as a therapist, it is important to create a therapeutic setting, meaning the patient understands what you do and why, this way the nocipetive stimuli is not categorised as pain, triggering an orthosympathic reaction, but is interpreted as 'this is my pain and this will make me better', not triggering orthosympathic acivity and trofothropic tuning of the cells. the patients heals, regards

Thanks Jory, I can better explain now. 

To clarify I am not referring to pain that is directly or indirectly as a result of noxious stimulus. I am referring to pain that becomes evident in the 24-48 hours after a manual therapy or exercise therapy intervention.

I have observed many people automatically assume all unexplained pain is "bad". Many transient pains seem to be related to a change of state the neuro-musculoskeletal system.

So my question refers to pain that is absent of nociception. I wonder if some cultures would view this pain differently. Is it a western view that all pain is bad?

Thank you Marika you have hilighted some valuable points.

pain can be experienced absent of nociception, as in pain is a perception, an example is insentitization and allodynia. Is is indeed a vieuw that pain is bad and needs to be solved by pain killers, rather then to see pain as an ally that helps you to prevent (further) harm, have a nice day

Cheers Jory,

 I wonder if there are any qualitative studies about the positive value of pain.

Please ask Jörgen Quaghebeur grtz

EXCELLENT OBSERVATIONS AND QUESTION HEIDI !

Outstanding answers Marika and Jory.

There are many peer review publications on the influence of race, ethnicity and culture on the pain experience.  These terms are sometimes used in a confusing fashion.

I will send you a link that you can review an outstanding article in free full access (via Pub Med Central or PMC site)  that addresses the key issues you refer to. I then suggest searching for those articles that reference this article.

Here is a brief quote from the introduction- enjoy "Culture typically refers to behavioral and attitudinal norms, inherited ideas, beliefs, values and knowledge transmitted and reinforced by members of the group . Culture shapes many aspects of the experience of pain, including pain expression, lay remedies, social roles, expectations, perceptions of the medical system, when/how/where to seek care, healthcare practices, illness beliefs and behaviors, and receptivity to medical care interventions. As described by Edwards and colleagues, ‘ethnicity’ is likely the most appropriate term in most research studies on the topic, given the importance of the biopsychosocial model, as ‘ethnicity’ is comprised not only of race, but also refers to social, psychological and cultural characteristics, all inseparable from one’s self-identification as a member of a particular group."

Best wishes !

Keep up your thoughtful work !

Alan

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3654683/

Alan, good to mention the biosocial filters that colour interpretation of a physical sensation as pain (... and good/bad... and needing painkillers or requiring to "raise" some 'higher' function). This should also be done for the author of the research project. Including: at what point does a therapist recognise that, yes, the patient is 'actually' experiencing pain?

Heidi, is your project purely a literature review or theoretical? It seems to me that to access the  'meaning' of pain after an intervention would require listening to patients in their own words. Also, are you covering the case of an improvement (through pain or without it) of a manipulation that hurts? What about pain that shifts body side?

When I have a child as a patient in the clinic, too young to describe the (pain)sensation in words, I ask to draw how it feels, this works very good and also gives realy intersting results. Merry Christmas

drawing pain: excellent. I found some things by drawing how the pain moves around the body.

it reveals where the pain starts and goes, but even more interesting: it reveals the type of pain. A young child often cannot formulate stabbing, itching, nagging, tootpainlike, burning, pulsating, deep, vague,... pain. But if the childs draws a knife or a fire, you know the kind of pain he or she experiences

Pain means something is going wrong. Ergonomically speaking it is just an information. Once the underlying mechanism is corrected it disappears. Giving pain killers is accepting our ignorance ofthe cause and inability to rationally correct it.

Hello Marika,

My topic is:

Effects of a novel approach to manual therapy on chronic low back pain: A report of five cases.

The approach I will be taking theoreticaly stimulates spinal reflexes to illicit ideomotor muscle actions that effectively mobilises tissues and joints. Including nerves, having seen astounding effects using this technique on significant nerve traction injuries. There absolutely no painful manipulation. Yes often sensations can be experienced that change sides, are felt in distal areas of the body, during the intervention and the days following.

The weight of an individual limb is gently lifted held and supported at the joints. Any discernable (through palpation) muscle tension is allowed

to express itself as movement. These movements are not predetermined, all movements are only supported and assisted into expression by the amelioration of the effects of gravity.

Anecdotally this approach has been extremely effective in stubborn and chronic pain cases of musculoskeletal origin. In saying this I have seen effects also in rheumatic conditions. This is coupled with possible vagus nerve stimulation, identifiable by the clients deep relaxation , 'drifting off' and borborigmi.

The approach considers the body as a dynamic neural and information system net. I think the techniques communicates a sense of safety and support through the manual application of touch and strain amelioration. A manual application of the therapeutic alliance so to speak.

Its now time I formally examine whether the obeserved clinical outcomes actually translate into meaningful changes and reduction in pain for my clients.

My experiences as a clinician have led me to post graduate study in an effort to understand this observed phenomena and decipher whether it is relevant to my field.

The question I have raised,

"Is it an ubiquitious assumpton that pain is an undesirable experience?" arose due to the observations and feedback  from clients/patients in my clinical work who have been referred to my clinic with chronic musculoskeletal pain. Many do edxperience immediate relief of a significant degree of their pain immediately post intervention. Most if not all of these clients then have an experience which they describe as intense pain 24-72 hours later. However how it is reported by them has sometimes unusual characteristics. For example, "I felt like I experienced every injury I have ever had in my entIre life all at the same time." 

Another example, "I thought I was going to die".

And then within 48 hours these sorts of comments:

"I woke up and haven't felt so good in ages"  and  "I felt fantastic".

My curiosity is about the transformation people experience, should every discomfort and very disconcerting experience be defined as pain? Does the lexicon of medicine need to utilise more descriptive terms for pain?

I am in the propcess of writing my reserach proposal for my Masters thesis and I hope to capture the experiences of my chronic pain case participants. I am uncertain whether the experiences of my clients as described above actually should be measured as a pain scale?

Can I utilise a different outcome measure for this aspect of their experience?

I will also be using functional measures such as Activities of Daily Living.

Jory

The idea of drawing the pain sounds very useful clinically, however is their any way to analyse this and demonstrate change without over scoping my project.

Would you have any suggestions?

Perhaps the drawings would be intersting supplementary information to the studies.

Very good point Marika about when does a therapist recognise that a patient is experiencing pain. I have just been reading Oliver Sacks again. He would ask patients,"Whats it like?". I interpret this as: what is it like to live in those symptoms?

Rajiv,

You enable me to illustrate very well my question:

Why and is it, always assumed pain means something is going wrong?

Can pain actually indicate something is going right?

If so how could this be clinically recognised and then does it require a new term?

If so do we require a new way of thinking about it and do we need to re-educate ourselves and our patients?

I will go back to a very simple example of delayed onset muscle soreness after muscle exertion.

The sports therapy literature often trials interventions to reduce DOMS. But what  if it is more beneficial to consider DOMS actrually represents tissue recovery. Why would you want to reduce this?

The use of NSAIDS after exercise has been shown to be deterimental to muscle function, and generally it is used to alleviate pain.

Hi Heidi,

Another aspect to consider in how pain is experienced can also be the personality of the patient. For example, if a patient is very high in harm avoidance, you have a person who automatically will anticipate harm and failure, even with support, and, probably will experience pain differently than a person low in harm avoidance and perhaps high in self-directedness, who knows who to automatically direct oneself towards healthy behaviours.

It doesn't really answer your question, just that people might express themselves differently regarding to their symptoms after treatment and that some will interpret it as pain more likely than others. It is a very interesting topic and questions! What is this treatment approach called?

Best regards,

Elin

Out of the big pucture: It could be a positive sign, if we seek the response of the treatment, e.g to elicit De Qi in acupuncture implementation, or to repeat the treatment when the pain reoccurs, e.g in treating facet low back pain with radiofrequency neurotomy (World J Orthop 2016, 7(5): 315-337). In case of infection, the pain could be beneficial as well.  Nociceptors release molecular mediators from their peripheral terminals, such as the neuropeptides CGRP andsubstance P, that have powerful effects on immune cell recruitment and activation during infection, so called pathogen detection by nociceptors (Pain 2016, 157: 1192-1193).

This discussion is very interesting.

Thank you everyone for your input, it is painting a good picture for me.

Dimitar thank you for those references. I  am curious about the physiology of what may be pain indicating beneficial changes.

Elin, yes I understand and can relate what you expressed to the people I am working with.

I do not have a name for this treatment approach.It is empirically derived from several years of clinical work.  In searching for understanding the observed phenomenom I  have found some similarities with: fascial unwinding;  Muscle Repositioning (Dr. Luiz Fernando Bertolucci); Dermoneuromodulation (Diane Jacobs);and Ideomotor motion (Barrett Dorko).

I do not wish to establish or call it anything at all, avoiding the creation of  yet another proprietary modality. I feel it is best described as a philospohy or an approach. This will be my challenge I think in my thesis. Which is why I have given my topic as: "...a novel approach to manual therapy" rather than a novel therapy.

The approach is to support and allow movement to occur, not dictate what that movement should be. Help the body find it's way with movement, it is not pre-determined by the therapist.

Thank you for your reply Heidi. I wish you all the best with your master project, it will be interesting to read when finished!

As you are aware "The World Health Organisation" defines pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

The attached file is IASP discussion of taxonomy of pain that may be of interested additional reading. Enjoy.

I agree with Alan above and add:

All pain is not necessarily an unqualified evil.  Low levels are necessary to stimulate pain inhibitory controls to dampen chronic pain experience.  (This is the theoretical operation of acupuncture.)  It also is a signal warning to the patient not to disturb healing tissues.

Pain is always what the patient says it is.  There are a lot of good reasons for this.  (1)   The subjective nature of pain prevents clinicians from scoring a child’s pain intensity by assuming it will be comparable to the reactions of other patients with similar pathologies.  Both genetics and previous pain experience differentiates and diversifies our responses to pain in ways that cannot be precisely anticipated. There is no uniform pain response for a given level of pain stimulus.   Pain is experienced as real to the individual because all pain starts and ends in the brain (mind).   (2)    Clinicians cannot tell the difference between anxiety, pain and non nociceptive distress in patients.  Even when there is no ostensible, organic reason for the pain complaints of a patient, we must assume their experience is real to them.  (3) Multiple studies with physicians, nurses and dentists, demonstrate that clinicians who cause pain in patients tend to underestimate their pain. It has been hypothesized that the reason for this is that clinicians who cause pain have a psychological need to rationalize away pain the they cannot alleviate. It is human nature to want to blame something else.  (4)  There is no objective measure of pain that is clinically available that is better than the patient’s behavioral or self-report.    (5) The cost of being wrong is high.  When clinicians dismiss a patient's distress behavior as owing to some other construct and are wrong, they can cause suffering, loss of trust, Long-term sensitization and (in the case of procedure pain) Classical Fear Conditioning.  These consequences will occur in direct proportion to the intensity of the pain experienced.   Long-term sensitization is the neurological response to a single stimulus.  It is an increase in receptive fields and a decrease in thresholds that result in an amplification of pain experience for future pain exposures.   Things that did not previously hurt can now hurt.  Classical Fear Conditioning is the neurological response to two or more stimuli.  A pain stimulus becomes associated with a neutral stimulus (room geometry, white coat, gloves, mask).  The next time the neutral stimulus is seen, it is recognized by the amygdala which sends a message to the adrenals which trigger elevated heart rate, elevated respiration and a vague sense of foreboding (anxiety) or panic.  This is a reflexive anxiety/distress response that can debilitate a patient's ability to tolerate future necessary medical treatments.  Since it is entirely reflexive, it is a limitation to the individuals freedom of will.  

The moral of the story here is that you must let the patient be the person who decides how much pain they have.  You must accept their self- report.  

If you need any citations for the above let me know.  Good luck!

Thank you very much Dennis for your in depth answer.

Just to clarify I am not using manual therapy techniques that directly invoke a pain experience. The pain occurs one to two days after a non invasive session of movement exploration through supported ideomotor muscle contractions. In addition often the new pain shows up in a completely different region of the body than the original pain.

I suspect an ostensible reason for stable chronic musculoskeletal pain does exist. Demonstrable anecdotally by it's predictable behaviour. Here one day gone the next , following the discovery of movement in previously inhibited tissues. I use the term inhibited tissues to avoid the presumptive term adhesions.

Yes please can you provide refernces for points 2) and 3) and 4).

Hi Heidi,

I come from a background where procedure pain is more problematic than chronic pain.  Pain assessment  is more straightforward since one need only ascertain that there is evidence of tissue trauma.   Still, about half of the pediatric dentists in the US want to have the authority to revise downward the pain reports of the child during invasive procedures while the other half accept the patient's pain reports.  Almost always, the only time those pain reports are revised downward is when the patient's pain reports are of high intensity and in conflict with the common experience of the clinician with the majority of other patients.  It is at these times that our need is great to rationalize away or in some way downgrade the pain the we cannot alleviate.  What concerned me was your statement "should every discomfort and very disconcerting experience be defined as pain? Does the lexicon of medicine need to utilize more descriptive terms for pain?" To your curiosity as to whether medicine may need a more descriptive lexicon to describe patient distress I submit that there are only three broad categories of distress; pain, anxiety and non-nociceptive sensory distress (distress from light, taste, smell, etc.).   Your patients are the ones to determine which of these constructs constitute their distress, not the clinician.  The lexicon of subdescriptors within these groups will no doubt evolve to assist clinicians and patients in understanding etiology of pathogenicity of distress. However,  a new addition to the lexicon cannot redefine pain into some other construct.  Sorry, I feel as though I have waded into semantic quicksand.  Let me just finish by say that since pain is both a sensory and emotional experience, the emotional dimension of pain is not a false contribution to pain experience and it cannot be extracted from the pain construct to reduce it to solely the sensory component.  Sorry if I am preaching to the choir.

References: The truth about our inability to know what is in the mind of the patient (point 2) is apriori but it is supported by the evidence for points 3 and 4.  The citations for these statements are below: (3) Multiple studies with physicians, nurses and dentists, demonstrate that clinicians who cause pain in patients tend to underestimate their pain. (a), (b), (c).   It has been hypothesized that the reason for this is that clinicians who cause pain have a psychological need to rationalize away pain the they cannot alleviate.(d)  It is human nature to want to blame something else.  

(a)Marquié L, Raufaste E, Lauque D, Mariné C, Ecoiffier M, Sorum P. Pain rating by patients and physicians: Evidence of systematic pain miscalibration.Pain 2003, April;102(3):289-96.

(b)  Versloot J, Veerkamp JSJ, Hoogstraten J, Assessment of pain by the child, dentist, and independent observers.  Pediatric Dentistry 26(5):445-449, 2004. 

(c)  Bagheri SC, Perciaccante VJ, Bays RA. Comparison of patient and surgeon assessments of pain in oral and maxillofacial surgery.  CDA J  36(1):43-50, 2008.

(d)  Walco GA, Burns JP, Cassidy RC. The Ethics of Pain Control in Infants and Children.  In, Pain in Infants, Children and Adolescents,  Second Edition.  Schechter NL, Berde CB, Yaster M, Eds. Philadelphia, Lippincott, Williams and Wilkins; 2003, pp 157-168.

And to point (4):  There is no objective measure of pain that is clinically available that is better than the patient’s behavioral or self-report.  (e) (f)

(e)  Sweet SD, McGrath PJ. Physiological Measures of Pain. In: Measurement of pain in infants and children.   Finley GA, McGrath PJ, Eds. Seattle, IASP Press; 1998, 59-81.

(f)  Robinson ME, Staud R, Price DD.  Pain Measurement and Brain Activity: Will Neuroimages Replace Pain Ratings? Journal of Pain. 2013;14(4): 323–327. doi:10.1016/j.jpain.2012.05.007.

Good luck out there in New Zealand!

Cheers Dennis,

I have given your points serious thought.

You have discussed some issues that are relevant to the ethical considerations of my proposed case series and to my clinical work.

Yes I do understand the different constructs of pain. I also have heard and read accounts of people that indicate sub acute pain to them just means that they are healing, I do think this does warrant further inquiry.

However having thought in particular about your point of clinicians tendency to revise downward the pain reports of their patients, I think I need to be much clearer in communicating the high likelyhood that they may experience strong pain (or perhaps this is distress, as you say not for me to determine which) for 24-48hrs after the intervention. This will affect  either their choice to participate in the intervention or when it is to be scheduled.

The reports from my clients of this phenomenon is unusual and to date I have been unable to find any literature aside from DOMS studies that reports similarly.

I will go back to some of these individuals and ask more questions about how they coped, and what more would they have needed in terms of support or information.

Kind regards.