The challenge of pain
José Aparecido
28 Mar 2014 12:25
The challenge of pain
José Aparecido Da
Silva
Department of
Psychology
University of São
Paulo at Ribeirão Preto
Prefácio do
número especial da revista Psychology & Neuroscience
(https://www.psycneuro.org/index.php/psycneuro)
dedicado a Pain Perception.
Pain is a universal phenomenon experienced from birth to the end of life
(Marchand, 2012). It exists from the simplest type that is so light and
inconsequential, to an intolerable type that requires treatment, to the
persistent, chronic type that is beyond cure. Reductions of activity that
usually do not make the patient’s life unbearable are the reason why more than
80% of people seek medical care to treat pain, making pain the main reason why
people seek medical treatment.
However, not everybody feels pain
the same way. Women report feeling pain more than men, and the elderly are more
likely to suffer from chronic pain than the young. Therefore, treating pain is
a complex and stressful task that requires consideration of the type of pain
that the patient experiences and the motivational, cognitive, emotional, and
personality characteristics of the individual who suffers from pain.
Fundamental information about the choice of effective, tolerable, and safe
treatment reveals how difficult treatment will be for healthcare professionals
to relieve pain in affected individuals (Marchand, 2012).
Basic and clinical research on pain
has provided progressive and continuous advances in the last decades,
especially with regard to a better understanding of the neurophysiological and
psychological mechanisms of pain and most adequate attitudes and treatments
that are required for pain management. Understanding that pain is not only a
pathological outcome but also a problem in and of itself, medical terms such as
“hidden pain” and “idiopathic pain” have been used when its exact cause is
unknown. Although this appears to be simplistic, such diagnostic knowledge that
pain can exist even when one cannot determine its origin is relevant for
different treatments.
For a comprehensive overview of the
multiple facets and interfaces of pain, examining both its physiology and psychology
becomes necessary. As a subjective experience, pain requires different
mechanisms of interpretation that can be physiological, such as the result of an
injury, or psychological, such as the anticipation of an injury.
Although one might be able to differentiate
purely physiological aspects from psychological aspects at the experimental
level, the same does not necessarily hold true at the interpersonal level when
working with patients who are in pain. In the latter case, these two dimensions
are deeply connected. Such subjectivity is also manifested in different
cultures with regard to pain perception and expression. Additionally,
descriptors of pain also vary, positioning themselves in different perspectives,
such as sensorial-discriminative, motivational-affective, cognitive-behavioral,
and nociceptive (Melzack,1973; Melzack & Wall, 1982).
Despite being considered a negative
experience, pain is a universal experience in the animal world and essential
for survival. Playing a role as an alarm signal, pain is in fact the principal
symptom when recognizing an ailment of a body organ. Coupled with monitoring
the progression of trauma and evaluating of how serious it is, pain forces us
to adopt preventive behaviors to protect us from further worsening of the most
diverse injuries.
Because of the different
origins of pain and modulation by different physiological and psychological processes,
the idea that a single drug can relieve all types of pain becomes
inconceivable. Each patient represents a unique and genuine case for whom physiological,
emotional, and cognitive aspects are components of pain perception. This fact requires
that pain treatment take an interdisciplinary approach, building a true bridge
between scholars, practitioners, and clinicians from different disciplines. We
must consider multiple factors, from knowledge of the neurophysiological
mechanisms of pain to understanding the emotional and attentive factors that
modulate pain perception and expression (Melzack,1973; Melzack & Wall, 1982).
We must also consider the possible bias caused by subjective pain measurements.
In this context, pain measurement remains a great issue. Pain assessment
constitutes a cornerstone of its treatment (Da Silva & Ribeiro-Filho, 2006).
Without proper evaluation, clinicians cannot determine whether the intervention
is effective. Therefore, reliable and valid pain measurements are critical for
understanding the effectiveness of analgesics and other treatments in clinical
practice. Because pain assessment is necessary for its effective treatment,
everything that contributes to the knowledge of its measurements also
contributes to pain reduction and the relief of pain-induced suffering. One
cannot base the efficacy of a new therapeutic approach on only the clinician’s
perception of whether the approach is satisfactory for adequate pain control
(Da Silva, Ribeiro-Filho & Matsushima, 2010).
One
issue that is extremely important in the clinical/hospital environment is the lack
of proper pain measurement to ascertain which treatment or therapeutic
intervention is best. Without such measurements, determining whether a
treatment is necessary, is effective, or should be stopped is difficult. Conversely,
with appropriate pain measurements, determining whether the risks of a given
treatment outweigh the damage caused by the clinical problem itself is possible.
One can also choose the best and safest intervention among different
therapeutic options.
Thus, better monitoring and analysis
of the mechanisms of action and side effects of different drugs allow examination
of the nature of pain, its origins, and clinical correlates as a function of
the patient’s emotional, motivational, cognitive, and personality
characteristics. Sometimes only rough pain estimates, such as “pain present” or
“pain absent,” are necessary for clinical interventions. However, to better
understand the phenomenon and evaluate the efficacy and tolerability of
interventions, using more sophisticated pain measurements to assess intensity
and cognitive and affective responses linked to pain becomes necessary (Miller,
Colloca, Crouch & Kaptchuk, 2013).
Pain is essential, as is the
preservation of the integrity of the human organism, which would not be able to
live long without a very precise alarm system. Understanding pain requires the convergence
of knowledge from different disciplines and at different levels, never reducing
it to merely neurophysiology or pharmacogenomics. Recalling Richard Chapman, prior
Director of the Center of Research on Pain of Utah University, in the United
States, “Pain is in the other extremity, the human being as a whole. It is a
conscious experience that emerges from our complex brain. People suffer from
different complex ways” (Chapman & Syrjala, 2001). Therefore, understanding this subjectivity is
our great challenge, especially knowing how to measure and evaluate pain,
regardless of whether the pain is our own or the pain of others.
This special issue is dedicated to comprehensively
understanding pain and analyzing different theoretical, experimental, and
practical aspects of pain. Each manuscript herein constitutes an excellent
source of information for clinicians and researchers that is broadly relevant
for any healthcare professional who is interested in these types of studies. The
knowledge contained herein will also be extremely useful for undergraduate and
graduate students.
I would like to thank Prof. Dr. J.
Landeira Fernandez, Editor-in-Chief of Psychology
& Neuroscience, for the kind invitation to act as Guest Editor for this
issue. His encouragement, support, and “regular requests,” certainly made this
task a pleasant one, without the least notion of pain.
Finally, I dedicate this special
issue to the memory of my friend and colleague, Prof. Dr. Nilton Ribeiro-Filho,
who was more than a brother and a scientist with whom I was fortunate to share
many ideas in the area of perception and psychophysics and challenging the current
measurements of pain.
References
Chapman, C.R., & Syrjala, K.l. (2001). Measurement
of pain. In: J.D. Loeser, J.J. Bonica (Eds.), Bonica’s management of pain (pp. 310-328). Philadelphia:
Lippincott Williams & Wilkins.
Da
Silva, J.A., & Ribeiro-Filho, N.P. (2006). Avaliação e mensuração de dor: pesquisa, teoria e prática. Ribeirão Preto, SP: Funpec-Editora.
Da
Silva, J.A., Ribeiro-Filho, N.P., & Matsushima, E. H. (2010). Mensurando o
quinto sinal vital: a dor. Ribeirão Preto, SP: Funpec-Editora.
Marchand, S. (2012). The phenomenon of pain. Seattle: IASP Press.
Melzack, R. (1973). The puzzle of pain. New York: Basic Books.
Melzack, R., & Wall, P.D. (1982). The challenge of pain. New York: Basic
Books.
Miller, F.G., Colloca, L., Crouch, R.A., &
Kaptchuk, T.J. (2013). The placebo: a reader.
Baltimore: John Hopkins University Press.
