PPCCN part 1: Pain, Focus APT 1 BaMed period 1.

3, line 2,

PM Parallel to this focussed pain assignment, you will prepare the PPCCN patient interview
and the associated qualitative research assignment.

Focus:
- Fit and misfit between the scientfic / professional pain world on the one hand (model and
evidence directed) and the (experiential) patient pain world on the other hand.
PM As yet,we will not explore care aspects, since we’ll deal with these in focus APT 3

Key aspects
- Different pain worlds on the internet
- Critical reflection on pain (scientific, professional, historical, cultural)
- The patients pain experience and the existential (meaning) perspective

Means
- Materials as offered in this intro and instruction
- Interactive expert session Critical Thinking about Pain:
o Brigitte Brouwer (neurologist, pain specialist)
o Rob de Bie (epidemiologist, specialised in physical therapy)
o Rob Houtepen (medical philosopher)
- Portfolio deliverable: Part of the annotated source list you turn in with your patient
interview.

Introduction
Line 1 will introduce you to the basic knowledge and skills required for a (future) physician
to address pain complaints in patients. Line 2 herewith invites you to reflect on the
limitations of the medicoscientific perspective and of the professional perspective more
generally. Not because there is anything wrong with these perspectives, but because you
need to understand why they will quite often not succeed in dealing satisfactorily with
chronic pain complaints from the patient perspective.
We also invite you to actively and explicitly compare the medico scientific and professional
pain perspective with alternative perspectives more generally. Again, not because the latter
are more useful. But because it will help you as a medical professional, in your contacts
with patients with chronic pain complaints, to maybe understand what their ‘pain horizon’ is.

Instruction
1. Have a look at professional and experiential pain video’s on Youtube. Take a few from
our selection on both sides in appendix 1 and maybe add some of your own choice and
in your native language. How would you characterize the differences between these two
‘pain worlds’?
2. Put these ‘different pain worlds’ in a broader perspective by reading 1 short summary of
the history of pain theory and 1 further article from ‘both sides’ each, as per instruction in
Appendix 2.
3. Reflect on the pervasive power of metaphors for pain, both within and outside the
medical world, through the material in Appendix 3: where do metaphors help and what
are their limitations?
Appendix 1

Pain explanation video’s from the professional world:

Divide:
- What is chronic pain and how does it work? Guardina Australis, Youtube 2022
https://www.youtube.com/watch?v=xbSr32OWcX4 [explanation for patients, in 3.07)
- Persistent pain explained in 3 minutes. Kinetic Labs, Youtube 2019
https://www.youtube.com/watch?v=jyHeAQbFs34 (in a rehabilitation medicine context: 3.07)
- Acute vs Chronic pain. Health Navigator NZ. Youtube 2019 https://www.youtube.com/watch?
v=-yVXUvP0CwA (explanation for patients, in 3.25)
- Tame the Beast – It's time to rethink persistent pain. Youtube 2018
https://www.youtube.com/watch?v=ikUzvSph7Z4 [with Dutch subtitles]
- Understanding Pain in less than 5 minutes, and what to do about it!. Live active
chiropractic. Youtube 2014 https://www.youtube.com/watch?v=C_3phB93rvI (in 5.00 indeed)
- Understanding pain & what to do about it in less than 5 minutes. Defense & Veterans
Center for Integrative Pain Management, Youtube 2016. https://www.youtube.com/watch?
v=cLWntMDgFcs [explanation for patients, in 5.30 actually]
- Persistent pain. Patient Information Video. Somerset NHS Foundation Trust. Youtube
2022 https://www.youtube.com/watch?v=RpipxPa3baE (8.37)
- Pain Explained. Central London Community Healthcare NHS Trust. Youtube 2013.
https://www.youtube.com/watch?v=B14_2TS7RHM (in 6.19)

Video’s on patient’s chronic pain experiences:

Divide:
- Coming to terms with chronic pain. Healthtalk.org (2018)
https://healthtalk.org/chronic-pain/coming-to-terms-with-chronic-pain (a number of short video testimonies
on accepting chronic pain)
- Struggling to be me with chronic pain. National Institute for Health and Care Research.
Youtube 2014. https://www.youtube.com/watch?v=FPpu7dXJFRI [10.01: actor plays a synthesis
person bases on large scale qualitative research on the experience of patients with chronic pain)
- My Chronic Pain Story. Fibromyalgia. Weylie Hoang, Youtube 2019
https://www.youtube.com/watch?v=SF8f8ybgbvI (21.22: Youtube influencer relates her life with pain,
diagnosed as fybromyalgia)
- Living with chronic pain - Jack’s Story. This Messy Happy. Youtube 2022
https://www.youtube.com/watch?v=46pMpibOAek (24.59: friend interviews chronic pain patient on his life
with pain)
- My Fibromyalgia Story. Andrea Severson. Youtube 2016 https://www.youtube.com/watch?
v=t1W_OrHHA58 (20.44)
- Robert's Story: Working, Hiking and Kayaking While Living with Chronic Back Pain .
Dartmouth Health. Youtube 2013 https://www.youtube.com/watch?v=0Ga_0Iuq4VI (4.08: regained
functiopnal abilities after 25 years of pain)
Appendix 2

Summary of medicoscientific pain models and the biopsychosocial model

All
- Lindsay A. Trachsel; Sunil Munakomi; Marco Cascella. Pain Theory. National Library of
Medicine, StatPearls, April 20, 2022. https://www.ncbi.nlm.nih.gov/books/NBK545194/

Extended tips for chronic pain patients

Divide
- Understanding & Managing Long-term Pain. British Pain Society 2015. PDF or from:
https://www.britishpainsociety.org/people-with-pain/patient-publications/
- Pain Education Toolkit. Oregon Pain Guidance. 2022
https://www.oregonpainguidance.org/paineducationtoolkit/ [explanation and tips for pain patients]
- Pete Moore, Frances Cole. The Pain Toolkit. NHS 2010 (pdf) or
https://www.paintoolkit.org/pain-tools [self management tips for pain patients]

Alternative, cultural and existential perspectives

Divide:
- Joanna Bourke. The secret language of pain: Why our most agonizing moments defy
explanation. Salon.com Sept 6, 2014
https://www.salon.com/2014/09/06/the_secret_language_of_pain_why_our_most_agonizing_moments_de
fy_explanation/ [broad perspective on the ‘subjectivity’ of pain)
- Rob Boddice. The politics of pain. AEON. 3 January 2023 https://aeon.co/essays/pain-is-not-
the-purview-of-medics-what-can-historians-tell-us [beyond the limitations of the medical pain perspective)
- Roland Sussex. How different cultures experience and talk about pain.
theconversation.com, 2015 https://theconversation.com/how-different-cultures-experience-and-talk-
about-pain-49046 [cultural differences within modern western societies regarding pain)
- SRDTde Siqueira  Existential Meaning of Patients with Chronic Facial Pain. 17 February
2018. https://link.springer.com/article/10.1007/s10943-018-0583-5 [plea for an existential perspective,
with examples of chronic facial pain]

A literary option if you are thus inclined (for those drawn to existential reflection)
- Leslie Jamison. The Empathy Exams. Culture.org, February 1, 2014 https://culture.org/the-
empathy-exams/ (on the great divide between personal experience and professional empathy, here in the
context of Simulated Patient Contacts)
Appendix 3
The metaphorical nature and limits of mechanistic medico-scientific pain knowledge

Intro
In her famous book Illness as Metaphor, the American author Susan Sontag asserted that
metaphors on illness are not innocent. She analysed that cancer literature was ridden with
war metaphors: fighting, battling, weapons, … Such metaphors promote a very one sided
attitude towards a disease that will often turn out to be incurable. They may hinder patients
in developing more acceptance and adaptation based attitudes toward their illness.
In her book Pain. The science and culture of why we hurt, the Canadian author
Marni Jackson has claimed that something similar often still holds for pain: the underlying
metaphors in understanding pain and dealing with it, in medical science and in lay culture,
may not be helpful. They may sustain an unrealistic view of what medicine has to offer:

“The successful treatment of pain calls for more communication between patient and
doctor, communication between the professions, and a view of medicine as something
unfinished and integrated, rather than specialized, standardized and technology based. …
Perhaps the metaphors should shift from war to the environment. Medicine needs to look at
pain not as a foreign invasion, but as a kind of environmental problem in the body. Chronic
pain is like a toxic spill, with damage that eventually spreads far beyond the original site. …
In order to prevent the cost of pain from spreading, medicine is slowly evolving from the
notion of curing, fixing and conquering to a more questing approach. Pain is not always
conquerable, but it is adaptable. … Work against pain and you lose. Work with pain, and
the struggle lightens.” (pp 356-357)
Let’s see how helpful or limiting current pain metaphors are, through steps A, B, and C.

A. The McGill Pain Questionaire (https://www.sralab.org/rehabilitation-measures/mcgill-pain-

questionnaire + see the version in your native language), the ‘measuring instrument’ that has
dominated the pain world in the past 50 years, provides a good starting point to reflect
on the pervasive metaphoric nature of pain knowledge: How helpful? Which limitations?
Which potential pitfalls?

B. An indication of lay persons metaphors for pain:

- 14 Pain Metaphors, Idioms and Similes. March 17, 2021. SymbolismandMetaphor!.com
https://symbolismandmetaphor.com/pain-metaphors-idioms-similes/
- Sonya Huber. Metaphoring into pain. Blog. US Pain Foundation. Dec 18, 2019
https://uspainfoundation.org/blog/metaphoring-into-pain/
Compare this with what you know as pain expressions from your own surroundings. Can
you think of more adequate or helpful ‘lay’ metaphors for pain?
C. The metaphors of Medico-scientific pain theories

Gate control theory:

Chronic pain models:
Biopsychosocial pain model
For critical reflection on medico scientific pain metaphors:

“ Mechanisms are emphasised in medical discourse. ‘What is pain?’ is a difficult question to

answer, but opiate and GABA receptors can be identified, tested in experiments, and the
results published in articles rich with schematics and diagrams. In this way, the simple is
represented simply, demonstrating the secret and dangerous power of visual
representations that avoid images of human beings in pain. Standing on the shoulders of
schematics, medicine appears powerful and knowledgeable. Yet the schematics are
metaphors which perpetuate themselves to the detriment of complex truth. Schematics are
visual metaphors that limit understanding because of extreme simplicity. …
Yet the unacknowledged metaphorical basis of the diagram (nerves are wires) and the fact
that the diagram is a basic building block common in medico biological texts, leads to the
creation of a powerful metaphor-based illusion. Much of the understanding of pain gets
relegated to a diagram such as this one. Although to understand pain, one must learn nerve
signalling, one should also recognise that nerve signalling serves as the physiological basis
of a metaphorical system. …
Mechanistic discourses are possibly inferior than religious ones in terms of articulating pain,
because of their inherent lack of meaning. When modern-day Rene burns his finger, he
knows that physical pain is the result of nociceptors sending a signal from the periphery to
the brain, as well as top-down processes modulating that same signal, as well as (perhaps)
a God overseeing the process. But Rene also knows much more that science doesn't know
yet: Rene knows he can reach for certain medications that will give him analgesia (he
knows he can thank the mechanistic discourse for that) but if he wishes to make sense of
his pain, his knowledge of the spinothalamic tract won't help him. If the fire was due to poor
enforcement of building codes, or Rene lost his job due to a global financial crisis, turned to
state-taxed alcohol in order to numb his pain, and inadvertently left a cigarette burning in
bed, resulting in extensive burns. . .knowing wire A leads to wire B won't help Rene cope on
the burn unit. He has a problem of meaning, not a problem of neurology. Meaning is
inherently bound up in metaphor and Rene needs better metaphors to reflect the complexity
of his plight.”

Excerpts from: Shane Neilson. Pain as metaphor: metaphor and medicine. Med Humanit.
2016 Mar; 42(1): 3–10.. doi: 10.1136/medhum-2015-010672