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9 Articles in Volume 9, Issue #3
Amino Acids and Diet in Chronic Pain Management
Clinical Case Study of Low-level Laser Therapy
Comorbidity of Musculoskeletal Injury Pain and PTSD
Craniofacial Pain of Cardiac Origin
Intellectual and Moral Tasks in Intersection – Part 1
Opioid Antagonists in Pain Management
Post-traumatic Headaches, Migraines, and Sleep Disorders
Restoration of Normal Cervical Lordosis
Tension Headaches

Intellectual and Moral Tasks in Intersection – Part 1

Assessing the experience of pain: making the subjective objectively appreciable.

Pain medicine is a human practice in every sense, confronting us with the limitations of our understanding and compelling us to strengthen the bonds between ourselves and others. As much as it is a human practice, pain medicine is a stewardship of knowledge. It requires objective judgment and assessment and must confront the formidable task of objectifying the subjective phenomenon of pain to determine the right treatments for both the pain syndrome and the patient in whom the pathology is expressed.

It is this expression of the experience of pain that remains enigmatic. The chief reason communication of pain is so difficult is that we, as a human and scholarly community, are far from reaching agreement on what exactly it is that we are talking about. This essay is the first of a two part series that explicates how the intellectual tasks of knowing about pain—as well as its experience and expression in the pain patient—are constituent to the moral responsibility of pain medicine and fundamental to the ethical processes of informed consent, respect for autonomy, and sustenance of agency.

Herein, we present a sampling of ideas addressing both what should be defined as pain and what dimensions should be included in an assessment of pain. We then synthesize those ideas into a conceptual model using a multi-dimensional vector representation of the experiential pain space. This model gains applicability when coupled with standardized, easily administered, assessments. We will discuss the tools that may be most useful in this regard. The goal is to expand understanding of the unique challenge of clinical pain assessment while keeping the ethical integrity and value of this encounter well in view.

Hermeneutics and Dynamics of the Clinical Encounter

We have claimed that “…knowledge of pain is limited by problems of understanding and explanation: what is subjectively understood cannot be directly explained, and what can be explained does not reflect that which is subjectively understood.”1 Empirical knowledge of etiology and treatment is fruitless without knowledge of the patient’s subjective existence as a person in pain. Pain, by its very nature, cries out to be understood.2 Medicine, as a hermeneutic endeavor, attempts to resolve this paradox via the inter-subjective structure of the clinical encounter. Within this hermeneutic framework, the physician uses interpretive skill to synthesize the clues gathered in the clinical meeting into a more meaningful picture of the patient’s pain experience. As this domain deepens and expands to foster appreciation for the ways in which pain-as-pathology affects the patient-as-person, the pain practitioner’s abilities and efforts—to both understand pain and make prudent clinical decisions as relate to therapeutics—will likely become increasingly adept.

At the juncture of the clinical encounter, the life-worlds of patient and physician are united by a common goal of healing. The responsibility each party assumes in order to achieve this goal lays the foundation for an ethics of pain medicine. The core ethical issues of the clinical encounter in pain medicine can be posed by two fundamental questions:

1) Is the pain physician fulfilling the telos of pain medicine by providing effective and beneficial treatment of pain?
2) Is the pain physician upholding the values inherent to the profession of pain medicine?

To affirmatively answer these ethical questions requires not only knowledge of pain writ large, but knowledge of pain as it is manifested in the individual. Therefore, as a first step toward right and good treatment, the primary goal of pain medicine is to make the subjective experience of pain objectively accessible, assessable, and appreciable.

Challenges of Communicating Pain

Although one can point to the part of the body where pain seems to originate or to the instrument inflicting that pain, neither patient nor physician can point to the pain itself. As Wittgenstein argues, even if we manage to fix our attention inward and “point” to the pain itself, there can be no language for our introspective, immediate private sensations.3 Despite these difficulties, we do have ways of talking about pain. We use metaphor, as well as pain behavior and visual cues, to signal pain to others. However, pain behavior can be faked or repressed, visual cues such as blood or tissue damage do not correlate to pain intensity—as anyone who has experienced a paper cut will attest—and metaphors may not be useful across cultural borders.

Effective communication requires both someone who signals and someone who understands. To understand someone who speaks of her own pain, we must imagine pain we do not feel based upon the model of pain which we have felt.3 In light of this, any understanding of another’s pain is dependent just as much on our personal experience as it is on an other’s ability to express it. Valerie Hardcastle claims “…our ways of discussing pain are beyond repair…our best strategy is simply to scrap them and start over.”4 But we ask if such a complete overhaul is really necessary. Using existing language, many astute and compassionate practitioners successfully diagnose and treat patients’ pain. If we stop talking about pain altogether, how can we possibly continue to help those who suffer? A counterpoint to Hardcastle’s bold and rather nihilistic assertion is put forth by Ronald Melzack, who has sought to use the linguistic tools we have at present to assess and identify the dimensions of pain. But, if such linguistic tools for describing pain are to some extent inadequate, then the task is to analyze the scope and nature of these informational gaps and augment those means of assessment and evaluation until we develop new tools that more fully compensate, or wholly bridge, the gaps.

Value of Narrative in Pain Medicine

We posit that pain often compels expression in order to satisfy the need for meaning and relief. Thus, narratives of pain not only communicate self, but create self. Consequently, from a physician’s perspective, the pain narrative can be important as both a diagnostic tool, and as a form of therapy.5 In this way Rita Charon’s definition of narrative as “a story with a teller, a listener, a time course, a plot, and a point”5 is most useful. Narrative entails more than just simple answers to a series of questions asked by the physician. Rather it can become an open-ended reflection on aspect(s) of the patient’s life that facilitate communication with the physician and participation in the clinical encounter through sharing of values, goals, needs, and first-person experience.

A physician imbued with the skills of recognizing, absorbing, interpreting, and appreciating the stories of chronic pain (as symptom and illness) can not only recognize and understand the patient’s viewpoint, but can work to bring the patient’s experiential and physician’s medical viewpoints into better alignment—thereby enlarging the inter-subjective and clinical space that they share. The difficulty of expressing the pain experience makes the role of the teller exceptionally challenging and sometimes taxing. The reciprocal duty of the pain physician as listener is to record the narrative, respect the value of its telling, trust that what is said has meaning, and reflect upon, and communicate whatever coherence or meaning emerges.5 Pragmatic analysis of narrative will reveal that while some stories are genuine, truthful, insightful, and revealing, others are disingenuous, deliberately misleading, or beside the point.6 However, much can still be gleaned from the latter categories of narrative. Even untruthful stories reveal much about the patient, their motives, the way they see the world, and the way they think.

Without doubt, narrative can be influenced by, and pursuant to, factors of secondary gain. It can be disjointed, unclear, or altogether cut off by the severity of pain and, in such cases, verbal and nonverbal accounts of pain can be non-congruent. These challenges, however, do not lessen the overall value of narrative to pain medicine, nor do they disavow the moral and therapeutic importance of actively listening to the patient’s narrative as a means to gain insight to the existential reality of “being a patient” through the nexus of explanation.

Defining Pain

In many ways, the challenges of communicating and speaking about pain reflect the basic problem of defining pain. The International Association for the Study of Pain’s definition of pain as “…an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”7—although standardized and valid—still does not resolve the extant controversy surrounding how we can and/or should make pain an objectively- appreciable entity given its subjective, individually variable, and often ambiguous qualities.

When someone states, “I am in pain,” they refer to the experience, not to the workings of a biological system. In our opinion, the definition of pain as a physical, emotional, and spiritual experience best validates the viewpoint of the painient. To the person in pain, pain is not a sensation or a perception, pain simply is. It is the experience, and not the system, that is directly accessible to the patient and, while the physician can perform limited tests to ascertain the activity of the system, the subjective nature of the pain can only be apprehended through a sharing or telling of experience. Although it is the system that unites the disparate experiences of pain, it is the unique quality of the experience caused by this system that is essential to “understanding” others’ pain.

Multi-Dimensional Model of the Pain Experience

Whether seen as perception, sensation, system, or experience, pain is made up of multiple interacting dimensions and is influenced by many factors. These component parts bridge definition to assessment since, in order to measure a subjective phenomenon, it must first be defined. Equally important is the weight or proportion of items given to the dimensions in the assessment.8 The dimensions suggested for the pain experience are numerous and each patient’s pain is distinctly affected by combinations of these dimensions. The determination of this unique dimensionality allows the physician some measure of inter-subjective knowledge necessary to apprehend the experiential aspects of a patients’ pain.

Toward these ends, we have developed a conceptual model of pain as a multidimensional vector space. There have been several prior attempts to resolve pain into component vectors. One of the most notable was put forth by Dennis Turk.9 His model, called the Multi-Axial Pain system, included three axes: the medical-physical, the psycho-social, and the behavioral-functional, and was presented as a comprehensive pain assessment strategy incorporating physical findings with psychosocial and behavioral assessments. In an attempt to ground this model in clinical reality, Turk sought to match each of the axes with a form or tool of assessment. The medical-physical dimension was perhaps the most problematic since a quantifiable procedure to assess conventional medical findings does not yet exist for chronic pain. The psycho-social axis can be defined as the patients’ perceptions of the impact of pain on their lives, and can be quantified by self-report measures that have proven reliability. To give a value to the behavioral-functional axis, it is necessary to identify a set of pain behaviors that could be reliably evaluated, as well as gather input from the patient and the patient’s significant others on the extent of functional activity.

“By translating the magnitude of a uni-dimensional pain score into a vector in three-dimensional space, our model is designed to help the physician discover the unique dynamics and dimensionality of a patient’s individual pain experience.”

Our putative model for the chronic pain experience, like Turk’s, parses the realms of pain-as-experience into three broad and variable dimensions that are accessible to the physician in the clinical encounter.

The sensory dimension includes the temporality, quality, location, and intensity of the raw pain sensation, and can provide important clues to the etiology of the pain.

The affective dimension encompasses those ways in which pain impacts the patient’s manner of being in the world, including the emotional effects, level of suffering caused, and the meaning that the pain may have to the patient. It is in this dimension that pain as illness is most completely represented.

The responsive dimension significantly affects both behavioral expression and first person reports of pain. For example, is the patient active or is she bedridden? Does she tend to over-exaggerate or under-report pain in verbal and nonverbal communication? Is she using adaptive or maladaptive coping mechanisms to deal with pain?

Our model differs from Turk’s in several ways. First, and most significantly, we present this as a qualitative model and do not seek to quantify each dimension presented. While it is possible that quantifying and plotting a specific point could have application (e.g.- in research settings), we believe that the calculations involved would be tedious, and the work-to-benefit ratio would prohibit its use in clinical practice. Instead, our model could be best used to construct a conceptual, three-dimensional depiction of where a particular patient’s pain is situated in the putative “experiential space domains.” When used in this way, such representation could suggest the utility of particular assessment tools to both clarify the major experiential dimension(s), and allow some insight to how other aspects of the pain experience factor into the general clinical picture. Second, while we agree with Turk that psychological response is affected by social environment, we choose to separate internal and external response factors by arguing instead for an emotional-affective internal dimension and a culturally- and socially-mediated behavioral-responsive dimension.

By translating the magnitude of a uni-dimensional pain score into a vector in three-dimensional space, our model is designed to help the physician discover the unique dynamics and dimensionality of a patient’s individual pain experience. By identifying the chief component of the pain—i.e., whether sensory, behavioral, or affective—the physician can determine which available interventions would be most appropriate for a particular case. In practicality, this conceptual model can ease the transition from what can be done to what should be done for the patient so as to best meet health and life goals. In many instances, one or more of the factors contributing to pain may be unchangeable. In those cases, pain may still be ameliorated by manipulating one of the other identified factors. In this way, the multi-dimensional model of the pain experience also lends itself to palliative applications in which the focus of treatment shifts from curing to a more holistic goal of providing comfort and healing by manipulating those factors that can still be controlled.

Using Existing Assessment Tools

Any model is of little use in everyday clinical practice unless it informs a practical assessment strategy. Therefore, we feel that a battery of assessments—organized around the dimensions we have proposed—can provide a sort of toolkit that enables pain physicians to engage and articulate the model in practice. Although most of the tools presented here are of the self-report category, the nonverbal information gathered by physical examination should not be neglected, especially in cases where the patient is unable or unwilling to communicate. There are a myriad of pain questionnaires and assessment tools available to measure causes and effects but none, however, are able to truly capture the existential essence of pain. To grasp the fullness of the pain experience, the physician must synthesize the results of these assessments into a complete picture of the patient’s pain. Such a synthesis is necessarily more than merely the sum of its component parts.

Of those self-report measures, we include generalizable assessments of pain intensity that can be quickly and easily used to gather preliminary information and gauge treatment efficacy. The most common of these are the pain scales—the bare minimum, but still reasonably valuable evaluations—used by almost every clinician in situations involving pain. Drawbacks of these metrics include the uni-dimensionality of the scale as well as lack of sensitivity to treatment effects as compared with other measures.

Of the assessments developed to reveal specific sensory attributes of pain, the McGill Pain Questionnaire (MPQ) was the first and remains the most widely used. Dubuisson and Melzack have validated the diagnostic utility of the MPQ by demonstrating that different pain syndromes are consistently described in unique constellations of words.10 Other strengths of the MPQ include its expedience and cross-cultural reliability. But the discriminative capacity of this tool is limited when the patient presents with high levels of anxiety or psychological disturbance.11 Therefore, although the MPQ is designed to measure affective and evaluative, as well as sensory dimension of pain, we believe that there are more effective assessments available for these more psychologically- and socially-influenced dimensions.

Assessments for the affective dimension of pain can measure distress, disability, and/or overall health of the patient. Not all of these tools will be useful for the treatment of every patient. The physician must first gather enough background information from narrative or patient interview to determine which assessments will be most helpful. Behavioral assessment encompasses many specific methods of scoring and coding the frequency and quality of a patient’s pain behaviors over a specified observation period. Advantages of the behavioral method of pain assessment are that it is first-hand, reliable, quantitative, and overcomes any language barriers between patient and physician. Although this method is indispensable in assessing the non-communicative patient, there are many possible pitfalls of the behavioral approach. Foremost among these is that the observed behavior may be skewed by a patient’s reaction to both observation and possible treatment(s). Additional drawbacks are 1) the inescapable element of observer bias, and 2) the fact that pain behaviors are inconsistently manifested.

Although we have not been able to identify any standardized tools to fully elucidate the cultural factors inherent to, and influencing, the experience and/or expression of pain, Marie Rodriguez Le Sage presents a set of questions that should be asked and appreciated in the interest of developing a pain-relevant cultural competency.12 These include:

1) How do you identify your pain?
2) What do you think caused your pain?
3) Why do you think it started when it did?
4) What do you think the pain means?
5) What treatment do you think you should receive?
6) What are the chief problems and benefits that pain has caused?
7) What do you fear most about the pain?

Conclusion

To suggest one universally capable, and/or correct method of assessment is to say that there is one patient and there is one pain. Of course, this would be fallacious given the subjective nature of pain in both experience and expression among individuals. Yet, without some semblance of objectivity, assessment loses clinical value and treatment planning is reduced to a guessing exercise. For these reasons, we have tried to pair available objective tools with a conceptual model in such a way that they can be tailored to accommodate the clinical needs of the physician and depict the subjective pain experience of the patient.

Vital to the choice of assessment is the determination of the nature and dimensionality of the pain itself. Patient narrative is perhaps the most valuable tool the physician has at her disposal to gain insight to the dimensionality and existential impact of pain. Thus, despite the difficulty of talking about and describing pain, language remains a critical element of clinical assessment.

In sum, pain assessment serves to enlarge the interactive space of the clinical encounter by increasing mutual understanding and, in this way, must be specific to the pain syndrome, the patient, and the physician. Here, we again confront the paradox of maintaining an individualized and patient-centered focus, while still gathering information that is objective enough to remain medically relevant. A given patient’s pain experience cannot be understood simply by reading a completed form, but an individualized assessment has little value if it cannot be compared to other cases. Until we find an objective indicator of subjective pain, we must continue to use the knowledge gained to date and the measures and metrics that are available—together with insight and ingenuity to develop more effective ways of conceptualizing, evaluating, and ultimately treating pain. To do otherwise is to fall short of the moral responsibilities of pain medicine—as profession, practice, and as an individual and public good rendered to those in pain.

Acknowledgments

This essay was adapted from the authors’ paper “Pain assessment: A multi-dimensional model for conceptualizing the experiential dimensions of pain – practical and ethical implications,” forthcoming in the journal Pain Physician, and excerpted here with permission of the publisher. This work was conducted while Jill Kaspar and Dr. Mark Boswell were Visiting Scholars in the Departments of Medicine and Neurosciences, and Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC. Ms. Kaspar was supported in part by funding from Grinnell College, Iowa; Dr. Boswell was supported by the Laurance S. Rockefeller Trust as a Rockefeller Visiting Scholar.

Notes and References

  • llness: Part 1, Pract Pain Manag. 2006. 6(6): 70-73.
  • 2. Morris D. The Culture of Pain. Berkeley: University of California Press; 1991.
  • 3. Wittgenstein L. Philosophical Investigations. Anscombe GEM. Translator: Blackwell. Oxford. 1953.
  • 4. Hardcastle VG. The Myth of Pain. The MIT Press. Cambridge. 1999.
  • 5. Charon R. Narrative Medicine. Oxford University
Last updated on: February 21, 2011
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