Thoughts on “Reconsidering fetal pain” – by Stuart WG Derbyshire & John C Bockmann

Sculpture by Fabio Viale

“…we propose that the fetus experiences a pain that just is and it is because it is, there is no further comprehension of the experience, only an immediate apprehension.” – Reconsidering Fetal Pain (2019), by Stuart WG Derbyshire, John C Bockmann

I agree with this proposal.

Experiencing pain is being in an animal-like state. But, experiencing pain is not knowing that this is pain. I think experiencing pain becomes a state of knowing only if a person is a competent language user. 

A consequence of this idea is that pain experience is not always immediately transparent or lucid to the person experiencing it. Odd as it sounds, to be in pain is not to know pain. This challenges the Cartesian philosophy of mind.

Following Derbyshire and Brockman, the fetus or neonate experiences pain, but without understanding or recognition.

Emre Ihan asked me: “Do you think learning is a form of recognition? A lot of neonates pull their legs away when nurses and their parents touch their heels, after weeks of heel lancing (heel pricks for blood tests). Could this be an anticipation of pain, and thus recognition that pain is imminent…”

Compare the neonate’s behaviour with a dog walking beside a road with the flow of traffic. The behaviour of the dog conforms to our left-hand drive convention, but it does not do so because it understands that convention.

In the same way, a chicken that stretches its neck and wings as in the mating ritual of the wandering albatross is not stretching its neck because it understands, or has a conception of, this mating pattern.

Point 1. There is behaviour that conforms to a complex pattern.

Point 2. This behaviour is not explained through a conception or understanding of that pattern. The behaviour just accidentally realises part of a complex pattern. 

Point 3. The explanation for the behaviour is explained by its relation to the complex patterned whole.

A plausible explanation of the neonate’s behaviour is in terms of the survival value to groups of humans of this form of behavior. These behaviours are performed because they form part of a hard-wired evolutionary pattern, not because the neonate recognises or follows a set of cognitive rules that are an abstract description of the pattern.

Thus, the neonate, like the dog or chicken, does not engage in their patterned behaviour “on purpose.” The neonate does not intend to follow rules or apply social norms.

Developmentally, that skill emerges later when the neonate is a child and learns, if it is fortunate enough, the concept of pain.

Call for Abstracts: Meanings of Pain, Volume III

Sculpture by Fabio Viale

Volume III Topic: Meanings of pain in vulnerable or special patient groups

Series Editor: Dr Simon van Rysewyk
Publisher: Springer

The Meanings of Pain book series describes how the meaning of pain changes pain experience – and people – over time.

Pain in the moment is experienced as immediately distressing or unpleasant. If pain persists over time, more complex meanings about the long-term consequences, or burden of pain, can develop. These meanings can include existential meanings such as despair or loneliness that focus on the person with pain, rather than pain itself.

Meanings of Pain offers a vocabulary of language about pain and meaning. An objective of the series is to stimulate self-reflection on how to use information about meaning in clinical and non-clinical pain settings. The book series is intended for people with pain, family members or caregivers of people with pain, clinicians, researchers, advocates, and policy makers.

Although chronic pain can affect anyone, there are some groups of people for whom particular clinical support and understanding is urgently needed. This applies to “vulnerable” or “special” groups of people and to the question of what pain means to them.

Volume III focuses on describing the meanings of pain in groups of “vulnerable” or “special” people, such as:

  • Infants or children
  • Women
  • Older adults
  • People with a physical or intellectual disability
  • People with a brain injury
  • People diagnosed with a disease
  • Veterans
  • Athletes
  • Workers
  • Addicts
  • People with mental illness or mental disorders
  • Homeless people
  • People in rural or remote communities
  • People in multicultural communities
  • Indigenous peoples

Invited chapter types
The editor Dr Simon van Rysewyk invites contributions for Volume III on the meanings of pain in vulnerable or special patient groups. The following manuscript types will be considered:

  • Original Research (e.g., original clinical, translational, or theoretical research)
  • Reviews (e.g., Systematic Reviews, Meta-analytic reviews, Cochrane type reviews, Pragmatic Reviews)

Authors interested in submitting a chapter for publication in Volume III are invited to submit a 350-word Abstract, which includes the name and contact information of the corresponding author, to:

Dr Simon van Rysewyk
simon.vanrysewyk@utas.edu.au

Abstract Deadline: open

“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 in Volume II

“Meanings of Cancer-Related Pain”

Sculpture by Fabio Viale

Australian Pain Society Annual Scientific Meeting 2020
Hobart Tasmania

Topical Session
Tuesday, April 7, 2020, 3.30-5.00pm

Session Description: Cognitive factors are important determinants of cancer-related pain experience. Simon van Rysewyk describes some common meanings and beliefs that people have about cancer, illness, and pain, and the consequences these meanings have in relation to common help-seeking behaviours or coping strategies people choose to adopt. Suffering is a cognitive and emotional response to recurrent perceived losses experienced in some people with cancer. Megan Best presents on the challenges in assessing people with cancer-related suffering and the relationship of suffering to cancer-related pain. Melanie Lovell compares levels of suffering in people with cancer-related pain versus non-cancer chronic pain, highlighting differential meanings of existential or spiritual distress and mood dysfunction. Best and Lovell outline management approaches to cancer pain and suffering that are not responsive to analgesia, such as meaning- or peace-centred therapies.

Session Objectives
At the end of the session, attendees will know:
– Common meanings of cancer-related pain and how people apply these meanings to cope with their pain
– Common meanings of suffering in cancer-related pain and the relationship between these meanings and non-cancer chronic pain experience and mood dysfunction
– Effective approaches to diagnosis and management of cancer-related pain symptoms, including interventions based on meaning

Presenter Duties
Chair: Professor Jane Phillips, University of Technology, Sydney
Organiser/Presenter 1: Dr Simon van Rysewyk, University of Tasmania
Presenter 2: Dr Megan Best, University of Sydney
Presenter 3: Associate Professor Melanie Lovell, University of Sydney

Humans beings are persons and organisms

Sculpture by Fabio Viale

As organisms, human beings interact with the world and each other through causal mechanisms that control us and every other physical thing. As persons, we act in the world through our thoughts, emotions, attitudes, or desires.

Accordingly, human beings are describable in two distinct, but complementary ways: in terms of the way the world is, through scientific descriptions of the causal mechanisms and laws that explain physical things, or, in terms of the way the world seems, through descriptions of personal experiences and meanings.

One or the other way of describing human beings comes into focus depending on the questions we ask about ourselves or the world. The features of personal experience—thought, feeling, speech and action—are amenable to standard scientific explanation as specific changes in the body. Traditionally, scientific research has had much to say about the physical nature of pain, but much less about the personal experience or meaning of pain. Indeed, the meaning of pain remains a blind spot in knowledge.


A description of a human being as a person means that there is a way of understanding of human beings in which personal experience and meaning, rather than physical causation alone, is needed to answer the question, “What is happening?”

Human persons can distinguish between how things are in the world and how things seem to me. I can recognise within myself a perspective or point of view on the world and identify it as belonging to me. Every person has such a unique perspective; this is partly what it means to be a person rather than a physical thing. In contrast, a scientific description of the world does not presuppose any personal point of view. Physical science does not use words like “I”, “here,” or “now”. Does this mean that “persons” are unobservable to standard quantitative science?

Possibly. Imagine a complete explanation of pain according to the final neurophysiology of pain—whatever it turns out to be. Such an explanation of pain would, to put it very crudely, accurately map specific neurophysiological changes in physical parts in the living human organism and all their true causal interactions across time. However invaluable such an explanation would be to pain medicine, it could not describe the way pain seems to the person who experiences it, for which of the physical objects described in this explanation is me with pain, here, now? Immediate pain always seems a certain way to persons, and this “seeming” determines the experience of the person with pain. In describing personal pain, human beings use language with other meanings than the language used in neurophysiology. The final neurophysiological explanation of pain therefore could explain only one dimension of pain in human beings—the physical dimension—in language that could not capture the personal experience, burden, or meaning of pain.


A philosophical assumption of neurophysiology is that a person is identical with his or her body. Person and body are one and the same thing. In terms of personal experience, however, the identity between person and body escapes personal understanding. For example, when I feel a pain, there is no information or evidence, or nothing that I could discover about my body subsequent to the experience of pain, that could demonstrate it to be false. When I feel a pain, I simply know that I am in pain.

In person to person interactions, we commonly respond to each other as though we are not identical with the human body, but in a compelling sense operating “through” the body, which seems to be a vehicle of thought, emotion, pain or suffering. We feel that each person we encounter in the world is a unique perspective that is not the body, but the “self”, which peers out through the face. The human face is the social instrument of persons. In seeking to understand you, or adjust how the world or your experience seems to you, I interact with you through your embodied perspective.

In pain experience, it is my loss of personal control over my body, and its dominion over me, that create the compelling sense, for me and for others, of an “incarnate” person. Pain imposes a significant vulnerability on persons: the vulnerability of a free person who is overwhelmed in his or her body by the presence of pain. This can make the person, and the person’s significant others, feel answerable for what he or she experiences.


“Pain Takes Over Everything”: The Experience of Pain and Strategies for Management

Marie Crowe, Deb Gillon, Cate McCall, and Jennifer Jordan

Abstract 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: (1) body as obstacle; (2) disrupted sense of self; (3) invisible but real; (4) unpredictability; and (5) 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”
– “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 (mindfulness and cognitive behavioural therapy).

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.

Meanings of Pain, Volume II, on Springer.

External Links
Painaustralia
Pain Health
Chronic Pain Australia

Pain Fact Sheets
The Nature and Science of Pain (Painaustralia)
Prevalence and the Human and Social Cost of Pain (Painaustralia)
Clinical Assessment of Pain (Painaustralia)
Multidisciplinary Pain Management  (Painaustralia)
Chronic Pain – A Major Issue in Rural Australia (National Rural Health Alliance)
Chronic Physical Illness, Anxiety and Depression (Beyond Blue)
Neuropathic (Nerve) Pain (Painaustralia)
Self-Managing Chronic Pain (Painaustralia)
The Pain Toolkit Australia (www.paintoolkit.org)
Chronic Pain Management Strategies (NSW ACI)
Communicating and building a pain treatment team (NSW ACI)
Pain and Physical Activity (NSW ACI)

Brisbane Pain Research Symposium 2019

This free whole-day symposium at UQ is open to all members of the community with an interest in advancing pain research and treatments.

About this Event

Hosted by the IMB Centre for Pain Research, we invite you to a whole-day multidisciplinary pain research symposium on Friday 29 November 2019 at the Queensland Bioscience Precinct Auditorium.

Building on the outstanding success of last year’s symposium which attracted over 250 registrants from right across the community, this upcoming student-led event brings together pain research groups from different disciplines across Brisbane and provides a platform for researchers at all career stages to showcase their work alongside leading national and international speakers in the field.

Our aim is to stimulate scientific discussion, collaboration and ongoing engagement to advance pain research and treatments with all sectors of the community, i.e. basic & clinical pain researchers, people living with pain-related conditions, medical practitioners & allied health professionals, academics and hospital administrators, industry representatives, government health agencies & regulatory bodies, people caring for those living with pain-related conditions and community support groups.

Instructions for submitting an abstract for a poster presentation or short talk are further below (FAQs). Postgraduate research candidates (Hons, Masters, PhD), early career researchers (ECRs) and clinicians are particularly encouraged to submit an abstract for the symposium.

Generous prizes for the Best Posters and Best Punchy Poster Talks will be available!

Abstract submissions are also welcome from hospital administrators, industry representatives, government health agencies & regulatory bodies, and community support groups.

Learn more about this event here.

Call for Papers: Pain Medicine Special Issue, “Meaning in the Context of Pain”

Sculpture by Fabio Viale

Dear reader,

Pain Medicine is planning an interdisciplinary Special Issue, “Meaning in the Context of Pain.” I am the lead guest editor; Dr John Quintner and Prof Milton Cohen are guest editors.

Meaning is an essential dimension of the experience of pain. Empirical evidence from qualitative and mixed method studies suggests that pain is not only associated with a common meaning of “threat” or “danger,” but also is experienced as immediately distressing or unpleasant. If this combined meaning persists over time, people’s concerns may shift from the experience of pain onto themselves as persons. As a result of this shift, powerful existential meanings such as hopelessness or loneliness may develop. Such experiential meanings interact with desires to reduce or eliminate pain, and with expectations about the perceived efficacy of a particular treatment for pain. These meanings may in turn result in a spectrum of negative moods, such as depression or despair, and negative beliefs such as fatalism. Such negative components of the emotional dimension are often at the core of the lived experience of pain.

Despite this evidence, the preference for and consequent overwhelming dominance of biomedical explanations in pain clinical practice and research has meant that this other dimension of the experience of pain has been overlooked.

Special Issue Themes and Sub-Themes

Themes of the “Meaning in the Context of Pain” Special Issue include, but are not restricted to, the following:

  • Common experiential meanings of pain in different contexts
    • Chronic non-cancer pain or cancer-related pain
    • Pain in special or vulnerable groups
    • Pain and mental illness
    • Pain and substance abuse
    • Pain and fatigue
  • How meaning modifies the experience of pain
    • Pain and personal identity over time, including stigmatisation
    • Family meanings and the experience of pain (e.g., “psychosomatic families”)
    • Perceived meaningfulness of life, including suicidality
    • How symbolic manipulation of meaning (e.g., verbal instruction) can change pain experience
    • Perceived meaning of different types of medical treatment
    • “Catastrophising” and “fear-avoidance” as expressions of meaning
    • The limits of meaning: when no meaning can be given to an experience of pain (e.g., “medically unexplained pain”)
    • Coming to terms with “pain acceptance”
  • Therapeutic implications of meaning
    • Similarities and differences in meanings of pain between the person in pain versus observers
    • The influence of meaning on pain scale ratings
    • Implications of meaning-making for self-control or self-management of pain
    • How patients’ meanings of pain can inform treatment planning
    • Strategies patients use to find meaning in their pain
    • Work rehabilitation and returning to work

  • Experiential research methods to study meanings of pain
    • Ethnography, narrative, phenomenology, grounded theory, and single-case study methods
    • Other research methods: Neurophenomenology, The Descriptive Experience Sampling Method, The Experiential-Phenomenological Method, The Elicitation Interview Method, quantitative designs, quantitative-qualitative designs

The meaning of “meaning” and clinical applications or implications of meaning in the context of pain must be addressed in detail in all contributions.

Keywords: pain, meaning, patient experience, pain management

Invited article types

Within the scope of the themes and sub-themes described above, the guest editors invite contributions considered in the form of the following manuscript types, in order of importance:

  • Reviews (e.g., Systematic Reviews, Meta-analytic reviews, Cochrane type reviews, Pragmatic Reviews)
  • Original Research (e.g., original clinical, translational, theoretical or philosophical research)

See Instructions to Authors in Pain Medicine.

If you wish to submit an article for consideration in this Special Issue, please let me know at: simon.vanrysewyk@utas.edu.au. Then, email me a 400-word description/summary/abstract by November 1, 2019.

Thank you for your time.

Does “pain” need redefining?

By Simon van Rysewyk,1 John Quintner,2 Milton Cohen3
1School of Humanities, University of Tasmania, Australia; 2Arthritis & Osteoporosis Western Australia; 3St Vincent’s Clinic and Clinical School, University of New South Wales, Australia

Presented at the 2019 Patient Experience Symposium, April 29-30, 2019, Sydney, Australia.

Introduction: The widely accepted definition of pain promulgated by the International Association for the Study of Pain (IASP), although useful in a clinical context, is written mainly from the perspective of the “observer”.  As such it fails sufficiently to capture the perspective of the “experiencer” of pain.
Methods: This presentation briefly analyses the historical development of the IASP definition, and some of the commentaries and suggested modifications to it over almost 40 years. Common factors of pain that patients experience are described, together with theoretical insights from philosophy and biology.
Results: Major problems with the IASP definition of pain include: (i) the stance of the observer is privileged over that of the experiencer of pain; (ii) the obligatory linking with “tissue damage” focuses attention on the body as distinct from the person; and (iii) the validity of the experience when there is no obvious “cause” is questioned. A revised definition of pain is offered: Pain is a mutually recognisable somatic experience that reflects a person’s apprehension of threat to their bodily or existential integrity.
Conclusion: This definition integrates the subjectivity or “first-person” level of experience of pain, and the challenge for the “second-person” of clinical evaluation (if not also intervention) towards objective “third-person” goals. This redefinition of pain is compatible with that of the IASP but more philosophically sound, biologically relevant, clinically applicable, and meaningful for people experiencing pain and for health care professionals who engage with them.

Download here.

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

Featured

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.

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.

Should investigators introspect on their own pain experiences as study co-participants? – Simon van Rysewyk and Carl L. von Baeyer

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van Rysewyk S, von Baeyer CL. Should investigators introspect on their own pain experiences as study co-participants? In: van Rysewyk S (2016). Meanings of Pain. Springer International Publishing AG: Switzerland.

Abstract

The question of investigators introspecting on their own personal pain experiences in pain studies has received little attention in the literature. Study of this question may reflect ethical reservations about the many points at which self-interest may lead us to introspect on personal experiences through personal biases that in turn impair professional decision-making and perception. Despite this valid concern about research co-participation, we offer three reasons why investigators can introspect on personal pain as co-participants in their own pain studies. First, there is historical precedent for investigator participation and co-participation in scientific pain research using introspection as a study method. Second, general concerns about variability in self-report based on introspection on pain experience partly derive from true fluctuations in personal pain experience and perceived interests in self-reporting pain, not simply error in its scientific measurement. Third, the availability of the Experiential-Phenomenological Method, a mixed research method for the study of human experiences, allows investigators to co-participate with naïve participants in their own studies by encouraging passive introspection on personal pain experiences.

Download a copy of the chapter here.

 

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.

Towards raising awareness of qualitative pain research

While awareness of qualitative research of lived pain is slowly increasing in the field of pain, it is far from established and needs cultivating from within the field by pain researchers (Mitchell & MacDonald, 2009; Osborn & Rodham, 2010; Price & Barrell, 2012). Pain research has traditionally been dominated by quantitative research methods, which have their roots in physiology, physics, biology, and psychophysics, arising from mathematics, statistics, and psychometrics (Price et al. 2002; Price & Aydede, 2005; Price & Barrell, 2012). This trend continues unabated today, and perhaps explains why Osborn and Rodham (2010) found that many individual pain researchers have not yet accumulated a significant body of qualitative pain research. A body of qualitative pain research would enable researchers to develop their arguments in more depth concerning the nature and types of personal meanings apparent in pain experience, especially clinical pain experiences across the lifespan. The rationale for conducting qualitative pain research is likely not clear to many in the field of pain, and researchers are probably unaware of the potential richness of qualitative pain data to uniquely describe lived pain or the diverse tools available for analyzing qualitative data. In line with this, Osborn & Rodham (2010) found that many of the qualitative pain studies they reviewed used only one type of analysis (i.e., data analysis was not triangulated), description rather than interpretation prevailed in discussion of data meaning, and research methods were not thoroughly described.

A powerful reason to conduct more qualitative pain research is the common complaint from clinical pain patients that they feel they have never had an opportunity to fully explore their lived pain experiences with health care professionals, that no one has ever fully understood what is wrong with them and, most importantly, that no one appears to be listening (e.g., Melzack, 1990; Hoffmann & Tarzian, 2001; Hansson et al. 2011; McGee et al. 2011; Thacker & Moseley, 2012; De Ruddere et al. 2014). Clinical failure to sufficiently appreciate patient pain and its felt meanings can result in profound patient dissatisfaction, exacerbation of feelings of isolation and confusion, among other negative existential appreciations, and cause up-regulation of nociception (Butler et al. 2003). Despite this significant problem in the treatment and management of clinical pain, some pain researchers (e.g., Apkarian et al. 2011; Wortolowska, 2011) and government agencies (e.g., National Research Council of the National Academies, 2008; National Institutes of Health, 2011) have argued for replacing first-person patient experiential pain data with brain-imaging data.

Although qualitative research alone cannot solve these challenges, because of its exploratory nature, it can complement quantitative clinical pain research to describe lived pain and the psychosocial factors that improve or worsen the efficacy of pain interventions, as well as core intervention components that are associated with desired or undesired patient outcomes (Price et al. 2002; Price & Aydede, 2005; Price & Barrell, 2012; Thacker & Moseley, 2012).

References

Apkarian, A. V., Hashmi, J. A., & Baliki, M. N. (2011). Pain and the brain: specificity and plasticity of the brain in clinical chronic pain. Pain, 152(3 Suppl), S49–64.

De Ruddere, L., Goubert, L., Stevens, M. A. L., Deveugele, M., Craig, K. D., & Crombez, G. (2014). Health Care Professionals” Reactions to Patient Pain: Impact of Knowledge About Medical Evidence and Psychosocial Influences. The Journal of Pain, 15(3), 262–270.

Hoffmann, D. E., & Tarzian, A. J. (2001). The girl who cried pain: a bias against women in the treatment of pain. The Journal of Law, Medicine & Ethics, 28(s4), 13–27.

McGee, S. J., Kaylor, B. D., Emmott H., & Christopher, M. J. (2011). Defining chronic pain ethics. Pain Medicine, 12, 1376–1384.

Melzack, R. (1990). The tragedy of needless pain. Scientific American, 262(2), 27–33.

National Institutes of Health. (2011). Biomarkers for chronic pain using functional brain connectivity. Common Fund NIH Government.

National Research Council of the National Academies. Emerging cognitive neuroscience and related technologies. (2008). Washington, DC: National Academies Press.

Price, D. D., & Aydede, M. (2005). The experimental use of introspection in the scientific study of pain and its integration with third-person methodologies: The experiential-phenomenological approach. In M. Aydede (Ed.), Pain: New Essays on its Nature and the Methodology of its Study (pp. 243–273). Cambridge, Mass.: MIT Press.

Price, D. D., & Barrell, J. J. (2012). Inner Experiences and Neuroscience. Merging the two perspectives. Cambridge, Mass.: MIT Press.

Price, D. D., Barrell, J. J., & Rainville, P. (2002). Integrating experiential-phenomenological methods and neuroscience to study neural mechanisms of pain and consciousness.

Thacker, M. A., & Moseley, G. L. (2012). First-person neuroscience and the understanding of pain. The Medical Journal of Australia, 196(6), 410–411.

Wortolowska, K. (2011). How neuroimaging can help us to visualise and quantify pain? European Journal of Pain, 5, 323–327.