Reconsidering Fordyce's classic article, "Pain and suffering: what is the unit?" to help make our model of chronic pain truly biopsychosocial

Prognosis of patients with post-Covid-19 condition: Prospective cohort cluster analysis at one year

OBJECTIVE

We aimed to identify clinically relevant clusters among patients with post-Covid-19 condition (PCC) and assess prognosis overall and within clusters.

METHODS

Prospective cohort study of patients with PCC attending a rehabilitation clinic. We monitored patient reported outcome measures (PROMs): EuroHIS quality of life and symptoms. Unsupervised hierarchical cluster analyses were performed to identify clusters of patients with different quantity of symptoms, and symptoms presenting together. Preliminary findings on symptom prevalence and quality of life at 12 months are reported.

RESULTS

Among 409 patients, 70.4% were women, with an average baseline of 20.3 (SD 6.8) symptoms. Three clusters emerged based on symptom quantity, labelled by the average number of symptoms at baseline: Cluster-11 (17% of all patients), Cluster-17 (35%), and Cluster-25 (48%). Multinomial logistic regression showed female sex, multiple comorbidities predicting more symptoms. Four symptom-based clusters were defined: fatigue and cognitive complaints; pain, trouble sleeping, palpitations and other symptoms; gastrointestinal symptoms; and emotion-related symptoms. Linear regression models showed that female sex, multiple comorbidities, anxiety, use of antidepressants, BMI and smoking were among the determinants of symptom clusters. In 12-month follow-up, symptom count decreased, and quality of life improved across all clusters, with 9% having good quality of life at baseline and 33% at 12 months.

CONCLUSION

Four patient clusters based on symptoms were identified in the PCC cohort. Prognosis was favorable across all clusters, with symptom reduction and improved quality of life observed. Female sex, comorbidities, BMI, and mental-health related variables predicted higher symptom burden, suggesting multifactorial origins of PCC.

Perspectives on community-based system change for people living with persistent pain: insights from developing the "Rethinking Pain service"

In this perspective article we advocate community-based system change for people living with persistent pain. Our view is that greater use of the voluntary and community sector, in partnership with the clinical sector, creates the conditions for a "whole person" approach to pain management, leading to greater personalised care for adults living with long-term pain whilst having the potential to ease some of the pressures on General Practitioners and other clinical services. We advocate pain care that is socially connected, meaningful within socio-cultural contexts and aligned with the principles of salutogenesis. We provide an example of a UK National Health Service (NHS) commissioned pain service called "Rethinking Pain" that operationalises this perspective. Led by the voluntary and community sector, Rethinking Pain works in partnership with the clinical sector to provide a central holistic pathway of care for people experiencing persistent pain. This is the first time that this model of care has been commissioned for persistent pain in this area of England. The Rethinking Pain service is underpinned by core values to work with people to manage their pain holistically. The Rethinking Pain team proactively engage with people in the community, actively approaching and engaging those who experience the biggest health inequalities. In this article we provide an overview of the context of pain services in the UK, the rationale and supporting evidence for community-based system change, and the context, pathway, values, goals, and aspirations of the Rethinking Pain service.

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.

Questioning the Right to Pain Relief and Its Role in the Opioid Epidemic

The new discipline of palliative care helped to establish the right to pain relief at the end of life and the necessity of using opioids to achieve that goal. Professional pain organizations followed the United Nations' model for universal human rights in their declaration of a universal right to pain management. Both palliative care and pain medicine specialties worked to establish pain as a legitimate focus of medical treatment separate from its association with disease. Pain intensity became the metric used to determine the need for treatment and the success of that treatment. Opioids were favored as the most reliable and feasible means to reduced pain intensity. The Harrison Act of 1914 restricted legitimate opioid use to that prescribed by medical professionals as analgesics. This legislation helped establish opioids as specific painkillers that had a distinct capacity to induce addiction. This understanding of opioids as having distinct and separable analgesic and addictive potential was challenged by the 1970s discovery of an endogenous opioid system, which integrates pain and reward functions to support survival. Our modern pain neurophysiology places the patient with pain in a passive position from which it makes sense to assert a right to pain relief. To prevent future opioid epidemics we need to abandon clinical outpatient use of pain intensity scores and redefine the medical necessity of pain treatment as less about the reduction of pain intensity and more about the capacity to pursue personally valued activities.

Pain through the perspective of art and creativity: insights from the Unmasking Pain project

People struggle to tell their story of living with pain and when they do it is articulated in a way that may not be understood, heard or taken seriously. Unmasking Pain is an artist-led project that explored creative approaches to tell stories of life with pain. The project was led by a dance theatre company that specialises in storytelling and emotional experiences for players and audiences. The project involved artists and people living with ongoing pain co-creating activities and environments to curiously explore "oneself", through imagination and creative expression. This article discusses insights and perspectives emerging from the project. The project revealed the power of art to make-sense of oneself with or without pain, and how art facilitates expression of complex inner experience and personal stories. People described Unmasking Pain as "explorative joy despite pain", and "a new set of rules" that contrasts with those experienced during clinical encounters. We discuss how art has the potential to improve clinical encounters and promote health and well-being, and whether artist-led activities are an intervention, therapy, or something else. Pain rehabilitation specialists from the project described Unmasking Pain as "freeing-up thinking", allowing conceptual thought beyond the biopsychosocial model of pain. We conclude that art has the potential to shift people living with pain from "I can't do, I am not willing to do it" to "Perhaps I can, I'll give it a go, I enjoyed".

Biological sex influences psychological aspects of the biopsychosocial model related to chronic pain intensity and interference among South Korean patients with chronic secondary musculoskeletal pain in rheumatic diseases

Introduction

Pain is a prominent contributor to negative personal and social outcomes, including increased disability and mortality, in many rheumatic diseases. In the Biopsychosocial model of chronic pain, psychological and social factors share roles with the biology of the injury in determining each patient's pain and suffering. The current study explored factors associated with clinical pain intensity and interference among patients with chronic secondary musculoskeletal pain in rheumatic diseases.

Methods

In total, 220 patients experiencing chronic secondary musculoskeletal pain participated. Biological factors (age, biological sex, pain condition, pain duration, pain sensitivity, and comorbidity), socio-economic factors, psychological factors (pain catastrophizing and depressive symptoms), and pain intensity and interference were measured. Descriptive, multivariable linear regression and partial correlation analyses were conducted. Subgroup analysis by sex was conducted to examine differences in how different factors affect the pain experience.

Results

The mean age of the participants was 52.3 years (SD = 12.07) and ranged from 22 to 78. Average pain intensity was 3.01 (0-10 scale) and average total pain interference score was 21.07 (0-70 scale). Partial correlation found positive correlations between pain intensity and interference with depression (intensity: R = 0.224; p = 0.0011; interference: R = 0.351; p < 0.001) and pain catastrophizing (intensity: R = 0.520; p < 0.001; interference: R = 0.464; p < 0.001). In males, pain condition (β = -0.249, p = 0.032) and pain catastrophizing (R = 0.480, p < 0.001) were associated with pain intensity. In males, the simple correlation between pain intensity and depression (R = 0.519; p < 0.001) was driven by pain catastrophizing. In females, pain catastrophizing (R = 0.536, p < 0.001) and depressive symptoms (R = 0.228, p = 0.0077) were independently associated with pain intensity. Age (β = -0.251, p = 0.042) and pain catastrophizing (R = 0.609, p < 0.001) were associated with pain interference in males, while depressive symptoms (R = 0.439, p < 0.001) and pain catastrophizing (R = 0.403, p < 0.001) were associated with pain interference in females. Again, in males, the simple correlation between pain interference and depression (R = 0.455; p < 0.001) was driven by pain catastrophizing.

Discussion

In this study, females were more directly affected by depressive symptoms than males, regarding pain intensity and interference. Pain catastrophizing was a significant factor influencing chronic pain for both males and females. Based on these findings, a sex-specific approach to the Biopsychosocial model should be considered in understanding and managing pain among Asians with chronic secondary musculoskeletal pain.