Chronic Pain as a Hypothetical Construct: A Practical and Philosophical Consideration

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".

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.

A new version of a measurement for presence and impact of pain in children and adolescents - Presence and impact of pain in Kids (PIP-KIDS) questionnaire: Translation, cross-cultural adaptation and measurement properties into Brazilian-Portuguese

BACKGROUND

Musculoskeletal pain in children and adolescents is prevalent and responsible for high levels of disability. Instruments to measure the presence and impact of pain in this population are needed.

OBJECTIVE

To translate, cross-culturally adapt, then test the measurement properties (structural validity, reliability and construct validity) of a questionnaire (Presence and Impact of Pain in Kids (PIP-Kids) questionnaire) to measure the presence and impact of pain in children and adolescents.

DESIGN

Measurement properties study.

METHODS

We conducted a measurement properties study. We translated and culturally adapted the PIP-Kids questionnaire into Brazilian Portuguese. The structural validity was measured by Confirmatory Factor Analysis. Reliability was measured by Kappa Coefficient. Measurement error was measured by the percentage of agreement. Construct validity was measured by Spearman Correlation.

RESULTS/FINDINGS

We included 656 children and adolescents from public and private schools. During the translation and cross-cultural adaptation no changes to wording were necessary. Structural validity confirmed two domains. Reliability by Kappa Coefficient ranges from 0.20 to 0.68. Measurement error by the percentage of agreement ranged from 60.2 to 92%. Construct validity was confirmed with 80.5% in accordance with prior hypotheses.

CONCLUSION

The PIP-Kids questionnaire translation and cross-cultural adaptation were adequate. The PIP-Kids questionnaire also has adequate structural validity with two dimensions (presence and impact), fair reliability, good agreement, and adequate construct validity.

Machine learning algorithms distinguish discrete digital emotional fingerprints for web pages related to back pain

Back pain is the leading cause of disability worldwide. Its emergence relates not only to the musculoskeletal degeneration biological substrate but also to psychosocial factors; emotional components play a pivotal role. In modern society, people are significantly informed by the Internet; in turn, they contribute social validation to a "successful" digital information subset in a dynamic interplay. The Affective component of medical pages has not been previously investigated, a significant gap in knowledge since they represent a critical biopsychosocial feature. We tested the hypothesis that successful pages related to spine pathology embed a consistent emotional pattern, allowing discrimination from a control group. The pool of web pages related to spine or hip/knee pathology was automatically selected by relevance and popularity and submitted to automated sentiment analysis to generate emotional patterns. Machine Learning (ML) algorithms were trained to predict page original topics from patterns with binary classification. ML showed high discrimination accuracy; disgust emerged as a discriminating emotion. The findings suggest that the digital affective "successful content" (collective consciousness) integrates patients' biopsychosocial ecosystem, with potential implications for the emergence of chronic pain, and the endorsement of health-relevant specific behaviors. Awareness of such effects raises practical and ethical issues for health information providers.

The Tangled Knots of Neuroscientific Experimentation

The experimental method has promoted the popularity of neuroscientific research on the human mind. In this interdisciplinary enterprise, the experimental method, with its roots in natural science and experimental psychology, is often uncritically accepted as the royal road to investigate the human mind not only by neuroscientists, but by many philosophers as well, especially those inclined to some form of naturalism. It is rarely disputed that experiments reveal actual states of nature (here: of mind and/or brain). Experimental results are used to picture the human person or subject as an illusionary construct resulting from neuronal interactions. The present paper sketches some of the limitations of neuroscientific experiments in order to demonstrate that cognitive neuroscience is far from relying on firm methodological grounds. Numerous issues still have to be solved, some of which date back to the early days of modern science. At least, to make experiments work, many theoretical presuppositions have to be accepted and decisions of relevance have to be made in the scientific process. This implies that all scientific endeavor is constituted by persons making free decisions for good reasons, despite all reductionist claims to the contrary. The fact that we as scientists have to distinguish relevant from irrelevant aspects of experimental procedures is also crucial for dealing with the current replicability crisis in the life sciences including neuroscience.

Reconfiguring the biomedical dominance of pain: time for alternative perspectives from health promotion?

Strategies to reduce the burden of persistent pain in society are rooted in a biomedical paradigm. These strategies are located downstream, managing persistent pain once it has become a problem. Upstream activities that create social conditions to promote health and well-being are likely to help, yet health promotion discourse and research are lacking in pain literature. In this article, we argue that the subjective nature of pain has not sat comfortably with the objective nature of medical practice. We argue that the dominance of the biomedical paradigm, with a simplistic 'bottom-up' model of pain being an inevitable consequence of tissue damage, has been detrimental to the health and well-being of people living with persistent pain. Evidence from neuroscience suggests that bodily pain emerges as a perceptual inference based on a wide variety of contextual inputs to the brain. We argue that this supports community, societal and environmental solutions to facilitate whole-person care. We call for more salutogenic orientations to understand how people living with persistent pain can continue to flourish and function with good health. We suggest a need for 'upstream' solutions using community-based approaches to address cultural, environmental, economic and social determinants of health, guided by principles of equity, civil society and social justice. As a starting point, we recommend appraising the ways human society appreciates the aetiology, actions and solutions towards alleviating persistent pain.

Antinociceptive activities and mechanism of action of Cepharanthine

Cepharanthine is an alkaloid that isolated from Stephania cepharantha Hayata, however，its analgesic properties are unclear and the molecular targets that mediating Cepharanthine-induced analgesia are not explored yet. In the current study, mice pain models including hot plate, acetic acid-induced writhing and formalin tests were conducted to evaluate the antinociceptive actions of Cepharanthine. [³H]-ligand competitive binding assay was applied to determine the binding affinity and selectivity of Cepharanthine at κ, μ and δ opioid receptors. Cepharanthine-induced constipation was investigated using the small intestinal transit test. The results showed that intraperitoneal injection of Cepharanthine produced potent antinociception with an ED₅₀ value of 24.5 mg/kg in the acetic acid-induced writhing test. In the formalin test, Cepharanthine produced moderate antinociception with the maximum analgesic activity of 42.6 ± 11.3% in phase I and 60.1 ± 7.7% in phase Ⅱ, respectively. Cepharanthine had no effects in the hot plate test. In vitro radioligand binding assay, Cepharanthine exhibited a high affinity for μ opioid receptors with a Ki value of 80 nM, without binding to κ and δ opioid receptors. Correspondingly, Cepharanthine-mediated antinociceptive effects were antagonized by pretreatment with opioid receptor antagonist naloxone. Cepharanthine also decreased the small intestine propulsion rates in the small intestinal transit test. Together, this study firstly demonstrates that Cepharanthine produces potent antinociception in acetic acid-induced visceral pain and moderate antinociception in formalin-induced inflammatory pain, and its mechanism of action may be through activation of μ opioid receptors.

Imagined Examples of Painful Experiences Provided by Chronic Low Back Pain Patients and Attributed a Pain Numerical Rating Score

Objective

The pain numerical rating scale (NRS) is widely used in pain research and clinical settings to represent pain intensity. For an individual with chronic pain, NRS reporting requires representation of a complex subjective state as a numeral. To evaluate the process of NRS reporting, this study examined the relationship between reported pain NRS levels and imagined painful events reported by study subjects.

Design

A total of 149 subjects with chronic low back pain characterized by the NIH Research Task Force Recommended Minimal Dataset reported current pain NRS and provided imagined examples of painful experiences also attributing to these an NRS. We present a quantitative and qualitative analysis of the 797 pain examples provided by the study subjects.

Results

Study subjects tended to be able to imagine both highly painful 10/10 events and non-painful events with relative agreement across subjects. While NRS for the pain examples tended to increase with example severity, for many types of examples there was wide dispersion around the mean pain level. Examination of pain examples indicated unexpected relationships between current pain and the intensity and nature of the imagined painful events.

Conclusions

Our results indicate that the pain NRS does not provide a reliably interpretable assessment of current physical pain intensity for an individual with chronic pain at a specific moment.

Impact of a multidisciplinary pain management program on patient care utilization and cost of care

Objective

Chronic pain is a highly prevalent and costly condition with few proven treatment options. Since 2014, Geisinger’s Department of Pain Medicine has implemented the Multidisciplinary Pain Program (MPP), which consists of a 3-day educational seminar followed by 12 months of comprehensive care. This study examines the impact of MPP on care utilization and cost between 2014 and 2016.

Methods

A retrospective health insurance claims data analysis covering a 3-year period between January 2013 and December 2016. Among all patients referred to MPP during the period, a subset of those who were Geisinger Health Plan (GHP) members was identified (113 patients). Those who were GHP members and were referred to MPP after December 2016 served as the contemporaneous comparison group (69 patients). GHP’s claims data for the corresponding period were analyzed on a per-member-per-month (PMPM) basis.

Results

MPP was associated with US$754 PMPM reduction in total cost of care including prescription drug costs (P=0.014) and US$846 reduction in total medical cost excluding prescription drugs (P=0.006). These cost savings were attributable to reductions in utilization of high-end diagnostic imaging (52 per-1,000 members-per month; P=0.015) and acute inpatient admissions (20 per-1,000 members-per month; P=0.086).

Conclusion

Patients enrolled in MPP were less likely to use expensive diagnostic imaging and experienced fewer hospitalizations, resulting in total cost of care savings. These findings are consistent with the expectation that MPP improves health outcomes among patients suffering from chronic pain.

Recent development in antihyperalgesic effect of phytochemicals: anti-inflammatory and neuro-modulatory actions

INTRODUCTION

Pain is an unpleasant sensation triggered by noxious stimulation. It is one of the most prevalent conditions, limiting productivity and diminishing quality of life. Non steroidal anti inflammatory drugs (NSAIDs) are widely used as pain relievers in present day practice as pain is mostly initiated due to inflammation. However, due to potentially serious side effects, long term use of these antihyperalgesic drugs raises concern. Therefore there is a demand to search novel medicines with least side effects. Herbal products have been used for centuries to reduce pain and inflammation, and phytochemicals are known to cause fewer side effects. However, identification of active phytochemicals of herbal medicines and clear understanding of the molecular mechanism of their action is needed for clinical acceptance.

MATERIALS AND METHODS

In this review, we have briefly discussed the cellular and molecular changes during hyperalgesia via inflammatory mediators and neuro-modulatory action involved therein. The review includes 54 recently reported phytochemicals with antihyperalgesic action, as per the literature available with PubMed, Google Scholar and Scopus.

CONCLUSION

Compounds of high interest as potential antihyperalgesic agents are: curcumin, resveratrol, capsaicin, quercetin, eugenol, naringenin and epigallocatechin gallate (EGCG). Current knowledge about molecular targets of pain and their regulation by these phytochemicals is elaborated and the scope of further research is discussed.