Pain, suffering and risk

Is pain ever acceptable? A qualitative exploration concerning adult perceptions of chronic pain

BACKGROUND

Although the challenges of living with chronic pain are widely documented within existing literature, to our knowledge, the acceptability of pain for people living with persistent pain, has not been fully explored. The current study aims to explore what 'acceptable pain' means to adults living with chronic non-cancer pain (CPCP).

METHODS

A total of 117 participants (aged 21 to 77 years) worldwide were recruited using opportunity sampling. Participants completed an online qualitative survey. Qualitative analysis of the data used inductive reflexive thematic analysis.

RESULTS

Two themes were generated. The first theme-'I grin and bear it', described participants' desire and drive to push through their pain to live their daily lives to the best of their ability. Contrastingly, the second theme-'Thriving versus surviving', placed greater importance on leading meaningful and happy lives despite living with chronic pain. The acceptability of pain was found to be influenced by various factors including, but not limited to, pain severity, mental health, functionality, productivity and quality of life.

CONCLUSIONS

It can be difficult to identify when a clinically significant change in pain has occurred from numerical pain rating scales. We have identified two themes and a number of factors influencing the acceptability of pain. Understanding individuals' unique perceptions of what constitutes 'acceptable pain' is crucial for clinicians when assessing and managing chronic pain. Pain is a highly subjective experience, and what one person considers acceptable may differ significantly from another person's perspective. Recommendations to improve healthcare services for adults living with CNCP are proposed and directions for future research are explored.

SIGNIFICANCE

Adults with CNCP have unique experiences of living with and managing their chronic pain. CNCP was found to affect biological, psychological, and social aspects of an individual's life. The acceptability of pain exists on a continuum where adjacent parts are not noticeably different from each other, but the extremes of the continuum appear very distinct. The acceptability of pain is determined by the different factors that influence an individuals' ability to function on a day-to-day basis as well as their quality of life. While acceptable pain and manageable pain represent distinct aspects of the pain experience, the relationship between them is complex and plays a crucial role in how individuals cope with and adapt to chronic pain.

Chronic Struggle: An Institutional Ethnography of Chronic Pain and Marginalization

There have been several recent calls to re-think chronic pain in response to the growing awareness of social inequities that impact the prevalence of chronic pain and its management. This in turn has resulted in new explorations of suffering as it relates to pain. While laudable, many of these clinically oriented accounts are abstract and often fail to offer a critical theoretical understanding of social and structural inequities. To truly rethink pain, we must also reconsider suffering, beginning in the everyday expert knowledge of people with chronic pain who can offer insights in relation to their bodies and also the organization of the social circumstances in which they live. Our team undertook a sociological approach known as institutional ethnography (IE) to explicate the work of people in managing lives beset by chronic pain and the inequities that stem from marginalization. In keeping with our critical paradigm, we describe participant accounts as situated, rather than lived, to de-emphasize the individual in favour of the social and relational. Through our analysis, we offer a new concept of chronic struggle to capture how pain, illness, economic deprivation, and suffering constitute a knot of experience that people living with chronic pain are obliged to simplify in order to fit existing logics of medicine. Our goal is to identify the social organization of chronic pain care which underpins experience in order to situate the social as political rather than medical or individual. PERSPECTIVE: This article explicates the health work of people living with chronic pain and marginalization, drawing on their situated experience. We offer the concept of chronic struggle as a conceptualization that allows us to bring into clear view the social organization of chronic pain in which the social is visible as political and structural rather than medical or individual.

Edgework, institutions and enhanced interrogation

The Enhanced Interrogation programme was a medicalised interrogation programme that was designed by the United States in the wake of 9/11. It is now widely recognized that the Enhanced Interrogation programme engaged in some activities that were, at the least, tantamount to torture. The programme was designed by Psychologists and overseen by other professionals, including medical professionals. This article argues that the Enhanced Interrogation programme displayed many of the features of what Sociologists refer to as Edgework. It demonstrated voluntary risk-taking by health and other professionals; this risk-taking pressed up against catastrophic outcomes across multiple dimensions; risks were taken for the purposes of escaping a death-saturated macrosocial context; and the health professionals in the programme were highly skilled. The article argues that a new form of Edgework can be detected by studying the programme, which the article refers to as 'Institutional Edgework'.

Pain, Culture and Pedagogy: A Preliminary Investigation of Attitudes Towards "Reasonable" Pain Tolerance in the Grassroots Reproduction of a Culture of Risk

In recent years a considerable body of psychological research has explored the relationship between membership of socio-cultural groups and personal pain perception. Rather less systematic attention has, however, been accorded to how such group membership(s) might influence individual attitudes towards the pain of others. In this paper, immersion in the culture of competitive sport, widely regarded as being exaggeratedly tolerant of risky behaviours around pain, is taken as a case-in-point with students of Physical Education (PE) in tertiary education as the key focus. PE students are highly-immersed in competitive sporting culture both academically and (typically) practically, and also represent a key nexus of cross-generational transmission regarding the norms of sport itself. Their attitudes towards the pain that others should reasonably tolerate during a range of activities, sporting and otherwise, were evaluated through a direct comparison with those of peers much less immersed in competitive sporting culture. In total, N=301 (144 PE, 157 non-PE) undergraduate students in the UK responded to a vignette-based survey. Therein, all participants were required to rate the pain (on a standard 0-10 scale) at which a standardised "other" should desist engagement with a set of five defined sporting and non-sporting tasks, each with weak and strong task severities. Results indicated that PE students were significantly more likely to expect others to persevere through higher levels of pain than their non-PE peers, but only during the sport-related tasks - an effect further magnified when task severity was high. In other tasks, there was no significant difference between groups, or valence of the effect was actually reversed. It is argued that the findings underscore some extant knowledge about the relationship between acculturated attitudes to pain, while also having practical implications for understanding sport-based pedagogy, and its potentially problematic role in the ongoing reproduction of a "culture of risk."

[Spirituality and health care. The perspective of patients with chronic pain]

Hintergrund

Chronischer Schmerz betrifft alle menschlichen Lebensdimensionen und wirft auch spirituelle Fragen auf, die im Rahmen eines multimodalen Behandlungsmodells berücksichtigt werden sollten.

Ziel der Arbeit

Wir untersuchten die Perspektive von Patienten mit chronischen Schmerzen zu spirituellen Themen und deren möglicher Integration in den Behandlungsprozess.

Material und Methoden

Es wurden fünf Fokusgruppen- und zwei Kleingruppeninterviews an fünf Studienzentren durchgeführt. Daran nahmen 42 Patienten mit chronischen Schmerzen teil, die aktuell in ambulanter oder stationärer Schmerzbehandlung waren. Die Interviews wurden transkribiert und einer thematischen Analyse unterzogen.

Ergebnisse

Drei Themen traten hervor: 1. Chronischer Schmerz durchdringt die gesamte menschliche Existenz. 2. Spirituelle Ressourcen stellen eine Möglichkeit im Umgang mit chronischen Schmerzen dar. 3. Patienten ist es ein Anliegen, mit Fachpersonen in einen Dialog treten zu können, der auch für spirituelle Themen offen ist. Diese haben aus Sicht der Teilnehmenden große Relevanz. Sie verknüpften sie vielfach, aber nicht ausschließlich mit religiösen Überzeugungen. Häufig wurde geschildert, in der Schmerzerfahrung nicht ernst genommen zu werden.

Diskussion

Strategien für einen effektiven Umgang mit chronischem Schmerz zu finden, stellt einen Wendepunkt im Leben dar. In diesem Prozess unterstützt ein offener Dialog mit Fachpersonen, der auch spirituellen Themen Rechnung trägt.

[Alterity of the body of the elderly: estrangement and pain in Public Health]

In old age, the ailing patient's body becomes estranged and reveals an awareness of alterity. This paper investigates how the body of the elderly addresses the estrangement as a subject, producing its own actions in the experience of disease and practice of public health. The research, developed using the qualitative approach of an anthropological nature, is based on the assumptions of ethnography. Individual interviews with a semi-structured script in the universe of 57 elderly people were conducted. The methodology of Signs, Meanings and Actions oriented the data collection and analysis enabling the investigation of representations and concrete behaviors associated with the otherness of the body. There was the sense of production of otherness in relation to two analytical categories associated with aging and disease. A split between the active body of the memory and another experienced with limitations in the present is detected, reflecting the confrontation of self-care and adherence to treatment. The body of the elderly individual is heir to a body image that remodels constantly, depriving the elderly of their place as contemporary owners of their bodies, as they become other persons.

The commensuration of pain: How nurses transform subjective experience into objective numbers

Commensuration-the transformation of different qualities into a common metric-has recently received increased scholarly attention. While mostly studied at the meso- or macroscale, this article extends the focus to microscale commensuration. Based on fieldwork in a Norwegian emergency medical service, the article analyses how nurses rated patients' pain intensity on a scale from zero to ten. While nurses were instructed to score pain by combining patients' self-report with their own 'objective' assessment, the article finds that their actual assessments relied almost solely on the latter. After exploring nurses' objections against the use of self-report, the article reconstructs the principles, methods and beliefs underlying nurses' 'objective' approach to pain scoring. In so doing, the article demonstrates how a fundamental aspect of human experience was filtered through nurses' professional gaze-to the advantage of some patients and the disadvantage of others. The article also advances theorising on microscale commensuration, thus providing guidance for future studies of how the world is transformed through the everyday production of numbers.

The complexities of contagion: The experience of social isolation among children and youth living with cystic fibrosis in Canada

While cross-respiratory infection guidelines reduce the risk of infection, this may have deleterious impacts on the socialization skills of young people living with cystic fibrosis (CF). The purpose of this study was to explore the experience of social isolation among young Canadians with CF, as well as how they navigate these complex contamination restrictions. The thematic analytic qualitative research tradition was adopted and social theories of risk provided theoretical grounding. The youth described a pressing sense of social isolation in their everyday lives. Although most of the youth 'obeyed' the cross-contamination guidelines, some demonstrated a more carefree attitude. Social media was employed across the group as a tool to reduce isolation. In accordance with the sociology of risk, youth with CF demonstrate sophisticated decision-making abilities, navigating exceedingly difficult choices to preserve an always-precarious future. While necessary, cross-contamination guidelines might further marginalize an already isolated group of children and youth.

Building the evidence for CRPS research from a lived experience perspective

Background and aims

Pain is known to be a subjective experience yet the majority of pain related research does not address the lived experience of the condition. Difficult to diagnose, Complex Regional Pain Syndrome (CRPS) is often poorly managed. The aim of this paper was to identify and synthesise the currently available literature on experiences of living with chronic pain in order to understand where and how CRPS research may be best situated in the future.

Methods

A narrative review was performed and ProQuest, EBSCO, Informit, Scopus/Science Direct and Web of Science, Medline, CINHAL and Google Scholar were searched in order to identify the literature from 1998 until 2015. 301 papers were identified of which 197 described the lived experience of chronic pain conditions. 12 papers were examined closely to determine the experience of living with CRPS or a similar chronic pain condition that does not have a definite pain origin such as cancer or endometriosis.

Results

Known understandings of pain were identified and a model was developed depicting the lived experience of chronic pain starting with loss of the former healthy, pain free self and culminating in acceptance of the condition. Major themes identified were disbelief/invisibility of pain, loss, coping with a non-compliant/constant painful body, self-management and alleviating pain/treatment. The review also found that there is no peer-reviewed published literature on the lived experience of CRPS.

Conclusions

Little is known about the lived experience of CRPS. There appears to be a clear indication that research needs to be conducted into CRPS from a lived experience perspective in order to provide information to patients, the general public, health practitioners and policy makers of previously unknown characteristics of this condition which may improve health outcomes for this patient cohort.

It has been identified that patients and their families should be active participants in education of health practitioners and in providing information to inform the development of National Pain Strategies currently being devised throughout the world.

Implications

Research into the lived experience of chronic pain conditions, and CRPS in particular, can help to provide information to enhance understanding enabling national pain strategies and future treatment guidelines strategies to be devised appropriately.

Inviting pain? Pain, dualism and embodiment in narratives of self-injury

The role of pain in the practice of self-injury is not straightforward. Existing accounts suggest that self-injury does not cause 'physical' pain, however self-injury is also said to alleviate 'emotional' pain by inflicting 'physical' pain. This article explores these tensions using sociological theories regarding the socio-cultural and subjective nature of pain. Analysis derives from in-depth, life-story interviews carried out in the UK with people who had self-injured. Findings contribute to on-going debates within social science regarding the nature of pain. Participants' narratives about pain and self-injury both drew on and challenged dualistic models of embodiment. I suggest that self-injury offers a unique case on which to extend existing theoretical work, which has tended to focus on pain as an unwanted and uninvited entity. In contrast, accounts of self-injury can feature pain as a central aspect of the practice, voluntarily invited into lived experience.

Rethinking 'risk' and self-management for chronic illness

Self-management for chronic illness is a current high profile UK healthcare policy. Policy and clinical recommendations relating to chronic illnesses are framed within a language of lifestyle risk management. This article argues the enactment of risk within current UK self-management policy is intimately related to neo-liberal ideology and is geared towards population governance. The approach that dominates policy perspectives to 'risk' management is critiqued for positioning people as rational subjects who calculate risk probabilities and act upon them. Furthermore this perspective fails to understand the lay person's construction and enactment of risk, their agenda and contextual needs when living with chronic illness. Of everyday relevance to lay people is the management of risk and uncertainty relating to social roles and obligations, the emotions involved when encountering the risk and uncertainty in chronic illness, and the challenges posed by social structural factors and social environments that have to be managed. Thus, clinical enactments of self-management policy would benefit from taking a more holistic view to patient need and seek to avoid solely communicating lifestyle risk factors to be self-managed.

Restorying the self: an exploration of young burn survivors' narratives of resilience

The results of this exploratory study reflect a shift from public health studies that aim to examine the risk and prevalence of burn injury, toward eliciting survivors' subjective meaning-making processes beyond the injury event. We drew on a narrative framework to explore how young survivors' experiences of burn injury led to reconstructions of self and shifts in thinking about others and the world. Although participants' narratives revealed elements of heightened self-awareness, need for acceptance, and desire for recognition, these stood alongside counter narratives denoting positive, transformative, and resilient aspects of healing that reflected a rebirth of the self, life having purpose, and psychospiritual growth. A multidimensional and relational framework for resilience acknowledges the "deficient," but also recognizes the pathways to growth, healing, meaning, and purpose. This shift toward person-centered meanings has value in informing interventions beyond the immediate "wound care," toward the survivors' lifelong (re)negotiation of identity, appearance, psychological adjustment, and social reintegration.

From pleasure to pain: The role of the MPQ in the language of phantom limb pain

In opposition to the argument that pain is private, personal and unsharable, I propose that the intersubjectivity of pain is fundamental to it. Using the case of phantom limb, I show how a specific language of pain emerged and became concretized in the US circa 1975 with the advent of the McGill Pain Questionnaire (MPQ). Through widespread use of the MPQ, a language of pain materialized, one that was commonly used to describe the qualitative dimensions of phantom limb. After 1975, the terminology used within the medical literature was overwhelmingly consonant with the set of descriptors advanced by the MPQ. The utilization of a pain questionnaire to assess the qualitative dimensions of phantom limb effectively accentuated pain, and by 1980, what was once considered relatively rare became a common sequela of phantom manifestation.