Considering Precision and Utility When we Talk About Pain. Comment on Cohen et al

"I wish I knew then what I know now" - pain science education concepts important for female persistent pelvic pain: a reflexive thematic analysis

ABSTRACT

Pain science education (PSE) provides people with an understanding of "how pain works" grounded in the biopsychosocial model of pain; it has been demonstrated to improve outcomes in musculoskeletal pain conditions. Preliminary evidence suggests PSE may be effective for female individuals with persistent pelvic pain, but how the content of PSE needs to be modified for this group remains to be determined. A reflexive thematic analysis of qualitative data was performed to identify PSE concepts that female individuals with persistent pelvic pain consider important and why. Twenty individual, semistructured interviews were conducted with adult females who had engaged with PSE and had self-identified as having "improved" pelvic pain. Most participants had been diagnosed with endometriosis (n = 16). Four themes were generated capturing PSE concepts considered important by female individuals with "improved" pelvic pain: (1) "A sensitised nervous system leads to overprotective pain" validated their pelvic pain as being real; (2) "Pain does not have to mean the body is damaged (although sometimes it does)" provided reassurance that pelvic pain does not mean their condition is worsening; (3) "How I think, feel, and 'see' my pain can make it worse" enabled participants to find optimal ways to manage their pain; and (4) "I can change my pain… slowly" provided hope that pelvic pain can improve and empowered them to pursue pain improvement as a viable goal. This study generated 4 PSE learning concepts that were important to female individuals with improved pelvic pain and may be incorporated into PSE curricula for female individuals with pelvic pain.

Teaching Patients About Pain: The Emergence of Pain Science Education, its Learning Frameworks and Delivery Strategies

Since it emerged in the early 2000's, intensive education about 'how pain works', widely known as pain neuroscience education or explaining pain, has evolved into a new educational approach, with new content and new strategies. The substantial differences from the original have led the PETAL collaboration to call the current iteration 'Pain Science Education'. This review presents a brief historical context for Pain Science Education, the clinical trials, consumer perspective, and real-world clinical data that have pushed the field to update both content and method. We describe the key role of educational psychology in driving this change, the central role of constructivism, and the constructivist learning frameworks around which Pain Science Education is now planned and delivered. We integrate terminology and concepts from the learning frameworks currently being used across the PETAL collaboration in both research and practice-the Interactive, Constructive, Active, Passive framework, transformative learning theory, and dynamic model of conceptual change. We then discuss strategies that are being used to enhance learning within clinical encounters, which focus on the skill, will, and thrill of learning. Finally, we provide practical examples of these strategies so as to assist the reader to drive their own patient pain education offerings towards more effective learning. PERSPECTIVE: Rapid progress in several fields and research groups has led to the emergence 'Pain Science Education'. This PETAL review describes challenges that have spurred the field forward, the learning frameworks and educational strategies that are addressing those challenges, and some easy wins to implement and mistakes to avoid.

We Are All in This Together-Whole of Community Pain Science Education Campaigns to Promote Better Management of Persistent Pain

Persistent pain is a major public health issue-estimated to affect a quarter of the world's population. Public understanding of persistent pain is based on outdated biomedical models, laden with misconceptions that are contrary to best evidence. This understanding is a barrier to effective pain management. Thus, there have been calls for public health-based interventions to address these misconceptions. Previous pain-focussed public education campaigns have targeted pain beliefs and behaviours that are thought to promote recovery, such as staying active. However, prevailing pain-related misconceptions render many of these approaches counter-intuitive, at best. Pain Science Education improves understanding of 'how pain works' and has been demonstrated to improve pain and disability outcomes. Extending Pain Science Education beyond the clinic to the wider community seems warranted. Learning from previous back pain-focussed and other public health educational campaigns could optimise the potential benefit of such a Pain Science Education campaign. Pain Science Education-grounded campaigns have been delivered in Australia and the UK and show promise, but robust evaluations are needed before any firm conclusions on their population impact can be made. Several challenges exist going forward. Not least is the need to ensure all stakeholders are involved in the development and implementation of Pain Science Education public messaging campaigns. Furthermore, it is crucial that campaigns are undertaken through a health equity lens, incorporating underrepresented communities to ensure that any intervention does not widen existing health inequalities associated with persistent pain. PERSPECTIVE: Public misconceptions about pain are a significant public health challenge and a viable intervention target to reduce the personal, social, and economic burden of persistent pain. Adaptation of Pain Science Education, which improves misconceptions in a clinical setting, into the public health setting seems a promising approach to explore.

"Nociplastic Pain": A Challenge to Nosology and to Nociception

The construct of "nociplastic pain" has met with divergent receptions. On the one hand it has been enthusiastically embraced, to the extent of conflation with central sensitization of nociception and the International Classification of Diseases 11th Revision (ICD-11) entity of "primary" pain, and the promulgation of "nociplastic pain syndromes." On the other hand, it has been rejected by those whose skepticism derives from the absence, by definition, of underlying activation of nociceptors. This article seeks to dissect these divergent views and search for reconciliation between them. One line of argument is that "nociplastic" pain, "primary" pain, and "central sensitisation of nociception" reflect different domains of inquiry and should not be conflated. "Nociplastic" pain emerges as a hypothesis that confers clinical legitimacy and utility; while that hypothesis needs a minor but important modification and continues to require testing, discipline in its usage is necessary. The other line of argument discovers an unexpected impasse: the construct of "nociplastic pain" describes a phenomenon that accords with the International Association for the Study of Pain definition of pain but occurs in the absence of nociception-as-currently-defined, thus challenging the definitional link between pain and tissue damage. The article offers a resolution of this impasse by suggesting that nociception-as-currently-defined be replaced by the resurrected concept of a nociceptive apparatus, activation of which is necessary but not sufficient for the experience of pain. One consequence would be to allow the assertions underpinning "nociplastic" to be tested empirically; another would be to relate the phenomenon of pain to a more biologically plausible basis than "actual" or "resemblance to" tissue damage. PERSPECTIVE: This article explores the major challenges posed by "nociplastic pain" to nosology and to nociception. While discipline in the clinical use of the construct is required, it also emerges that the main issue is the International Association for the Study of Pain definition of nociception. A reconceptualization of nociception is proposed for logical, biological, and clinical coherence.

A Manifesto in Defense of Pain Complexity: A Critical Review of Essential Insights in Pain Neuroscience

Chronic pain has increasingly become a significant health challenge, not just as a symptomatic manifestation but also as a pathological condition with profound socioeconomic implications. Despite the expansion of medical interventions, the prevalence of chronic pain remains remarkably persistent, prompting a turn towards non-pharmacological treatments, such as therapeutic education, exercise, and cognitive-behavioral therapy. With the advent of cognitive neuroscience, pain is often presented as a primary output derived from the brain, aligning with Engel's Biopsychosocial Model that views disease not solely from a biological perspective but also considering psychological and social factors. This paradigm shift brings forward potential misconceptions and over-simplifications. The current review delves into the intricacies of nociception and pain perception. It questions long-standing beliefs like the cerebral-centric view of pain, the forgotten role of the peripheral nervous system in pain chronification, misconceptions around central sensitization syndromes, the controversy about the existence of a dedicated pain neuromatrix, the consciousness of the pain experience, and the possible oversight of factors beyond the nervous system. In re-evaluating these aspects, the review emphasizes the critical need for understanding the complexity of pain, urging the scientific and clinical community to move beyond reductionist perspectives and consider the multifaceted nature of this phenomenon.

Perspectives on the insidious nature of pain metaphor: we literally need to change our metaphors

Metaphorical language is used to convey one thing as representative or symbolic of something else. Metaphor is used in figurative language but is much more than a means of delivering "poetic imagination". A metaphor is a conceptual tool for categorising, organizing, thinking about, and ultimately shaping reality. Thus, metaphor underpins the way humans think. Our viewpoint is that metaphorical thought and communication contribute to "painogenicity", the tendency of socio-ecological environments (settings) to promote the persistence of pain. In this perspectives article, we explore the insidious nature of metaphor used in pain language and conceptual models of pain. We explain how metaphor shapes mental organisation to govern the way humans perceive, navigate and gain insight into the nature of the world, i.e., creating experience. We explain how people use metaphors to "project" their private sensations, feelings, and thoughts onto objects and events in the external world. This helps people to understand their pain and promotes sharing of pain experience with others, including health care professionals. We explore the insidious nature of "warmongering" and damage-based metaphors in daily parlance and demonstrate how this is detrimental to health and wellbeing. We explore how metaphors shape the development and communication of complex, abstract ideas, theories, and models and how scientific understanding of pain is metaphorical in nature. We argue that overly simplistic neuro-mechanistic metaphors of pain contribute to fallacies and misnomers and an unhealthy focus on biomedical research, in the hope of developing medical interventions that "prevent pain transmission [sic]". We advocate reconfiguring pain language towards constructive metaphors that foster a salutogenic view of pain, focusing on health and well-being. We advocate reconfiguring metaphors to align with contemporary pain science, to encourage acceptance of non-medicalised strategies to aid health and well-being. We explore the role of enactive metaphors to facilitate reconfiguration. We conclude that being cognisant of the pervasive nature of metaphors will assist progress toward a more coherent conceptual understanding of pain and the use of healthier pain language. We hope our article catalyses debate and reflection.

Understanding pain in modern society: insights from attitudes to pain in the Medieval Period

Historical records provide knowledge about the way people lived in the past. Our perspective is that historical analyses of the Medieval Period provide insights to inform a fuller understanding of pain in the present era. In this article, we appraise critiques of the writings of people living with pain during the mid (high) to late Medieval Period (c. 1,000-1,500 AD) to gain insights into the nature, attitudes, lived experience, and sense-making of pain. In the Medieval Period, pain was understood in terms of Galen's four humours and the Church's doctrine of pain as a "divine gift", "punishment for sin" and/or "sacrificial offering". Many treatments for pain were precursors of those used in modern time and society considered pain to be a "shared experience". We argue that sharing personal stories of life is a fundamental human attribute to foster social cohesion, and that nowadays sharing personal stories about pain is difficult during biomedically-focussed time-constrained clinical consultations. Exploring pain through a medieval lens demonstrates the importance of sharing stories of living with pain that are flexible in meaning, so that people can connect with a sense of self and their social world. We advocate a role for community-centred approaches to support people in the creation and sharing of their personal pain stories. Contributions from non-biomedical disciplines, such as history and the arts, can inform a fuller understanding of pain and its prevention and management.