"Nociplastic Pain": A Challenge to Nosology and to Nociception.

The construct of "nociplastic pain" has met with divergent receptions. On the one hand it has been enthusiastically embraced, to the extent of conflation with central sensitization of nociception and the International Classification of Diseases 11th Revision (ICD-11) entity of "primary" pain, and the promulgation of "nociplastic pain syndromes." On the other hand, it has been rejected by those whose skepticism derives from the absence, by definition, of underlying activation of nociceptors. This article seeks to dissect these divergent views and search for reconciliation between them. One line of argument is that "nociplastic" pain, "primary" pain, and "central sensitisation of nociception" reflect different domains of inquiry and should not be conflated. "Nociplastic" pain emerges as a hypothesis that confers clinical legitimacy and utility; while that hypothesis needs a minor but important modification and continues to require testing, discipline in its usage is necessary. The other line of argument discovers an unexpected impasse: the construct of "nociplastic pain" describes a phenomenon that accords with the International Association for the Study of Pain definition of pain but occurs in the absence of nociception-as-currently-defined, thus challenging the definitional link between pain and tissue damage. The article offers a resolution of this impasse by suggesting that nociception-as-currently-defined be replaced by the resurrected concept of a nociceptive apparatus, activation of which is necessary but not sufficient for the experience of pain. One consequence would be to allow the assertions underpinning "nociplastic" to be tested empirically; another would be to relate the phenomenon of pain to a more biologically plausible basis than "actual" or "resemblance to" tissue damage. PERSPECTIVE: This article explores the major challenges posed by "nociplastic pain" to nosology and to nociception. While discipline in the clinical use of the construct is required, it also emerges that the main issue is the International Association for the Study of Pain definition of nociception. A reconceptualization of nociception is proposed for logical, biological, and clinical coherence.

Pain is Not a "thing": How That Error Affects Language and Logic in Pain Medicine.

Effectiveness in academic and clinical communication depends upon agreement on what words and concepts denote and on the consequent ability to argue logically and accurately. In the pain medicine literature there are many examples of imprecision and confusion in this respect, including misnomers and fallacies in reasoning. This article firstly critically examines some of these misnomers. Identified themes include pain being conceptualised as a "thing," conflation between nociception and pain, and confusion between stimulus and response and between the perspectives of the experiencer and the observer of "pain." Secondly, fallacies in reasoning are identified that contribute to imprecision and confusion. These include reification of pain, attributing to the brain functions that belong to whole organisms, and the illusory truth effect. Thirdly, these themes are identified also in constructs that are shown to be based more on speculation than on fact. Taken together, these observations reveal a need to review and, where necessary, modify terminology and concepts used in Pain Medicine. PERSPECTIVE: This article examines a number of words and constructs commonly found in the pain literature from the perspective of accuracy in terms of their consistency of usage, concordance with fact, degree of speculation and logical argument. A common major theme is the error of considering pain as a "thing" that has agentive properties. A need to clarify much of the language used in Pain Medicine is identified.

The Great Trade-off in Workers' Compensation: Perceptions of Injustice by Those Experiencing Persistent Pain.

INTRODUCTION: Some claimants harbor perceptions of injustice about the way they have been treated. In particular, those with ongoing and disabling pain have been generally dissatisfied by the way they have been managed by the systems designed to offer them financial compensation. AIM: In this paper we aim to explore possible factors that may contribute to their dissatisfaction. METHOD: We review the historical development of the various systems in which monetary compensation was awarded for personal injury. FINDINGS: In the latter years of the 19th century, a significant trade-off occurred in the German workers' compensation systems. On the one hand, employers accepted the principle of no-fault insurance and agreed to provide injured workers with monetary compensation and medical treatment. On the other hand, employees agreed to relinquish the right to sue their employer for negligence. However, awards under this legal system did not include assessments for ongoing pain, humiliation, or loss of social status as were incorporated in previous systems. CONCLUSION: Although the Prussian and German approach provided a utilitarian model for similar systems around the world, its failure to include some long-established benefits of a moral nature may have contributed to the current perceptions of injustice expressed by many injured workers experiencing persistent pain.

Why are assumptions passed off as established knowledge?

In this paper we attempt to explain the problems that can arise when assumptions made by experts in their respective fields of Medicine become widely accepted as established knowledge. Our hypothesis is that these problems are in large part attributable to a failure of the experts to follow the principles of logical argument. Empirical data to evaluate our hypothesis derives from an analysis of the reasoning processes employed in the generation of three syndromes drawn from the clinical discipline of Pain Medicine: myofascial pain, shoulder impingement and central sensitisation. We demonstrate a failure by the proponents of these syndromes to structure their scientific arguments in a logically valid fashion, which lead them to promote assumptions to the status of facts. In each instance those in relevant scientific journals responsible for content review accepted - and thereby promulgated - this fundamental error in reasoning. The wide acceptance of each of these assumptions as established knowledge affirms our hypothesis. Furthermore, we show that such uncritical acceptance has had significant consequences for many patients.

Why Are Women with Fibromyalgia so Stigmatized?

INTRODUCTION: Many female pain sufferers with medically unexplained pain are at risk of being stigmatized in our Western society. Fibromyalgia is offered as the exemplar condition. AIM: To understand why these women are being stigmatized. METHODS: A review of the recent literature was conducted with a focus on the perceptions of women with a diagnosis of fibromyalgia who have been stigmatized. RESULTS: Three intertwined themes emerged as contributing to their stigmatization: moralizing attitudes, disbelief as to the reality of pain, and pain's invisibility. CONCLUSION: Given how embedded the factors responsible for the stigmatization of women with fibromyalgia in Western society are, the realistic prospects for addressing this issue are poor.

Congenital Insensitivity to Pain: A Misnomer.

Congenital insensitivity to pain is an umbrella term used to describe a group of rare genetic diseases also classified as hereditary sensory autonomic neuropathies. These conditions are intriguing, with the potential to shed light on the poorly understood relationship concerning nociception and the experience of pain. However, the term congenital insensitivity to pain is epistemologically incorrect and is the product of historical circumstances. The term conflates pain and nociception and, thus, prevents researchers and caregivers from grasping the full dimensions of these conditions. The aims of this article were to review the epistemological problems surrounding the term, to demonstrate why the term is inaccurate and to suggest a new term, namely, congenital nociceptor deficiency. The suggested term better reflects the nature of the conditions and incorporates current understandings of nociception. PERSPECTIVE: The umbrella term congenital insensitivity to pain conflates pain and nociception, which is epistemologically unacceptable. We suggest a new term, namely, congenital nociceptor deficiency, that overcomes this problem and is concordant with current neurobiological knowledge.

Reconsidering the International Association for the Study of Pain definition of pain.

INTRODUCTION: The definition of pain promulgated by the International Association for the Study of Pain (IASP) is widely accepted as a pragmatic characterisation of that human experience. Although the Notes that accompany it characterise pain as "always subjective," the IASP definition itself fails to sufficiently integrate phenomenological aspects of pain. METHODS: This essay reviews the historical development of the IASP definition, and the commentaries and suggested modifications to it over almost 40 years. Common factors of pain experience identified in phenomenological studies are described, together with theoretical insights from philosophy and biology. RESULTS: A fuller understanding of the pain experience and of the clinical care of those experiencing pain is achievable through greater attention to the phenomenology of pain, the social "intersubjective space" in which pain occurs, and the limitations of language. CONCLUSION: Based on these results, a revised definition of pain is offered: Pain is a mutually recognizable somatic experience that reflects a person's apprehension of threat to their bodily or existential integrity.

Interdisciplinary Management of Complex Regional Pain Syndrome of the Face.

BACKGROUND AND PURPOSE: Orofacial pain disorders are relatively uncommon and pose a substantial diagnostic challenge. This case report documents the diagnosis and management of hemifacial pain in a patient who was referred to an interdisciplinary pain medicine unit. The purpose of this case report is twofold. First, it presents complex regional pain syndrome (CRPS) as a potential differential diagnosis in cases of facial pain. Second, it describes the successful adaption of contemporary management approaches for distal-extremity CRPS to treat people with CRPS of the facial region. CASE DESCRIPTION: The patient had hemifacial pain and concomitant motor and autonomic symptoms after a small laceration of the eyelid. Extensive specialist medical evaluations were undertaken to exclude an underlying structural pathology. After detailed clinical assessments by a physical therapist, pain physician, and clinical psychologist, a diagnosis of CRPS involving the face was made. OUTCOMES: The patient's pain was largely unresponsive to pharmacological agents. A modified graded motor imagery program, together with desensitization and discrimination training, was commenced by the physical therapist and clinical psychologist. A positive clinical response was indicated by a decrease in allodynia, normalization of motor control, and regained function in activities of daily living. DISCUSSION: Complex regional pain syndrome is an infrequently reported differential diagnosis that can be considered in patients with persistent facial pain. This case report highlights how careful examination and clinical decision making led to the use of an innovative therapeutic strategy to manage a challenging condition.