about the mechanistic difference between the two types of pain. They discovered that first pain was sharp or stinging, well localized, and brief, whereas second pain was dull, aching, throbbing, or burning, and poorly localized, and longer lasting. The qualities of second pain were felt when skin C-nociceptors were stimulated.

These findings were subsequently confirmed by Price (1972) based on researcher and naïve participant introspective reports. Temporal differences between first and second pain were introspected on and mechanistically explained in terms of central temporal summation in studies by Price et al. (1977), and Staud et al. (2001, 2008), using investigator- and naïve-participants.

Conducting self-experiments to study referred pain, collaborators Herbert Woollard and Edward Carmichael observed that 300 g of weight placed on the right testicle produced slight discomfort in the right groin, while 650 g on the right testicle caused severe pain on the right side of the body. They confirmed that injury to the testicles caused pain to be referred throughout the body. For instance, as the weight on the testicle increased to over 900 g, they reported pain “of a sickening character” not only in the groin but also spreading across the back (Woollard and Carmichael 1933).

Self-experimentation on pain has on occasion led to surprising results. The psychologist B. Berthold Wolff self-experimented in his pain psychophysics laboratory, varying thermal pain which was produced at that time by briefly shining a strong light on a spot on the forearm blackened with candle black for a calibrated time and intensity of exposure (Hardy et al. 1940). On one occasion, Wolff pushed the button to deliver the noxious stimulus, but then something unexpected happened: he screamed with pain, which was brief but intense and filled his whole body. He described it as the most intense whole-body pain he had ever experienced. Wolff later discovered that the light stimulus had been knocked off its correct aim, and had missed his forearm altogether and instead diffused onto the opposite wall where it created a very strong flash of light throughout the normally dark room. Wolff speculated that, as he was expecting to feel pain, the unexpected flash of strong light had the same effect, producing an experience of pain.

It is unclear if investigators today independently conduct self-experiments or co-participate in their own pain studies. The convenience of recruiting participants from university classes and the internet may have made self-experimentation or co-participation of pain seem somewhat redundant to researchers. The Declaration of Helsinki advises on conducting ethical research using patients and healthy volunteers, although it is unclear if this is reason enough for challenging independent self-experimentation or investigator co-participation. In self-experiments, the researcher is both investigator and single participant, so the requirement for informed consent could be waived. Still, there is clear historical precedent for scientific investigators successfully observing and analyzing their own experiences of pain. The results of such published self-experiments have been integrated into the body of knowledge of pain, and replicated in numerous studies using naïve participant introspective reports and standard scientific methods.

References

Dresser R (2013) Personal knowledge and study participation. J Med Ethics. doi:10.1136/medethics-2013-101390.

Hardy JD, Wolff HG, Goodell H (1940) Studies on pain: a new method for measuring pain threshold: observations on spatial summation of pain. J Clin Investig 19(4):649–657.

Head H (1920) Studies in neurology. Oxford University Press, London.

Landau W, Bishop GH (1953) Pain from dermal, periosteal, and fascial endings and from inflammation: electrophysiological study employing differential nerve blocks. AMA Arch Neurol Psychiatry 69(4):490–504.

Price DD (1972) Characteristics of second pain and flexion reflexes indicative of prolonged central summation. Exp Neurol 37(2):371–387.

Price DD, Hu JW, Dubner R, Gracely RH (1977) Peripheral suppression of first pain and central summation of second pain evoked by noxious heat pulses. Pain 3(1):57–68.

Staud R, Vierck CJ, Cannon RL, Mauderli AP, Price DD (2001) Abnormal sensitization and temporal summation of second pain (wind-up) in patients with fibromyalgia syndrome. Pain 91 (1):165–175.

Staud R, Craggs JG, Perlstein WM, Robinson ME, Price DD (2008) Brain activity associated with slow temporal summation of C-fiber evoked pain in fibromyalgia patients and healthy controls. Eur J Pain 12(8):1078–1089.

Woollard HH, Carmichael EA (1933) The testis and referred pain. Brain 56(3):293–303.

Reconsidering the International Association for the Study of Pain definition of pain

Cohen M, Quintner J, van Rysewyk S (2018). Reconsidering the IASP Definition of Pain. Pain Reports, 3(2).

Abstract

Introduction: The definition of pain promulgated by the International Association for the Study of Pain (IASP) is widely accepted as a pragmatic characterisation of that human experience. Although the Notes that accompany it characterise pain as “always subjective,” the IASP definition itself fails to sufficiently integrate phenomenological aspects of pain.

Methods: This essay reviews the historical development of the IASP definition, and the commentaries and suggested modificationsto it over almost 40 years. Common factors of pain experience identified in phenomenological studies are described, together with theoretical insights from philosophy and biology.

Results: A fuller understanding of the pain experience and of the clinical care of those experiencing pain is achievable through greater attention to the phenomenology of pain, the social “intersubjective space” in which pain occurs, and the limitations of language.

Conclusion: Based on these results, a revised definition of pain is offered: Pain is a mutually recognizable somatic experience that reflects a person’s apprehension of threat to their bodily or existential integrity.

Associated Commentaries:

Osborn M. Situating pain in a more helpful place. PAIN Reports 2018:e642.

Treede RD. The IASP definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes. PAIN Reports 2018:e643.

Download a copy of the paper here.

‘Meanings of Pain in Patients with Cancer’ – Cancer Pain Symposium 2017

Cancer Pain Symposium, 9 December, 2017

Sydney Vital

Abstract

Pain due to cancer, a common effect of the disease and its treatment, makes the experience of cancer more distressing for patients and their families. The meaning of cancer-related pain has been referred to as the “feared consequence of cancer”, and associated with pathology and death. However, if cancer-related pain is related to (non-cancer) pain and its common factors, of which the meaningfulness of pain is one, and not the cancer disease, then the meaning of cancer-related pain is clinically relevant. The meanings of personal experiences are important to human beings, and influence how we respond to life’s changing circumstances. A neglected aspect of the clinical management of cancer is the patient’s ability to make the experience of cancer meaningful, despite the presence of disabling pain. This presentation provides an overview of the meanings of pain, and some pilot data based on Lipowski’s meanings of chronic illness, which suggests that cancer-related pain is qualitatively closer to chronic non-cancer pain than to cancer. Ideas are provided for health care professionals to make cancer and cancer-related pain more meaningful to patients and their families.

Meanings of Pain, Volume I (2016, Springer)

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van Rysewyk S (2016). Meanings of Pain. Springer International Publishing AG: Switzerland.

  • First book devoted to study of the meanings of pain
  • Explains why meaning is important in the way that pain is felt
  • Promotes integration of qualitative and quantitative research methods to study meanings of pain
  • Includes insights that can aid in the clinical management of patients with pain

About Meanings of Pain, Volume I

Although pain is widely recognized by clinicians and researchers as an experience, pain is always felt in a patient-specific way rather than experienced for what it objectively is. This fact makes perceived meaning important in the study of pain. The book contributors explain why meaning is important in the way that pain is felt and promote the integration of quantitative and qualitative methods to study meanings of pain. For the first time in a book, the study of the meanings of pain is given the attention it deserves.

All pain research and medicine inevitably have to negotiate how pain is perceived, how meanings of pain can be described within the fabric of a person’s life and neurophysiology, what factors mediate them, how they interact and change over time, and how the relationship between patient, researcher, and clinician might be understood in terms of meaning.

Though meanings of pain are not intensively studied in contemporary pain research or thoroughly described as part of clinical assessment, no pain researcher or clinician can avoid asking questions about how pain is perceived or the types of data and scientific methods relevant in discovering the answers.

Reviews of Meanings of Pain

“Meanings of Pain offers an intriguing investigation into the implications of the psychological, sociological, and personal lived meanings of pain for the overall management of patients struggling with this chronic condition. … it may prove invaluable to the physician struggling to understand the intricacies of the patient pain experience, facilitating improved comprehensive pain therapy.” (Emily E. Smith-Straesser and Amanda M. Kleiman, Anestesia & Analgesia, Vol. 125 (5), November, 2017)

Pain Science and Sensibility Episode 29: Discussion of the book “Meanings of Pain”

Meanings of Pain – Book Review by Josie Billington (University of Liverpool), Andrew Jones, and James Ledson (The Royal Liverpool and Broadgreen University Hospitals NHS Trust)

Meanings of Pain – Book Review by Christin Bird

The Science and Philosophy of the Meaning of Pain – Review of Chapter 7, “A Scientific and Philosophical Analysis of Meanings of Pain in Studies of Pain and Suffering” in Meanings of Pain by Smadar Bustan – by Tim Cocks

Meanings of Pain – Book Review by Asaf Weisman

N=1 as a reference for general concepts of experiencing pain by Morten Høgh

New Developments

Springer is considering publishing Meanings of Pain in a multiple volume series. Watch this space for an update on this development.