Defining Something That is Sometimes Undefinable

Defining something that is sometimes indefinable - Pain

How do you define pain? Do we need a new definition? This is a thought question recently published in Pain by Amanda Williams and Kenneth Craig in November of 2016. The current definition of pain found in the IASP Taxonomy is:

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

This definition has been on the books unchanged since 1979; based on much of the work by Merskey in 1964 where the psychological aspects of pain started to be explored. In 1965, Melzack and Wall really turned the scientific and medical world upside down with their new theory in pain mechanisms. Obviously, there have been many more advancements in our understanding of pain since the Gate Theory. Nevertheless, this begs the question; do we need a new definition? The authors thought that we might and provided an alternative:

“Pain is a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components.”

The current definition has served us well in many ways.

• Pain is unpleasant, thus we should try to get rid of it. For the most part people do not want pain, which is why many believe people do not get addicted to pain. They may be addicted to the effects of being in pain (social attention that they get), but not the pain itself. 
• The idea of both sensory (i.e. physical) and emotional (i.e. psychosocial) is an important component. We know now that ALL pain has sensory components – pain has to be “located” somewhere in the body and have a sensory component to what it feels like. People do not have pain in their shoe or car. They have pain somewhere within themselves, a physical location. We also know that ALL pain has an emotional component. Pain emerges as a construct from a person’s nervous system. The human brain attaches emotions and meanings to all conscious experiences; it is just what is does. Just like when the heart beats it pushes blood through the body, it is just what it does. This is what our brains do; it does not mean that a person is overly emotional or faking about their pain. Nor does it make the pain any less real when emotions from our mind are attached to it. 
• Pain is an experience; that experience is what the person says it is. All experiences can only be fully experienced and expressed by the individual going through it. Pain will always be subjective. We will never have an objective measurement of pain that is quantifiably on an interval scale equally between everyone based on the input we give them. We may someday be able to measure nociception that we could quantify based on the input, but not pain. It would be as if we would be able to measure and tell you how much you love someone based on a bunch of set input criteria. 
• The next big thing this definition points out is that pain is associated with actual or potential tissue damage. Pain and injury are two separate things, yes they often go together, but they are only associated (not the same thing). Just like, you may have been “associated” with your best friend during high school. You probably did lots together; maybe you were almost inseparable. This just like pain and injury, which can be good and bad. The good – you and your friend would help each other out. Just like pain letting, you know that you injured something and you need to take care of it (sounds like a good friend). The bad – your friend did something illegal and everyone assumed you did it too because you were “guilty by association”. Just like pain that persists can bring poor unsuspecting tissues into the problem because they are “guilty by association.”

Therefore, as we can see this definition has some great components, why would the authors suggest that we might need a change? They pointed to three potential reasons. The current definition only points to sensory and emotional components and does not cover other potentially important characteristics, particularly cognitive and social. Second, they felt that “unpleasant” falls short and potentially trivializes severe pain. Lastly, is in regards to the final phrase “or described in terms of such damage”. This phrase was initially intended to give “a voice” to complaints by those with persistent pain that did not have evidence of tissue stress or damage. The current pendulum may have swung a bit too far in that, subjectivity and self-report are now potentially prioritized at the expense of non-verbal behaviors and those whose subjective experience cannot be communicated.

Therefore, as with any good thought experiment, it is only as good as the thoughts that are generated. So what you are your thoughts? Keep what we have or time for a new definition? Maybe you have one you like better; please share the comment section is open.

Thoughts?

Via - Kory Zimney, DPT
 

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