Do Doctors Undertreat Pain?

Routinely, physicians discount patients' pain reports and provide too little analgesia too late. Critics call them callous, sadistic, and Puritanical, but the causes of these clinical practices are different — namely, a psychological need to distance themselves from the pain they encounter and inflict, and more subtly, a peculiar concept of pain acquired in medical training.
Physicians learn to think of pain as a symptom to observe and explore in diagnosing and monitoring disease — not as a complaint to relieve quickly or fully. Moreover, pain-relief is regarded as subordinate to, and competing with efforts to cure or maintain the life of a patient. This training, I suggest, gives physicians a new, clinical concept of pain at odds with their prior, lay concept of pain whose manifestations standardly call for sympathetic efforts at relief.
The conceptual nature of this difference is obscured by thinking of pain as a solely private sensation, rather than as a sensation with public and social aspects (a la Wittgenstein). Although suppressed in certain clinical circumstances, these standard public and social aspects are shown in the very tests used in clinical pain research.
This clinical pain concept is rooted in Medicine conceived as preeminently curative and life-prolonging. Physicians are, however, themselves undermining this professional self-definition (by treating AIDS and Alzheimer's patients; by no longer pressing their patients to 'fight to the end'; by collaborating with non-medical healers). Accordingly, pain-relief may gain greater therapeutic status, and, so too, the ordinary concept of pain that medical training has suppressed.     

Determining heat and mechanical pain threshold in inflamed skin of human subjects

In a previous article in the Journal of Visualized Experiments we have demonstrated skin microdialysis techniques for the collection of tissue-specific nociceptive and inflammatory biochemicals in humans. In this article we will show pain-testing paradigms that are often used in tandem with microdialysis procedures. Combining pain tests with microdialysis provides the critical link between behavioral and biochemical data that allows identifying key biochemicals responsible for generating and propagating pain.Two models of evoking pain in inflamed skin of human study participants are shown. The first model evokes pain with aid of heat stimuli. Heat evoked pain as described here is predominantly mediated by small, non-myelinated peripheral nociceptive nerve fibers (C-fibers). The second model evokes pain via punctuated pressure stimuli. Punctuated pressure evoked pain is predominantly mediated by small, myelinated peripheral nociceptive nerve fibers (A-delta fibers). The two models are mechanistically distinct and independently examine nociceptive processing by the two major peripheral nerve fiber populations involved in pain signaling.Heat pain is evoked with aid of the TSA II, a commercially available thermo-sensory analyzer (Medoc Advanced Medical Systems, Durham, NC). Stimulus configuration and delivery is handled with aid of specific software. Thermodes vary in size and shape but in principle consist of a metal plate that can be heated or cooled at various rates and for different periods of time. Algorithms assessing heat-evoked pain are manifold. In the experiments shown here, study participants are asked to indicate at what point they start experiencing pain while the thermode in contact with skin is heated at a predetermined rate starting at a temperature that does not evoke pain. The thermode temperature at which a subject starts experiencing pain constitutes the heat pain threshold.Mechanical pain is evoked with punctuated probes. Such probes are commercially available from several manufacturers (von Frey hairs). However, the accuracy of von Frey hairs has been criticized and many investigators use custom made punctuated pressure probes. In the experiments shown here eight custom-made punctuated probes of different weights are applied in consecutive order, a procedure called up-down algorithm, to identify perceptional deflection points, i.e., a change from feeling no pain to feeling pain or vice versa. The average weight causing a perceptional deflection constitutes the mechanical pain threshold.     

Dread and the Disvalue of Future Pain

Standard theories of decision-making involving delayed outcomes predict that people should defer a punishment, whilst advancing a reward. In some cases, such as pain, people seem to prefer to expedite punishment, implying that its anticipation carries a cost, often conceptualized as ‘dread’. Despite empirical support for the existence of dread, whether and how it depends on prospective delay is unknown. Furthermore, it is unclear whether dread represents a stable component of value, or is modulated by biases such as framing effects. Here, we examine choices made between different numbers of painful shocks to be delivered faithfully at different time points up to 15 minutes in the future, as well as choices between hypothetical painful dental appointments at time points of up to approximately eight months in the future, to test alternative models for how future pain is disvalued. We show that future pain initially becomes increasingly aversive with increasing delay, but does so at a decreasing rate. This is consistent with a value model in which moment-by-moment dread increases up to the time of expected pain, such that dread becomes equivalent to the discounted expectation of pain. For a minority of individuals pain has maximum negative value at intermediate delay, suggesting that the dread function may itself be prospectively discounted in time. Framing an outcome as relief reduces the overall preference to expedite pain, which can be parameterized by reducing the rate of the dread-discounting function. Our data support an account of disvaluation for primary punishments such as pain, which differs fundamentally from existing models applied to financial punishments, in which dread exerts a powerful but time-dependent influence over choice.     

Pain and compassion in the neonatal unit -- a neonatologist's view

Research has shown that even extremely premature babies are sufficiently developed, anatomically and physiologically, to be capable of experiencing and responding to pain. All newborn infants and especially those who require intensive care in the first days of life are exposed to some painful procedures. Part of the neonatologist's role is the detection and management of pain in these infants. Difficult challenges come with this role. All medications carry known or potential adverse effects and limited research has been done in this vulnerable population. The benefits and risks of all available pain-relieving measures should be balanced when planning management. Compassion is no excuse for a high incidence of undesirable or dangerous side effects. We must proceed with great care.     

Coping with Phantom Limb Pain

Phantom limb pain is a chronic neuropathic pain that develops in 45–85% of patients who undergo major amputations of the upper and lower extremities and appears predominantly during two time frames following an amputation: the first month and later about 1 year. Although in most patients the frequency and intensity of pain diminish over time, severe pain persists in about 5–10%. It has been proposed that factors in both the peripheral and central nervous systems play major roles in triggering the development and maintenance of pain associated with extremity amputations. Chronic pain is physically and mentally debilitating, affecting an individual’s capacity for self-care, but also diminishing an individual’s daily capacity for personal and economic independence. In addition, the pain may lead to depression and feelings of hopelessness. A National Center for Biotechnology Information study found that in the USA alone, the annual cost of dealing with neuropathic pain is more than $600 billion, with an estimated 20 million people in the USA suffering from this condition. Although the pain can be reduced by antiepileptic drugs and analgesics, they are frequently ineffective or their side effects preclude their use. The optimal approach for eliminating neuropathic pain and improving individuals’ quality of life is the development of novel techniques that permanently prevent the development and maintenance of neuropathic pain, or that eliminate the pain once it has developed. What is still required is understanding when and where an effective novel technique must be applied, such as onto the nerve stump of the transected peripheral axons, dorsal root ganglion neurons, spinal cord, or cortex to induce the desired influences. This review, the second of two in this journal volume, examines the techniques that may be capable of reducing or eliminating chronic neuropathic pain once it has developed. Such an understanding will improve amputees’ quality of life by blocking the mechanisms that trigger and/or maintain PLP and chronic neuropathic pain.     

Origins of Phantom Limb Pain

Phantom limb pain (PLP) is a chronic neuropathic pain occurring in 45–85% of patients who undergo major amputations of the upper and lower extremities. Chronic pain is physically and mentally debilitating, affecting an individual’s potential for self-care and the performance of daily living activities essential for personal and economic independence. In addition, chronic pain may lead to depression and feelings of hopelessness. A National Center for Biotechnology Information study found that in the USA alone, the annual cost of dealing with neuropathic pain is more than $600 billion, with an estimated 20 million people in the USA suffering this condition. PLP manifest predominantly during two time frames post-amputation: during days to a month and again at around 1 year. In most patients, the frequency and intensity of the chronic neuropathic pain diminish over time, but severe pain persists in about 5–10% of patients. The development and maintenance of neuropathic pain is attributed to extremity amputations causing changes in peripheral axon properties and neuronal circuitry in both the peripheral and central nervous systems: peripheral axons, dorsal root ganglia, the spinal cord, and the cortex. However, it is not clear how the changes in neuronal properties in these different locations affect neuropathic pain. Is pain initiated by one set of post-amputation changes while the pain is maintained by another set of changes? If one set of amputation-induced changes, such as those of peripheral axons, are reverted to normal, is the chronic pain reduced or eliminated, while reversing another set of neuronal changes and neuronal circuits to normal do not reduce or eliminate the pain? Or, must all the amputation-induced changes be reverted to normal for pain to be eliminated? While this review examines the mechanisms underlying the induction or maintenance of PLP, it is beyond its scope to examine the mechanisms that may permanently reduce or eliminate neuropathic pain. This paper is the first of two reviews in this journal and deals with the causes of chronic PLP development and maintenance, while the second review examines potential mechanisms that may be responsible for promoting the capacity to coping with PLP by reducing or eliminating it.     

Toward Conceptual Cohesiveness: a Historical Analysis of the Theory and Utility of Ecological Boundaries and Transition Zones

Ecological transition zones are increasingly recognized as systems that play a critical role in controlling or modifying flows of organisms, materials, and energy across landscapes. Many concepts describing transitional areas have been proposed over the years, such as the prevalent and durable ecotone concept. Confusion among ecologists and land managers about transition zone concepts and the isolation of studies that use only one transition concept can hinder unified progress in understanding these key systems. Currently, a movement toward conceptual synthesis under the umbrella concept of ‘ecological boundary’ is underway. Here we examine the history and theoretical baggage of the ecotone, riparian zone, and several other concepts. Subsequently, we present a conceptual cluster analysis, which facilitates a better understanding of the similarities and differences between boundary and transition concepts. We emphasize the hierarchical nature of these concepts: higher-level synthetic concepts can be used in the development of theory, whereas lower-level concepts allow more specificity and the formulation of operational definitions. Finally, we look briefly at the utility and future use of boundary and transition zone concepts.     

From arctic lemmings to adaptive dynamics: Charles Elton's legacy in population ecology

We shall examine the impact of Charles S. Elton's 1924 article on periodic fluctuations in animal populations on the development of modern population ecology. We argue that his impact has been substantial and that during the past 75 years of research on multi-annual periodic fluctuations in numbers of voles, lemmings, hares, lynx and game animals he has contributed much to the contemporary understanding of the causes and consequences of population regulation. Elton was convinced that the cause of the regular fluctuations was climatic variation. To support this conclusion, he examined long-term population data then available. Despite his firm belief in a climatic cause of the self-repeating periodic dynamics which many species display, Elton was insightful and far-sighted enough to outline many of the other hypotheses since put forward as an explanation for the enigmatic long-term dynamics of some animal populations. An interesting, but largely neglected aspect in Elton's paper is that it ends with speculation regarding the evolutionary consequences of periodic population fluctuations. The modern understanding of these issues will also be scrutinised here. In population ecology, Elton's 1924 paper has spawned a whole industry of research on populations displaying multi-annual periodicity. Despite the efforts of numerous research teams and individuals focusing on the origins of multi-annual population cycles, and despite the early availability of different explanatory hypotheses, we are still lacking rigorous tests of some of these hypotheses and, consequently, a consensus of the causes of periodic fluctuations in animal populations. Although Elton would have been happy to see so much effort spent on cyclic populations, we also argue that it is unfortunate if this focus on a special case of population dynamics should distract our attention from more general problems in population and community dynamics.     

Back Pain Prevalence and Its Associated Factors in Brazilian Athletes from Public High Schools: A Cross-Sectional Study

Most studies on the prevalence of back pain have evaluated it in developed countries (Human Development Index—HDI > 0.808), and their conclusions may not hold for developing countries. The aim of this study was to identify the prevalence of back pain in representative Brazilian athletes from public high schools. This cross-sectional study was performed during the state phase of the 2015 Jogos dos Institutos Federais (JIF), or Federal Institutes Games, in Brazil (HDI = 0.744), and it enrolled 251 athletes, 173 males and 78 females (14–20 years old). The dependent variable was back pain, and the independent variables were demographic, socioeconomic, psychosocial, hereditary, exercise-level, anthropometric, strength, behavioral, and postural factors. The prevalence ratio (PR) was calculated using multivariable analysis according to the Poisson regression model (α = 0.05). The prevalence of back pain in the three months prior to the study was 43.7% (n = 104), and 26% of the athletes reported feeling back pain only once. Multivariable analysis showed that back pain was associated with demographic (sex), psychosocial (loneliness and loss of sleep in the previous year), hereditary (ethnicity, parental back pain), strength (lumbar and hand forces), anthropometric (body mass index), behavioral (sleeping time per night, reading and studying in bed, smoking habits in the previous month), and postural (sitting posture while writing, while on a bench, and while using a computer) variables. Participants who recorded higher levels of lumbar and manual forces reported a lower prevalence of back pain (PR < 0.79), whereas feeling lonely in the previous year, obesity, and ethnicity exhibited the highest prevalence ratio (PR > 1.30). In conclusion, there is no association between exercise levels and back pain but there is an association between back pain and non-exercise related variables.     

Fetal Pain: An Infantile Debate

The question of whether a fetus can experience pain is an immense challenge. The issue demands consideration of the physical and psychological basis of being and the relation between the two. At the center of this debate is the question of how it is that we are conscious, a question that has inspired the writing of some of our most brilliant contemporary philosophers and scientists, with one commentary suggesting surrender. In my earlier review I attempted to draw together the various strands of thinking that had attacked the question of fetal pain and relate them back to the bigger question of consciousness. In their vituperative response, Benatar and Benatar bite off my finger before looking to where I am pointing. I will examine each of their criticisms and attempt to redirect the readers' interest towards examining the subjectivity of pain and the mediating links between physiology and experience.     

A Bayesian Perspective on Sensory and Cognitive Integration in Pain Perception and Placebo Analgesia

The placebo effect is a component of any response to a treatment (effective or inert), but we still ignore why it exists. We propose that placebo analgesia is a facet of pain perception, others being the modulating effects of emotions, cognition and past experience, and we suggest that a computational understanding of pain may provide a unifying explanation of these phenomena. Here we show how Bayesian decision theory can account for such features and we describe a model of pain that we tested against experimental data. Our model not only agrees with placebo analgesia, but also predicts that learning can affect pain perception in other unexpected ways, which experimental evidence supports. Finally, the model can also reflect the strategies used by pain perception, showing that modulation by disparate factors is intrinsic to the pain process.     

Can Healthy Fetuses Show Facial Expressions of “Pain” or “Distress”?

Background

With advances of research on fetal behavioural development, the question of whether we can identify fetal facial expressions and determine their developmental progression, takes on greater importance. In this study we investigate longitudinally the increasing complexity of combinations of facial movements from 24 to 36 weeks gestation in a sample of healthy fetuses using frame-by-frame coding of 4-D ultrasound scans. The primary aim was to examine whether these complex facial movements coalesce into a recognisable facial expression of pain/distress.

Methodology/Findings

Fifteen fetuses (8 girls, 7 boys) were observed four times in the second and third trimester of pregnancy. Fetuses showed significant progress towards more complex facial expressions as gestational age increased. Statistical analysis of the facial movements making up a specific facial configuration namely “pain/distress” also demonstrates that this facial expression becomes significantly more complete as the fetus matures.

Conclusions/Significance

The study shows that one can determine the normal progression of fetal facial movements. Furthermore, our results suggest that healthy fetuses progress towards an increasingly complete pain/distress expression as they mature. We argue that this is an adaptive process which is beneficial to the fetus postnatally and has the potential to identify normal versus abnormal developmental pathways.     

Unearthening Old Data: Darwin was Indeed Correct About Earthworm Behavior

Charles Darwin is well known for his studies on the expression of emotions in animals and humans and as founding father of the concept of sexual selection. Yet it is commonly believed that the various arguments Darwin developed about behavior were usually illustrated only by anecdotes and observations recounted by explorers, naturalists, or zookeepers, and lacking any experimental approach. Here we show that this is not true. In his last book, The Formation of Vegetable Mould Through the Action of Worms (1881), Darwin mentions a series of meticulous experiments he ran to test his hypotheses about why earthworms plug their burrows and comes to the conclusion that earthworms seem to act in an intelligent way. His study can still function as a prime example of how to design an experiment for testing hypotheses. Only one part was missing in Darwin’s research: statistical analyses. We retrieved his data and analyzed them statistically. Based on these results, we cannot reject his conclusion as the statistical analyses confirmed Darwin was right. This shows that Charles Darwin already used a hypothetico-deductive approach, and he can thus be seen as the first true behavioral ecologist—a representative of a discipline that has been recognized for only about a hundred years.     

Is There Such a Thing as Psychological Pain? and Why It Matters

Medicine regards pain as a signal of physical injury to the body despite evidence contradicting the linkage and despite the exclusion of vast numbers of sufferers who experience psychological pain. By broadening our concept of pain and making it more inclusive, we would not only better accommodate the basic science of pain but also would recognize what is already appreciated by the layperson—that pain from diverse sources, physical and psychological, share an underlying felt structure.     

疼痛与社会支持的相关研究

疼痛是一种不愉快的感觉,伴随着现有的或潜在的组织损伤。个体对疼痛的反应不仅是对实际或潜在组织损伤的反应,同时也受到社会因素的影响。大量研究都支持了社会支持对疼痛有着重要的影响。本文主要综述了疼痛与社会支持研究的理论模型,在临床疼痛和实验室疼痛条件下社会支持与疼痛的相关研究,最后对今后的研究方向做了展望。     

The parenthood argument

Don Marquis is well known for his future like ours theory (FLO), according to which the killing beings like us is seriously morally wrong because it deprives us of a future we can value. According to Marquis, human fetuses possess a future they can come to value, and thus according to FLO have a right to life. Recently Mark Brown has argued that even if FLO shows fetuses have a right to life, it fails to show that fetuses have a right to use their mother's body, evoking Judith Jarvis Thomson's famous violinist case. In the wake of Brown's conclusion, Marquis presents a new argument—the parenthood argument (PA)—which he believes shows that abortion is seriously morally wrong. Here I argue that the PA fails to show abortion is seriously morally wrong for the same reasons FLO fails to show abortion is seriously morally wrong.     

Cardiomyopathy in mice with paternal uniparental disomy for chromosome 12

Mice inheriting both copies of MMU12 either maternally or paternally demonstrate imprinting effects. Whereas maternal uniparental disomy 12 (matUPD12) fetuses are growth retarded and die perinatally, paternal UPD12 (patUPD12) fetuses die during late gestation and exhibit placentomegaly and skeletal muscle maturation defects. To examine further the developmental consequences of UPD12, we intercrossed mouse stocks heterozygous for Robertsonian translocation chromosomes (8.12) and (10.12). We report that at 13.5-14.5 dg patUPD12 hearts exhibit increased ventricular diameter, thinner, less compact myocardium, and deep intertrabecular recesses when compared to controls. These data provide evidence for cardiac failure, a lethal condition, and suggest a role for an imprinted gene(s) in normal heart development.     

Tschermak: a non-discoverer of mendelism. II. A critique

An examination of Tschermak's two papers of 1900 not only reinforces our conclusion cited in our first paper on Tschermak that he was not a rediscoverer of Mendelism, but also he did not understand Mendel when he had read it. His concept of dominance differed from that of Mendel, and his use of his own concept is inconsistent and contradictory. His discussion of his backcross data indicated that he had no idea of the nature of Mendelian ratios. Nowhere did he develop the ideas of segregation and independent assortment.     

Considerations of specimen damage for the transmission electron microscope, conventional versus scanning

We have previously shown that the transmission scanning electron microscope is capable of giving a resolving power equal to that of a conventional electron microscope, that it can be used to provide all the same contrast modes, but that it offers the advantage of new forms of contrast and can provide direct numerical outputs (Crewe &; Wall, 1970a,b; Crewe et al. 1970; Crewe, 1970).One question that we have not previously discussed is that of specimen damage, but in view of the similarity in performance between the two types of machine it has become important to do so.Recent remarks of Scherzer (1971) have been widely misinterpreted as indicating that the scanning microscope causes more specimen damage. However, he has confined his attention to the highest conceivable resolution of 0·4 Å, where we agree with his general conclusion (barring advances in scanning microscope technology). As we will demonstrate, the conclusion is not valid for normally attainable resolutions.