Why is pain so difficult to measure and facilitate?

Why is it so difficult to explain what we feel when we hurt? Obviously, this is an important indicator of health. Doctors have to develop new ways of explaining and treating agony. Next is a story John Walsh Mosaic in the first person, which is very serious approach to the study of this question. One night my wife sat up in bed and said, “Only that I was here.” She pointed at her belly and grimaced. “It feels like something’s wrong.” Idly noting that the clock was 2 am, I asked what it’s like to the pain. “If something bites me without stopping,” she said.

An hour later she again got up with pain in her eyes. “Worse,” she said. “It’s very frustrating. Can you call the doctor?”. Miraculously, the family doctor answered a call at 3am, listened to her symptoms and came to the conclusion: “It may be your Appendix. You delete it?”. No, not removed. “Probably appendicitis,” he suggested, “but if it was dangerous, you would be much harder than it is now. Go to the hospital in the morning, but for now take some paracetamol and try to sleep.”

Half an hour later, as things started to happen. She woke up a third time, but now the pain was so wild and brutal that her face looked like it burned at the stake. Time for murmuring consolations and marital procrastination has expired. I called the local ambulance, dressed quickly, pulled on her Bathrobe, and we went to the hospital of St Mary at 4 am.

The Registrar poked with a needle in the wrist of my wife and said, “are You hurt? And now? And how about this?” before to conclude: “Impressive. You have a very high pain threshold.”

The pain was caused by pancreatitis caused by escaped gall stones that came out of her gall bladder and went, escaped prisoners, asylum in her pancreas, causing the agony. She took a course of antibiotics, and a month later her gall bladder removed.

“This is a common surgery”, happily said the surgeon, “so you’ll be back to normal very soon. Some people feel well enough to independently take the bus after the operation”. His optimism was misplaced. My lovely wife, with her amazingly high pain threshold, stayed overnight and returned home, accompanied by a battery of painkillers. When they ceased to act, she writhed in pain.

During this recovery period, as I watched her grimace and a grinding of the teeth, listening to the light moans before ibuprofen and codeine finally took the pain under control, I asked questions. Chief among them was this: at least someone in the medical field can speak about the pain with knowledge? Assumptions a family doctor and surgeon seemed slippery, generalized, vague — and possibly dangerous.

I would also like to know whether there is any agreed word, which would help the doctor understand the patient’s pain. I remembered that my father, a General practitioner in the 1960-ies, who worked in South London, loved to recount the colorful pain symptoms that are heard: “Like I’ve been attacked with a staple gun”, “like rabbits running up and down my spine,” “if my penis opened cocktail umbrella.” A few of them, he told me, match the symptoms listed in the medical textbook. So what was he to do? To read the aspirin?

It seems to understand human pain, we have a giant failure. I wanted to see how the doctors suffer the pain — what language is used to describe something invisible that we cannot measure, except as a verbal subjective description, and that treated only derivatives of opium that are rooted in the middle ages.

In the study of pain clinics use a primary procedure, giving the patient a pain questionnaire by McGill. It was developed in the 1970’s, two scientists, Ronald Maltacom and Warren Torgerson from McGill University in Montreal, and is still used as the main tool to measure pain in hospitals around the world.

Melzak began to list the words that patients use to describe their pain, and to classify them in three categories: sensory (this includes heat, pressure, sensation of “pulsation” or “knocking”), affective (associated with emotional effects such as “tedious”, “disgusting”, “grueling” or “terrible”) and, finally, evaluation (depending on experience — from “annoying” and “problem” to “terrible”, “unbearable” and “excruciating”). All these words do not sound very efficiently, like the Duchess complains about the ball that does not meet her standards.

But the bars of the suffering of Melaka formed the basis for what became the McGill questionnaire. The patient listens to a list of “descriptions of pain” and says, does every word his pain — and based on this evaluates the intensity of the feeling. The clinic workers then put a tick in the appropriate places. This gives them a number or percentage, which will then work to assess, decreases or increases the patient’s pain.

Recently were also introduced to the scale of the National initiative on pain control PQAS (Scale of evaluation of the quality of pain), in which patients are asked to indicate from 1 to 10, how intense — sharp, hot, dull, cold, sensitive, itchy, etc. — the pain they had last week.

The problem with this approach is the inaccuracy of the scale from 1 to 10, where 10 is the “most strong pain sensation imaginable”. The patient could imagine the worst pain in General and to give the figure of their pain? The British middle class, who have never been in a war zone, hardly able to imagine anything stronger than a tooth ache or injury on the tennis court. Women who have experienced childbirth, can mark all the rest as any 3 or 4.

My friend is a novelist, specializing in the First world war, drew my attention to the memoirs of Stuart the Clot in which the author describes time spent in the field hospital. He is surprised by the stoicism of the wounded soldiers. “I heard the boys on a stretcher, crying weakly, but they could ask for water or a cigarette. The exception was a man with a bullet through his hand. I think it was the strongest pain because all the wires were severed and the mind”.

The use of questionnaires to identify pain points, not impressive Steven MacMahon of the London pain consortium, which was organized in 2002 to promote international research in pain.
“Together with the measurement of pain comes lots of problems. I think the obsession with numbers is a simplification. Pain is not one-dimensional. She has no scale — a lot or a little — she has other goods: how dangerous she was, how frustrating emotionally, how it affects your ability to concentrate. Obsession with measurement probably comes from the regulators who think that the medications needed to show the effectiveness of using them”.

The pain may be acute or chronic. Acute pain is a temporary or occasional feeling of discomfort, which is usually treated with medication, while chronic pain persists over time and is becoming an everyday evil companion. But as patients become resistant to the drugs needed and other forms of pain treatment.
“I would say that 55-60 percent of our patients suffer from back pain,” says Adnan al-Qaisi, head of the Center for pain management and neuromodulation at St. Thomas hospital in London, the largest center for the study of pain in Europe. “The reason that we do not pay attention to the requirements that are imposed on us life, regarding how to sit, stand, walk, etc. We sit for hours in front of the computer, and the body exerts strong pressure on the small joints of the back.”

Al-Qaisi believes that in the UK the emergence of chronic low back pain has increased drastically over the last 15-20 years, resulting in a loss of 6-7 billion pounds, if we talk about working days. Otherwise, the clinic treats severe, chronic headaches and injuries from accidents that affect the nervous system.

Do they use a questionnaire the McGill? “Unfortunately, Yes,” said al-Kaisi. “This is a subjective measurement. But the pain may be exaggerated for personal reasons or due to problems at work, so we’re trying to learn something about the patient’s life — how he sleeps, walks and stands, eats. This concerns not only the patient but also his entourage”.

The challenge is how to transform this information into scientific data. “We are working with Raymond Lee, chief of biomechanics at the University of South Bank, to know whether it is possible to objectively measure the patient’s disability due to pain,” he says. “They’re trying to develop a tool, like the accelerometer, which will give an accurate idea of how active or passive the patient, and the reason why comes the pain in the process of sitting or standing. We would very much like to get away from the simple survey of the patient, how acute the pain”.

Some patients come with pain that is much worse than lumbago. Al-Kaisi describes one patient — we’ll call him Carter — who was suffering from a horrible condition, ilio-inguinal neuralgia, which causes severe burning and stabbing pain in my groin.
“He had surgery in the area of the testes and the inguinal nerve was cut. The pain was excruciating when he came to us, he was on four or five different drugs, opiates in high doses, anticonvulsant medications, opioid patches, paracetamol, and ibuprofen. His life is turned upside down, the work stops.”

The anguished Carter became one of the biggest successes of al-Qaisi.

In 2010, the hospital guy’s and St. Thomas offers a program for adults with chronic pain which has not undergone treatment in other clinics. Patients come for four weeks, away from the familiar environment and put myself in the hands of psychologists, physiotherapists, occupational health specialists and nurses, who will develop a program to free people from pain.

Many of these strategies come under the heading of “neuromodulation,” which is often found in circles of pain management. Simply put, this term refers to the distraction of the brain from the constant torture of the pain signals it receives from the periphery of the body. Sometimes it’s a distraction cleverly carried out by an electric current.

“We were the first center in the world who started to use the spinal cord stimulation”, proudly says al-Kaisi. “We are trying to send small electrical signals to the spinal cord, inserting the wire into the epidural area. It’s only one or two volts, so the patient feels only a tingling over the place, which hurts, but not real pain. The patient feels nothing but his pain subsides. It is not an invasive procedure, we send patients home the same day.”

When Carter, the one with the groin pain, refused to respond to any other treatment, al-Kaisi opened his magic box of tricks. “We gave him the stimulation of dorsal roots ganglion,” he says. “She’s overstimulated spine and sent impulses to the spinal cord and brain. Ten days the pain intensity decreased by 70% — personal words of the patient”.

“He wrote me a very nice letter and said I changed his life that the pain is completely gone and he is back to normal. He said that his work saved his marriage too, and he wants to return to the sport. This is a surprising result. This will not give any other therapy.”

According to Irene Tracey, head of the Department of clinical neurosciences the Nuffield at Oxford University, the greatest recent breakthroughs in treating pain is to understand chronic pain as a stand-alone. “We always thought of it as an acute pain, which lasts and lasts — and if chronic pain is just a continuation of acute pain, let’s fix the cause of acute and chronic will disappear, too. This plan failed. Now we consider chronic pain as shifting to another place, with other mechanisms, such as changes in genetic expression, chemical release, neurophysiology and the work of the neurons. This is a paradigm shift in the study of pain — we just completely new look at chronic pain.”

Some media referred to Tracy as “the Queen of pain.” But despite her nickname, she was quite pleasing: bright eyes, enthusiasm, friendliness and active conversation talking about the woman over 50 for themselves. She talks about pain with knowledge. It is no problem to describe the “high pain” on a ten scale McGill: “three times I gave birth, and my 10 very different from 10, which was before having children. This scale has gone through a complete recalibration”. But how to explain the higher pain people who didn’t give birth? “I say: imagine that you arm caught in the car door is ten.”

In recent years, according to her, there was an explosion in understanding how the brain is involved in pain. Brain imaging, she says, helps to connect the subjective pain with objective perception. “It fills a gap between what you see and what you report. We can explain why the patient is suffering from pain, even if you don’t see it on an x-ray or something. It helps to shed the light of truth for poor people who suffer from pain, but they did not believe.”

But you hardly ever see the pain glowing and pulsating on the screen in front of you. “Visualization of the brain has taught us how to operate the network of the brain and what it is,” she says. “This is not a pain measuring device. It is a tool that gives you a fantastic understanding of anatomy, physiology and neurochemistry of your body and can tell us why you hurt and where to go to try to fix it”.

Some of the ways, she says, wonderfully direct and mechanical — like spinal cord stimulation using wire al-Kaisi. “Currently, there are devices that you can attach to the head and using them to manipulate the parts of the brain. They can be worn as a swimming cap. They are portable and permitted by ethics. They are easy to use and great for survivors of stroke and people in rehabilitation”.

Researchers from the research laboratory human pain at Stanford University are working to gain a deeper understanding of individual reactions to pain in order to develop a more targeted treatment. The center was established in 1995 by Martin Angstom from the Department of anesthesiology. His first studies were devoted to finding reliable methods for quantitative assessment of pain. Then Angst dealt with opiate pharmacology, studying how quickly the body builds tolerance to drugs.

In the laboratory now conducts research initiative — migraine, fibromyalgia, facial pain and so on — but most of all she’s interested in back pain. Although among the special types of treatment are mindfulness, acupuncture, cognitive behavioural therapy and neural response in real time, in a broader sense, the laboratory plans to collect a massive database on the basis of the army patients.

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