Do we need an updated definition of pain?

Do we need an updated definition of pain? In 1996 Anand and Craig [1] asked for “a new perspective on the definition of pain”, criticizing the IASP-definition from 1979 [2]. In 2008 the IASP council, however, “after a spirited discussion”, saw no need to alter the definition because it “has proven very useful and is an appropriate one” [3]. Nevertheless, Williams and Craig [4] quite recently reiterated that an updating of the definition is necessitated by recent advances in the understanding of pain. No one would disagree that pain research and therapy have made progress during the past years and that we need a better understanding of persistent pain in particular. Yet, the strive for a more comprehensive and precise definition of pain is in my view misguided and will not lead to a deeper understanding of pain as a phenomenon, nor will it be helpful clinically.Firstly – like many other everyday words - pain does not lend itself to a precise definition, and clear thinking is not encouraged by forcing complex phenomena into definitional straightjackets. Merskey [5] in a letter commenting on the Anand And Craig paper [1] expressed this point succinctly: “It is a misdirection of energy to attempt to change the meaning of a word that, so far as I can tell, has been used everywhere - or perhaps almost everywhere - in a particular way for thousands of years. Efforts should rather be directed to a steady improvement in the recognition of probable pain patterns and their predictive value in relation to treatment”. Indeed, we all know what pain is without knowing the definition, and the least problem is to know when we feel pain and for others to understand what we mean when we say, “my knee hurts”, or “I have a splitting headache”. Even though persons may describe their pain experience in many ways, we easily understand that the person feels pain. At a practical level, it is hard to see how a more comprehensive definition of pain would help researchers in designing experiments and selecting patients for clinical studies.Secondly, and more seriously, the updating proposed by W and C [4] confuses rather than clarifies, because they fail to distinguish pain as a feeling from its causes and mechanistic explanations [6]. For example, by introducing “cognitive” and “social” in the definition they confuse the feeling of pain with its multitude of causes and modifying factors. The comment by Whitburn et al. [7] illustrates the futility of trying to find a precise, yet complete definition, by pointing out that the new definition would not include labour pain. Many other examples might be found. Alcock [8] and Wright and Ayede [9] identify a further problem: by removing the phrase “.. .or described in terms of such damage” patients who experience pain without any evidence of tissue damage are excluded from the new definition (e.g. pain induced by hypnotic suggestion). Rather than promoting a deeper understanding of clinical pain, well-intended updates may perpetuate conceptual confusion.In conclusion, a definition of pain cannot be more than an imperfect means of capturing salient aspects of a complex phenomenon, and the current IASP definition suffices for such a purpose. Notably, it avoids confusing pain as a feeling with its multifarious mechanisms and causes.conflict of interest: No conflict of interest.References[1]Anand KJS, Craig KD. New perspectives on the definition of pain. Pain 1996;67:3–6.8895225Anand KJS Craig KD New perspectives on the definition of pain Pain 19966736[2]Merskey H, Albe-Fessard D, Bonica JJ, Carmon A, Dubner R, Kerr FWL, Lindblom U, Mumford JM, Nathan PW, Noordenbos W, Pagni CA, Renaer MJ, Sternbach RA, Sunderland S. Pain terms: a list with definitions and notes on usage. Recommended bythe IASP subcommittee on taxonomy.Pain 1979;6:249–52.Merskey H Albe-Fessard D Bonica JJ Carmon A Dubner R Kerr FWL Lindblom U Mumford JM Nathan PW Noordenbos W Pagni CA Renaer MJ Sternbach RA Sunderland S Pain terms: a list with definitions and notes on usage Recommended bythe IASP subcommittee on taxonomy.Pain 1979624952[3]Loeser JD, Treede R-D. The Kyoto protocol of IASP basic pain terminology. Pain 2008;137:473–7.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000258359500005&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f31858304810.1016/j.pain.2008.04.025Loeser JD Treede R-D The Kyoto protocol of IASP basic pain terminology Pain 20081374737[4]Williams ACde C, Craig KD. Updating the definition of pain. Pain 2016;157:2420–3.10.1097/j.pain.000000000000061327200490http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000386016400006&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3Williams ACde C Craig KD Updating the definition of pain Pain 201615724203[5]Merskey H. Response to Editorial: New perspectives on the definition of pain. Pain 1996;66:209.Merskey H Response to Editorial: New perspectives on the definition of pain Pain 199666209[6]Brodal P. A neurobiologist’s attempt to understand persistent pain. Scand J Pain 2017;15:140–7.28850339http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000405971800030&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3Brodal P A neurobiologist’s attempt to understand persistent pain Scand J Pain 2017151407[7]Whitburn LY, Jones LE, Davey M-A, Small R. Supporting the updated definition of pain. But what about labour pain? Pain 2017;158:990–1.Whitburn LY Jones LE Davey M-A Small R Supporting the updated definition of pain But what about labour pain? Pain 20171589901[8]Alcock MM. Defining pain: past, present and future. Pain 2017;158:760–1.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000400440200024&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3Alcock MM Defining pain: past, present and future Pain 20171587601[9]Wright A, Ayede M. Critical comments on Williams and Craig’s recent proposal for revising the definition of pain. Pain 2017;158:362–3.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000397015500022&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f32809232810.1097/j.pain.0000000000000765Wright A Ayede M Critical comments on Williams and Craig’s recent proposal for revising the definition of pain Pain 20171583623 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Scandinavian Journal of Pain de Gruyter

Do we need an updated definition of pain?

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de Gruyter
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© 2017 Scandinavian Association for the Study of Pain
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1877-8860
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Abstract

In 1996 Anand and Craig [1] asked for “a new perspective on the definition of pain”, criticizing the IASP-definition from 1979 [2]. In 2008 the IASP council, however, “after a spirited discussion”, saw no need to alter the definition because it “has proven very useful and is an appropriate one” [3]. Nevertheless, Williams and Craig [4] quite recently reiterated that an updating of the definition is necessitated by recent advances in the understanding of pain. No one would disagree that pain research and therapy have made progress during the past years and that we need a better understanding of persistent pain in particular. Yet, the strive for a more comprehensive and precise definition of pain is in my view misguided and will not lead to a deeper understanding of pain as a phenomenon, nor will it be helpful clinically.Firstly – like many other everyday words - pain does not lend itself to a precise definition, and clear thinking is not encouraged by forcing complex phenomena into definitional straightjackets. Merskey [5] in a letter commenting on the Anand And Craig paper [1] expressed this point succinctly: “It is a misdirection of energy to attempt to change the meaning of a word that, so far as I can tell, has been used everywhere - or perhaps almost everywhere - in a particular way for thousands of years. Efforts should rather be directed to a steady improvement in the recognition of probable pain patterns and their predictive value in relation to treatment”. Indeed, we all know what pain is without knowing the definition, and the least problem is to know when we feel pain and for others to understand what we mean when we say, “my knee hurts”, or “I have a splitting headache”. Even though persons may describe their pain experience in many ways, we easily understand that the person feels pain. At a practical level, it is hard to see how a more comprehensive definition of pain would help researchers in designing experiments and selecting patients for clinical studies.Secondly, and more seriously, the updating proposed by W and C [4] confuses rather than clarifies, because they fail to distinguish pain as a feeling from its causes and mechanistic explanations [6]. For example, by introducing “cognitive” and “social” in the definition they confuse the feeling of pain with its multitude of causes and modifying factors. The comment by Whitburn et al. [7] illustrates the futility of trying to find a precise, yet complete definition, by pointing out that the new definition would not include labour pain. Many other examples might be found. Alcock [8] and Wright and Ayede [9] identify a further problem: by removing the phrase “.. .or described in terms of such damage” patients who experience pain without any evidence of tissue damage are excluded from the new definition (e.g. pain induced by hypnotic suggestion). Rather than promoting a deeper understanding of clinical pain, well-intended updates may perpetuate conceptual confusion.In conclusion, a definition of pain cannot be more than an imperfect means of capturing salient aspects of a complex phenomenon, and the current IASP definition suffices for such a purpose. Notably, it avoids confusing pain as a feeling with its multifarious mechanisms and causes.conflict of interest: No conflict of interest.References[1]Anand KJS, Craig KD. New perspectives on the definition of pain. Pain 1996;67:3–6.8895225Anand KJS Craig KD New perspectives on the definition of pain Pain 19966736[2]Merskey H, Albe-Fessard D, Bonica JJ, Carmon A, Dubner R, Kerr FWL, Lindblom U, Mumford JM, Nathan PW, Noordenbos W, Pagni CA, Renaer MJ, Sternbach RA, Sunderland S. Pain terms: a list with definitions and notes on usage. Recommended bythe IASP subcommittee on taxonomy.Pain 1979;6:249–52.Merskey H Albe-Fessard D Bonica JJ Carmon A Dubner R Kerr FWL Lindblom U Mumford JM Nathan PW Noordenbos W Pagni CA Renaer MJ Sternbach RA Sunderland S Pain terms: a list with definitions and notes on usage Recommended bythe IASP subcommittee on taxonomy.Pain 1979624952[3]Loeser JD, Treede R-D. The Kyoto protocol of IASP basic pain terminology. Pain 2008;137:473–7.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000258359500005&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f31858304810.1016/j.pain.2008.04.025Loeser JD Treede R-D The Kyoto protocol of IASP basic pain terminology Pain 20081374737[4]Williams ACde C, Craig KD. Updating the definition of pain. Pain 2016;157:2420–3.10.1097/j.pain.000000000000061327200490http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000386016400006&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3Williams ACde C Craig KD Updating the definition of pain Pain 201615724203[5]Merskey H. Response to Editorial: New perspectives on the definition of pain. Pain 1996;66:209.Merskey H Response to Editorial: New perspectives on the definition of pain Pain 199666209[6]Brodal P. A neurobiologist’s attempt to understand persistent pain. Scand J Pain 2017;15:140–7.28850339http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000405971800030&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3Brodal P A neurobiologist’s attempt to understand persistent pain Scand J Pain 2017151407[7]Whitburn LY, Jones LE, Davey M-A, Small R. Supporting the updated definition of pain. But what about labour pain? Pain 2017;158:990–1.Whitburn LY Jones LE Davey M-A Small R Supporting the updated definition of pain But what about labour pain? Pain 20171589901[8]Alcock MM. Defining pain: past, present and future. Pain 2017;158:760–1.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000400440200024&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3Alcock MM Defining pain: past, present and future Pain 20171587601[9]Wright A, Ayede M. Critical comments on Williams and Craig’s recent proposal for revising the definition of pain. Pain 2017;158:362–3.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000397015500022&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f32809232810.1097/j.pain.0000000000000765Wright A Ayede M Critical comments on Williams and Craig’s recent proposal for revising the definition of pain Pain 20171583623

Journal

Scandinavian Journal of Painde Gruyter

Published: Oct 1, 2017

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