Ref Moving Past the Normalization Heuristic to Unravel the Mystery of Pain

[zimney3pt]

Here is a recent editorial I wrote for a newer open access journal.


Curious to get comments and feedback. I might be taking on a guest editorial spot with the journal titled "Pain Neuroscience" so getting ideas of about topics and authors are also welcome. It's a new on-line open access journal so not much impact, but some is better than none I guess.

[marcel]

Short sited or short-sighted?

Consideration of these tissue based inputs is important, but also short sited when working with individuals in pain.

[Johnny_Nada]

I have one question, maybe its a comment, I don't know….

I read regularly that pain is normal and necessary for survival. I get that.

But

Living in pain is not normal. Says who? Might this be a false normalization heuristic feeding the pain epidemic?

[Frédéric]

I have one question, maybe its a comment, I don't know….

I read regularly that pain is normal and necessary for survival. I get that.

But

Living in pain is not normal. Says who? Might this be a false normalization heuristic feeding the pain epidemic?

I guess living with pain is normal but unwelcomed. Considering there is a hord of people claiming it isn't and that they can make you well it then seems not to be normal to the vast majority of people.

[Johnny_Nada]

Fred,

Unwelcome always, i agree. This idea that pain is something that should be abolished has lead to enormous dollars and poor outcomes for society based on this idea from healthcare that it can be abolished. Having a global war on pain is no different than a global war on love. Both emergent and complex things.

[Diane]

I think it's been a cultural perfect storm.
I think the big factors in the current chronic pain explosion are some combination of:
a) preventing children learning to deal with nociceptive input - e.g., no gravel on playgrounds, therefore no more skinned knees
b) increased surgery with poor pre-op pain ed/post-op pain control.

[zimney3pt]

Short sited or short-sighted?

good catch, looks I and the editing group missed that one.

[zimney3pt]

I have one question, maybe its a comment, I don't know….

I read regularly that pain is normal and necessary for survival. I get that.

But

Living in pain is not normal. Says who? Might this be a false normalization heuristic feeding the pain epidemic?

Point well taken, Matt.

I would agree that it may not be possible for some to live without pain, we honestly don't know that answer yet (but I'm leaning more toward the direction that some people will have pain their whole life - I think they can learn to function better but will probably have some pain unfortunately). My glass half-full mentality of trying to hold onto some hope that living with pain would not be "normal" in regards to the standard for which to live life is where the use of that statement comes from. Some people will live life with various disorders, but I tend not to think that should be the standard to expect. I don't think we would say it is normal to expect to get diabetes or cancer. I would agree that it probably is normal to expect that "something" will knock us off the normal life (we don't live forever), but what that will be is amazingly variable.

I guess the better question might be what is "normal"?

[Johnny_Nada]

Great point,
But those diseases are becoming the new normal. Statistically 50% sounds normal. With that said there are also ways to reduce the chances of getting them. Pain, not so much.

If we would all stop suggesting we know what normal is and it's relationship to non pathological pain we might get somewhere at reducing the costs and over treatments. A lot of people would be out of work so I don't see this happening anytime soon.

It has become this:

You have back pain? You should see (insert name) to have (insert modality)

The moment pain is verbalized we have learned or been taught to see someone or have something done. Unfortunately each branch has their definition of normal

[HeadStrongPT]

I have a long drive home after teaching on Wednesday nights and I get to thinking about things like this.

I hope this doesn't come off as mean-spirited but here goes. As callus as this may sound, we live in the most genetically permissive society in human history. Humans that probably wouldn't have made the cut 5000 years ago survive and many cases thrive and reproduce. This is a wonderful thing to a large extent. The flipside to this is that it probably produces a larger set of folks with traits that don't make tons of sense (persistent pain and other chronic diseases). For lack of a better way of putting it, if these folks were gazelles they would likely be supper. I'm aware that this metaphor is incomplete as there are many factors that drive these complex problems, but our support of a wider range of genetic variation probably doesn't help.

Instead of abandoning these folks, we've made the (I believe) wise choice to care for them and bring them into the herd. In doing so we have to concede that there are some problems too complex for our infinite wisdom. Not every problem can be solved. I wish we could be a bit more honest with ourselves and our patients about that.

Without using the "you are the genetically funky gazelle" metaphor of course.

[Johnny_Nada]

Rod,

I think of a dog with an injured paw. Obvious protection and withdrawal, but there is resolution and return to activity in a graded fashion. Is it always a perfect return, no, but they sure don't let it get them down. We don't see dogs with non-life threatening injuries going into a corner to never return to play or socializing.

Did neanderthal man have the ability to reserve himself to the back of the cave when he had back pain? If he did, natural selection (or a sabre tooth tiger, or his neighbor) took care of those genes….

[ste5e]

All aspects of human suffering are exploited by other humans for their gain.

Pain is just the bit that we experience daily in our work and personal lives.

But loneliness.
Popular or unpopular
Happy or Sad
Ugly or Beautiful.
Fat or thin.
And many more.

The business model of creating a false perception of what is normal and selling folk a way to bridge the percieved reality gap is as old as the hills.

Make a need. Address a need.

In what we have found our calling we are going against the economic realities of human exchange. We are barking at the moon. But we are right. We are morally right. We cannot stop.

Kind thoughts,
Steve

[AlisonSim]

I believe that culturally, particularly in the west, we tend to have a view that we are "entitled" to be pain free. There is a general feeling that because medicine is so clever and has an answer for most ailments, pain is seen as something we should be able to fix like any other unpleasant or pathological situation. Similarly we go out of our way to avoid pain in any situations and our exposure, tolerance and normalisation of these sensations doesn't happen as often as it might have. (Think of how labour pain can be seen in some circles as an entity to be removed or avoided ASAP)
Some cultures have an understanding that pain is part of life and like the dog with the sore paw, something to be taken in your stride. This behaviour has been modelled for generations and therefore pain is not seen as something that needs to be fought or removed, but as a part of life.

[Jo Bowyer]

Some cultures have an understanding that pain is part of life and like the dog with the sore paw, something to be taken in your stride.

When I was a young practitioner, the older generations who had lived through hard times, some of them before the era of social medicine, took moderate pain in their in their stride. Unless it affected their breathing or made them feel faint or nauseous, they coped with it. They attended for treatment in the hope that they could regain lost range of movement and strength. They were much more worried, sometimes to the point of obsession, with the movement or otherwise of their bowels.

[Chunk]

Alison, I completely agree. Jo, we have much to learn (for example, stoicism) from our seniors/elders. I've just assessed a 97 year old lady for a 'sore knee' (fit 90+ year olds are very common in N Saskatechewan!). We were chatting and she told me about how her family came to Canada from Europe when she was 5 years old. They were dropped off in the middle of the Northern prairies as 'settlers' and basically had to fend for themselves. Her older brother died that winter (aged 8) of starvation. She lives independently and needs no domestic support. She was happy with my explanation, wasn't too worried ("it was the doctor that referred her to physio") and as she was moving well, I expect she will take it in her (temporarily reduced) stride. I didn't ask but I presume her bowels are moving well too!