A Critical Evaluation Of The Trigger Point Phenomenon

The theory of myofascial pain syndrome (MPS) caused by trigger points (TrPs) seeks to explain the phenomena of muscle pain and tenderness in the absence of evidence for local nociception. Although it lacks external validity, many practitioners have uncritically accepted the diagnosis of MPS and its system of treatment. Furthermore, rheumatologists have implicated TrPs in the pathogenesis of chronic widespread pain (fibromyalgia syndrome). We have critically examined the evidence for the existence of myofascial TrPs as putative pathological entities and for the “vicious cycles that are said to maintain them. We find that both are inventions that have no scientific basis, whether from experimental approaches that interrogate the suspect tissue or empirical approaches that assess the outcome of treatments predicated on presumed pathology. Therefore the theory of MPS caused by TrPs has been refuted. This is not to deny the existence of the clinical phenomena themselves, for which scientifically sound and logically plausible explanations based on known neurophysiological phenomena can be advanced

An evolutionary stress-response hypothesis for chronic widespread pain (fibromyalgia syndrome). Pain Med

Abstract Objective. The study aimed to seek a unifying biological basis for the phenomena encompassed in fibromyalgia syndrome (chronic widespread pain and associated morbidities). Setting. While much progress has been made in the last decade in understanding chronic widespread pain, its pathogenesis remains stubbornly obscure and its treatment difficult. Two themes are gaining currency in the field: that chronic widespread pain is the result of central sensitization of nociception, and that chronic pain is somehow related to activation of a global stress response. Design. In this article we merge these two ideas within the perspective of evolutionary biology to generate a hypothesis about the critical molecular pathway involved in chronic stress response activation, namely substance P and its preferred receptor, neurokinin-1 (NK-1R), which has many empirically testable implications. Conclusion. Drawing on diverse findings in neurobiology, immunology, physiology, and comparative biology, we suggest that the form of central sensitization that leads to the profound phenomenological features of chronic widespread pain is part of a whole-organism stress response, which is evolutionarily conserved, following a general pattern found in the simplest living systems

A Policy-into-Practice Intervention to Increase the Uptake of Evidence-Based Management of Low Back Pain in Primary Care: A Prospective Cohort Study

BACKGROUND: Persistent non-specific low back pain (nsLBP) is poorly understood by the general community, by educators, researchers and health professionals, making effective care problematic. This study evaluated the effectiveness of a policy-into-practice intervention developed for primary care physicians (PCPs). METHODS: To encourage PCPs to adopt practical evidence-based approaches and facilitate time-efficient, integrated management of patients with nsLBP, we developed an interdisciplinary evidence-based, practical pain education program (gPEP) based on a contemporary biopsychosocial framework. One hundred and twenty six PCPs from primary care settings in Western Australia were recruited. PCPs participated in a 6.5-hour gPEP. Self-report measures recorded at baseline and at 2 months post-intervention included PCPs' attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS), evidence-based clinical practices (knowledge and skills regarding nsLBP management: 5-point Likert scale with 1  =  nil and 5  =  excellent) and practice behaviours (recommendations based on a patient vignette; 5-point Likert scale). RESULTS: Ninety one PCPs participated (attendance rate of 72%; post-intervention response rate 88%). PCP-responders adopted more positive, guideline-consistent beliefs, evidenced by clinically significant HC-PAIRS score differences (mean change  =  -5.6±8.2, p<0.0001; 95% confidence interval: -7.6 to -3.6) and significant positive shifts on all measures of clinical knowledge and skills (p<0.0001 for all questions). Self management strategies were recommended more frequently post-intervention. The majority of responders who were guideline-inconsistent for work and bed rest recommendations (82% and 62% respectively) at pre-intervention, gave guideline-consistent responses at post-intervention. CONCLUSION: An interprofessional pain education program set within a framework that aligns health policy and practice, encourages PCPs to adopt more self-reported evidence-based attitudes, beliefs and clinical behaviours in their management of patients with nsLBP. However, further research is required to determine cost effectiveness of this approach when compared with other modes of educational delivery and to examine PCP behaviours in actual clinical practice

Consumers’ experiences of back pain in rural Western Australia: Access to information and services, and self-management behaviours.

Background: Coordinated, interdisciplinary services, supported by self-management underpin effective management for chronic low back pain (CLBP). However, a combination of system, provider and consumer-based barriers exist which limit the implementation of such models into practice, particularly in rural areas where unique access issues exist. In order to improve health service delivery for consumers with CLBP, policymakers and service providers require a more in depth understanding of these issues. The objective of this qualitative study was to explore barriers experienced by consumers in rural settings in Western Australia (WA) to accessing information and services and implementing effective self-management behaviours for CLBP. Methods: Fourteen consumers with a history of CLBP from three rural sites in WA participated. Maximum variation sampling was employed to ensure a range of experiences were captured. An interviewer, blinded to quantitative pain history data, conducted semi-structured telephone interviews using a standardised schedule to explore individuals’ access to information and services for CLBP, and self-management behaviours. Interviews were digitally recorded and transcribed verbatim. Inductive analysis techniques were used to derive and refine key themes. Results: Five key themes were identified that affected individuals’ experiences of managing CLBP in a rural setting, including: 1) poor access to information and services in rural settings; 2) inadequate knowledge and skills among local practitioners; 3) feelings of isolation and frustration; 4) psychological burden associated with CLBP; and 5) competing lifestyle demands hindering effective self-management for CLBP.Conclusions: Consumers in rural WA experienced difficulties in knowing where to access relevant information for CLBP and expressed frustration with the lack of service delivery options to access interdisciplinary and specialist services for CLBP. Competing lifestyle demands such as work and family commitments were cited as key barriers to adopting regular self-management practices. Consumer expectations for improved health service coordination and a workforce skilled in pain management are relevant to future service planning, particularly in the contexts of workforce capacity, community health services, and enablers to effective service delivery in primary care

International Olympic Committee consensus statement on pain management in elite athletes

Pain is a common problem among elite athletes and is frequently associated with sport injury. Both pain and injury interfere with the performance of elite athletes. There are currently no evidence-based or consensus-based guidelines for the management of pain in elite athletes. Typically, pain management consists of the provision of analgesics, rest and physical therapy. More appropriately, a treatment strategy should address all contributors to pain including underlying pathophysiology, biomechanical abnormalities and psychosocial issues, and should employ therapies providing optimal benefit and minimal harm. To advance the development of a more standardised, evidence-informed approach to pain management in elite athletes, an IOC Consensus Group critically evaluated the current state of the science and practice of pain management in sport and prepared recommendations for a more unified approach to this important topic

Reconsidering the International Association for the Study of Pain definition of pain

Abstract. Introduction:. The definition of pain promulgated by the International Association for the Study of Pain (IASP) is widely accepted as a pragmatic characterisation of that human experience. Although the Notes that accompany it characterise pain as “always subjective,” the IASP definition itself fails to sufficiently integrate phenomenological aspects of pain. Methods:. This essay reviews the historical development of the IASP definition, and the commentaries and suggested modifications to it over almost 40 years. Common factors of pain experience identified in phenomenological studies are described, together with theoretical insights from philosophy and biology. Results:. A fuller understanding of the pain experience and of the clinical care of those experiencing pain is achievable through greater attention to the phenomenology of pain, the social “intersubjective space” in which pain occurs, and the limitations of language. Conclusion:. Based on these results, a revised definition of pain is offered: Pain is a mutually recognizable somatic experience that reflects a person's apprehension of threat to their bodily or existential integrity

At the edge of being: the aporia of pain

Despite the enlightening advances in conceptualising pain and the humanitarian responses of many health practitioners working in this area, it is still universally acknowledged that idiopathic pain, often termed chronic pain syndrome or pain for which there is no established physical pathology, is one of the most complex and difficult aspects of modern healthcare. The inadequacies of biomedicine to comprehend fully the complex phenomenon of pain has provided the impetus for this conference. This volume provides vivid and compelling accounts of the attempts to imaginatively link subjective pain experiences to current healthcare practice which were presented at the conference by practitioners, researchers and theorists across a wide range of disciplines A major theme of Part One of the volume was to gain deeper insight into the complex phenomenon of pain by addressing some of the limitations and barriers within current treatments and understandings. In the first chapter, Fink articulately addresses the philosophical and ethical lacunae within medical science ' of the pain experience. Beginning with the IASP definition, he questions a science of pain which fails to recognise the 'natural origins' and is unable to unite subjective and objective components which influence its expression, its meaning and its moulding. Next, Cohen and Quintner present the profoundly sensitive reflections of pain practitioners who recognise the reductionism of the models they are working within which inevitably result in marginalisation of the sufferer. They propose that clinicians have a moral and ethical obligation to engage in the aporia of pain, to allow the 'third space' of self-referentiality to emerge within the clinical encounter. Kalman and Scheman develop the subjectivity of interpersonal space further, using a range of examples to demonstrate the process of inflecting pain, whether in clinical or more personal settings. Finally Dubin's compassionate case studies of the highly stigmatising chronic pain trajectory vividly illustrate the multi-faceted nature of total pain as coined by Saunders 12, with its drastic financial and legal implications in addition to the mind-body-spiritual elements. In Part Two of the volume, experience of pain is again the key, but here the focus is more explicitly on the narration of chronic pain in a variety of contexts, where believability, self-identity, emotional distress and narrative restitution all play a part. Flaherty's chapter charts the linkage of social identity to the use of both licit and illicit intoxicating substances as a means of alleviating emotional pain amongst the GLBTQ community in Sydney. Nielsen uses a Goffmanesque - labelling theory inspired framework to investigate in-depth the relationship between chronic pain and stigma, and Buchinger Bodwell offers a sophisticated analysis of the crucial role that illness narratives play for those involved in treating chronic pain, as well as those who suffer from it. Finally McKenzie's empathetic case studies of emotion management by cancer survivors illustrate dramatically how enmeshed are mind, body and society in the phenomenological experience of pain

Stigmatization of patients with chronic pain: the extinction of empathy

Objective: To address how health professionals may inadvertently contribute to the stigmatization of patients with chronic pain. Setting: Formulation and implementation of the Australian National Pain Strategy. Design: Review of current concepts of stereotyping and stigma, consideration of their relationship to empathy, and how they might impinge upon the clinical encounter. Findings: The extinction of empathy, which we refer to as “negative empathy,” can overwhelm health professionals, allowing the entry of negative community stereotypes of chronic pain sufferers and add to their stigmatization. Prevailing dualistic frames of reference encourage this process. Conclusion: Greater awareness by health professionals of their own potential, often inadvertent, contribution to the stigmatization of their patients with chronic pain may serve as a basis for an expanded model of clinical engagement

Pain medicine and its models: Helping or hindering?

Objective: To identify whether the biopsychosocial framework of illness has overcome the limitations of the biomedical model of disease when applied in the practice of pain medicine. Design: Critical review of the literature concerning the application of biopsychosocial models to the praxis of pain medicine and the concepts of living systems. Results: The biopsychosocial model of illness, formulated by Engel in 1977, has generated the International Association for the Study of Pain (IASP) definition of pain, two major conceptual frameworks in pain medicine, and three putative explanatory models for pain. However, in the absence of a theory that seeks to understand the lived experience of pain as an emergent and unpredictable phenomenon, these progeny of the biopsychosocial model have been caught in circular argument and have been unable to overcome biomedical reductionism or the perpetuation of body–mind dualism. In particular, the implication that pain can be a “thing” separate and distinct from the body bears little relationship to the lived experience of pain. Such marginalizing results when an observer attempts to reduce the experience of the pain of another person. Conclusions: The self-referentiality of living systems (through their qualities of autopoiesis, noncentrality and negentropy) sees pain “emerge” in unpredictable ways that defy any lineal reduction of the lived experience to any particular “thing.” Pain therefore constitutes an aporia, a space and presence that defies us access to its secrets. We suggest a project in which pain may be apprehended in the clinical encounter, through the engagement of two autonomous self-referential beings in the intersubjective or so-called third space, from which new therapeutic possibilities can arise