Pain as the Perception of Someone: An Analysis of the Interface Between Pain Medicine and Philosophy

Should cancer pain still be considered a separate category alongside acute pain and chronic non-cancer pain? Reflections on ICD-11

Introduction

Traditionally, cancer pain has often been viewed as an independent third major category in pain medicine alongside acute pain and chronic non-cancer pain. However, the new chronic pain category MG30 in the eleventh version of International Classification of Diseases (ICD-11) includes cancer-related pain as one of its seven subgroups. In light of this, the aim of the paper is to investigate whether the traditional trichotomy should be replaced by a dichotomy between acute pain and chronic pain, cancer-related pain being part of both groups depending on the duration of pain.

Methods

The rationale for viewing cancer pain as a separate category is reviewed.

Results

Cancer being a deadly disease, cancer pain has a life-and-death and existential dimension that is different from non-cancer pain. It seems sensible to believe that this is an additional dimension to the suffering caused by cancer pain, and that clinicians should therefore take this existential dimension into consideration when assessing pain.

Conclusion

Without challenging the place of chronic cancer-related pain under the MG30 heading, it is concluded that while using ICD-11 in the future, pain clinicians should continue being mindful of the fact that the reality of death shapes the experience of cancer pain. The traditional trichotomy is therefore still valid and mirrors the fact that human beings are vulnerable (acute pain), temporal (chronic pain) and mortal (cancer pain).

Chronic Pain and Time - A Theoretical Analysis

Background

When theoretically discussing pain, the distinction between acute and chronic pain is not always taken into consideration. By contrast, informed by the pain medicine distinction between acute and chronic pain, the present theoretical paper analyses the phenomena of chronicity and chronification in the pain setting.

Methods

Philosopher Fredrik Svenaeus and his paper The phenomenology of chronic pain: embodiment and alienation (Continental Philosophy Review 2015;48:107-122) is used as a dialogue partner.

Results

Three aspects, relevant for clinicians, are discussed: (1) the distinction between emotion and mood, arguing that the process of chronification entails pain evolving from the former to the latter; (2) chronification as a process in which the pain patient becomes aware of his/her temporality, both the past and the future coming to the fore (as opposed to severe acute pain in which only the present counts, ie, getting rid of the pain now); (3) the acquisition of a pain-related narrative identity, interdisciplinary pain rehabilitation programs being described as helping patients regain a narrative identity that is not dominated by pain or by a fruitless chase after pain relief.

Conclusion

Chronic pain reminds us of our temporality and of the narrative character of our lives.

Neurofunctional Symmetries and Asymmetries during Voluntary out-of- and within-Body Vivid Imagery Concurrent with Orienting Attention and Visuospatial Detection

We explored whether two visual mental imagery experiences may be differentiated by electroencephalographic (EEG) and performance interactions with concurrent orienting external attention (OEA) to stimulus location and subsequent visuospatial detection. We measured within-subject (N = 10) event-related potential (ERP) changes during out-of-body imagery (OBI)—vivid imagery of a vertical line outside of the head/body—and within-body imagery (WBI)—vivid imagery of the line within one’s own head. Furthermore, we measured ERP changes and line offset Vernier acuity (hyperacuity) performance concurrent with those imagery, compared to baseline detection without imagery. Relative to OEA baseline, OBI yielded larger N200 and P300, whereas WBI yielded larger P50, P100, N400, and P800. Additionally, hyperacuity dropped significantly when concurrent with both imagery types. Partial least squares analysis combined behavioural performance, ERPs, and/or event-related EEG band power (ERBP). For both imagery types, hyperacuity reduction correlated with opposite frontal and occipital ERP amplitude and polarity changes. Furthermore, ERP modulation and ERBP synchronizations for all EEG frequencies correlated inversely with hyperacuity. Dipole Source Localization Analysis revealed unique generators in the left middle temporal gyrus (WBI) and in the right frontal middle gyrus (OBI), whereas the common generators were in the left precuneus and middle occipital cortex (cuneus). Imagery experiences, we conclude, can be identified by symmetric and asymmetric combined neurophysiological-behavioural patterns in interactions with the width of attentional focus.

Pain after mandibular ramus block harvesting and lateral ridge augmentation with and without involvement of platelet-rich fibrin: a randomized controlled trial

The purpose of this study was to evaluate pain after mandibular ramus block harvesting and lateral ridge augmentation. Autogenous bone block grafts were covered with platelet-rich fibrin (PRF) membranes (test group) or deproteinized bovine bone and a resorbable collagen membrane (control group). This study included 27 partially edentulous patients (test = 14, control = 13) with an indication for bone block augmentation before staged implant placement. Postoperative methylprednisolone (32 mg, day 1) and analgesics comprising ibuprofen (400 mg, four times daily) and paracetamol (1 g, four times daily) were prescribed for 1 week. Pain was recorded by the patient on a 100-mm visual analogue scale (VAS), hourly on the day of surgery and daily for the following 7 days. The average (mean ± standard deviation) maximum pain score over the whole observation period was similar in the test (13.6 ± 13.5) and control (21.0 ± 19.9) groups (P = 0.17). In conclusion, harvesting of a mandibular ramus block and lateral ridge augmentation, in conjunction with the pharmacological protocol described, is characterized by low postoperative pain. Adding PRF membranes to the surgical site generally resulted in slightly lower pain perception, although a statistically significant difference between the test and control groups was only identified on day 1 postoperative.