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Is It Even Possible to Accurately Measure Physical Pain?

It is an elementary logical error to say that because part x of a person’s brain lights up on a scan when he is suffering pain that he must be suffering pain when part x of his brain lights up.

by
Theodore Dalrymple

Bio

April 20, 2013 - 6:50 am

The experimenters took young adult volunteers and subjected an area of their skin to increasing levels of heat until it became painful, all the while scanning their brains. In another experiment they compared physical pain with social pain: the experimental subjects had recently had a broken relationship and their brain scans when being showed pictures of their late sexual partners were compared with those when subjected to painful warmth on their skins. They also studied the effect of painful stimuli when the patient had been administered a powerful analgesic.

The subjective feeling of physical pain correlated with activity in certain areas of the brain with considerable consistency. This, the authors stated, raises the hope that brain scans might be able to tell doctors when patients who are unable to express themselves for one reason or another are suffering pain, and thus treat their suffering.

The study has its limitations, however. It is an elementary logical error to say that because part x of a person’s brain lights up on a scan when he is suffering pain he must be suffering pain when part x of his brain lights up. This might be so, but it has to be shown to be so. In fact, it is prima facie rather unlikely, given the immense complexity of the brain and its vast numbers of interconnections. Furthermore, one must remember that the experiments were performed in a very simple situation, quite unlike the real-life situations that doctors actually face. Still, one cannot but admire the accumulated human ingenuity that made these experiments possible.

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Top Rated Comments   
It could still be abused. Even given the same objective amount of pain and suffering, people have far different subjective tolerances. Will life turn into a Monty Python skit?

Dr.: "Sorry, you're suffereing too much. I'm afraid we have to put you down?"

Patient: "No, I'm fine, really."

Dr.: "Who's the Dr. here, Mr. Smith? You're experiencing unbearable suffering. All our best machines say so!"

Patient: "No! I'm getting better! I feel like dancing!"

Dr.: "You're not fooling anyone, you know. Orderly, take him away!:

Patient: "I'm not dead yet!"

Orderly: *thump*

Dr.: "Much better."
1 year ago
1 year ago Link To Comment
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All Comments   (9)
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Here's the perspective of a chronic high pain patient..

Multiple spine fractures, four vertebrae in 91, thoracic, 7 vertebrae in 04. Lumbar and thoracic again, work related. Advanced osteoarthritis of the entire spine, cervical reconstruction in 07 neck fusion from C3 to T1.. four crushed discs removed, leaving me two in the thoracic and two in the lumbar.

after years of degrading discs, it's at the point, where pain is a constant unrelenting presence. Nuerontin, Oxycontin, and it still hurts like Hell most of the time. I can stand only for limited amounts of time, walking is painful, and I'm retired on a full SSD.

The thing is, the doctors and nurses are never really able to tell how bad it can get. When I had the surgery, I was so racked,.. I was in a kind of zoned out state, aware of what went on, but staring fixedly at something, and feeling like I was looking up from the botton of a pool, everything was hazy, slightly out of focus. I frequently simply forgot to trigger the morphine drip, never paged the nurses.. They'd come in, speak to me, and ask why?

I could never fully explain why.. as if, I was pulling back inside my own head, and compartmentalizing everything.. They'd hit the morphine button, check the call line and leave confused..

The morning after a 9 hour surgery, the surgeon came in, and unaided, I forced myself to sit up in bed, and he just stared at me..

See when I was in the Air Force, and an Officer (doctor) entered the room, it was proper to sit up, if you could since you couldn't stand at attention. So without even thinking about it, that very old reflex kicked in. He started telling me how great I was doing, and when I told him I didn't feel so "great" but thank you, he told me, no, you don't understand, I've done hundreds of these, and nobody has ever, on their own, just sat up so soon after a major surgery he'd done before. He said most people couldn't fight off the pain as well.

I understand it's subjective, pain is felt differently by different people.. and I'm not a snob about it, yes, when someone tells me the pain is so bad from a sprained ankle they can't stand it, for them, it's probably true. None of that, hey my booboo is worser than yours stuff... when people hurt they hurt.

So maybe the length of time to adjust,.. and your own unique perspective counts for a lot of the resistance. When I left the hospital, a nurse was helping me, and I apologized for being such a bother.. She wouldn't have it, she said the nurses loved working with me, because I never paged, never complained.. didn't cry scream or beg for more pain meds..

I left feeling like a freak or something.

I was oh.. 47 then.. and the whole of my life had been, the military ethos,.. grew up wanting a military career, and it didn't happen, I had a major hearing loss in a training accident, and was given an honorable medical discharge. worked 30 years grocery retail, heavy lifting unloading trucks, taking ever more extreme doses of Tylenol as the arthritis worsened..


You play through the pain was the only mindset I knew.. so maybe.. I learned through trial and error to process pain differently, though the family stories are my maternal grandfather had extreme resistence.. but I don't think it's resistence so much, as a almost insane need to be stoic about it.. My father was pretty strict, and showing pain was weakness.. and he hated that.. my son is becoming similar..

so I really don't know why, I have several anomalies, my cervical spine goes into my skull at a reversed angle, doc said it appeared to be a benign birth defect.. unusually heavy bone structure.. when fitted for dentures, they couldn't find a template big enough to fit my lower jaw.. so maybe there are some recessive genes at play..

I just know, that when I hurt the worst, I go quiet and don't say anything.. which is how my wife can tell when it's really bad. I tend to low ball my pain levels, or did before.. and my doctor now is very reluctant to up the dose, yet after all these years, I have developed a tolerance to the pain meds.. they raise them every couple of years, but I think he's afraid to go higher, since the state is being so intrusive about how many pain scripts doctors write.

He wants more surgery to lessen the pain.. two surgeons said with so many nerve roots pinched, it won't help.. so I'm trapped in a limbo, where the pain meds work less and less, yet the doctor seems to think I'm just feeling the winters weather..

A objective measure could help chronic life time pain patients if only so we get the correct level of relief..
51 weeks ago
51 weeks ago Link To Comment
If somebody screams, it hurts a lot. f they stop screaming, they're either in shock or dead. It doesn't take some psychbabbling egghead to figure it out.
51 weeks ago
51 weeks ago Link To Comment
Well the issue for measuring pain is two fold.

1. The signal sent by the nerves - how 'sensitive' they are.
2. The response of your brain to that pain. How much do /you/ tolerate pain.


Unless we can control for either one of them we can't tell how badly something hurts someone. If they're crying out in agony over something that we think barley hurts, then either:

A) They're a pathetic crybaby
B) They are sensing an agony that would have you reacting the same way.


There are some methods we can use to try and tease out answers, but they are not terribly pleasant. fMRI just adds another layer of subjectivity to it, by measuring O2 consumption and other markers of brain activity.

For instance, when you have a cut, the nerves that sense heat in your skin become exposed to liquids (with the skin broken). The reason that alcohol stings so much is because it causes those nerves to saturate: they are turned on at full. In that scenario, we could attempt to interview or observe the pain someone feels when they are literally in as much pain as that area of nerves can combine. Doesn't tell us the absolutes about the two parameters, but it does give us some information on personal thresholds of pain.

Though of course, I can't imagine getting enough volunteers for such a study. I certainly wouldn't.
51 weeks ago
51 weeks ago Link To Comment
Tempest in a teapot.

This minor article in NEJM was picked up by some newsy scientific media.

Background is the use of fMRI, functional MRI, a technique with interesting research implications but not in clinical practice. It is a way to grossly map areas of the brain that have increased blood flow. It is subject to too much signal to noise ratio to be of much clinical use .

No big deal that if you increase pain, in this case heat to an extremity, some areas light up. Then if you recall the experience similar areas light up.

If you give an analgesic you get different results. Proving that this analgesic actually works. Well not really because pain is a subjective experience but still semi interesting basic research.

Here is the conclusion from the abstract:
CONCLUSIONS
It is possible to use fMRI to assess pain elicited by noxious heat in healthy persons. Future studies are needed to assess whether the signature predicts clinical pain. (Funded by the National Institute on Drug Abuse and others.)

No breakthrough here.
51 weeks ago
51 weeks ago Link To Comment
Thank you, Doctor Dalrymple, for writing so deeply about the end of physical life.

I can't help admitting, however, that the title of your article, "Is It Even Possible to Accurately Measure Physical Pain?" kind of put me off (I'm glad I got past my own prejudices and into your eloquent discussion). Wouldn't "Is It Possible to Measure Physical Pain Accurately?" work better?

I ask this question not because I object to every split infinitive but because this particular split infintive seems unnecessary. My simple reworking of the title really does sound better. Does it not? My version doesn't dawdle: it gets right to the point.

Regarding a matter as serious -- indeed, uniquely serious -- as the end of life, I would trust perhaps no one but you, who have dealt for decades with the ultimate question first-hand.

God bless, and keep up the good work.
51 weeks ago
51 weeks ago Link To Comment
Thank you, Doc, for this succinct and honest description of a thought that is increasingly on one's mind as one grows older: "I pray that mine [death] will not come in the horrible ways I have seen as a doctor. I think, though I cannot be sure, that I would like to choose my moment if one of those horrible ways were mine."
Concerning the experiments you mention about the "pain" of heat on skin somehow being the same, except phonetically, as the pain of falling madly in love with a woman who won't give you the time of day... well I just don't buy it.
51 weeks ago
51 weeks ago Link To Comment
"Welcome my sister death" (Saint Francis of Assisi at the approach of his death)
also the gift of being a chosen one by Saint Francis
""Love has cast me into a furnace, love has cast me into a furnace, I am cast into a furnace of love. My new Bridegroom, the loving Lamb, gave me the nuptial ring; then having cast me into prison, He cleft my heart, and my body fell to the ground. Those arrows, propelled by love, struck me and set me on fire. From peace He made war, and I am dying of sweetness. The darts rained so thick and fast, that I was all in agony. Then I took a buckler, but the shafts were so swift that it shielded me no more; they mangled my whole body, so strong was the arm that shot them. He shot them so powerfully, that I despaired of parrying them; and to escape death, I cried with all my might: 'Thou transgressest the laws of the camp.' But he only set up a new instrument of war, which overwhelmed me with fresh blows. So true was His aim, that He never missed. I was lying on the ground, unable to move my limbs. My whole body was broken, and I had no more sense than a man deceased; Deceased, not by a true death, but through excess of joy. Then regaining possession of my body, I felt so strong, that I could follow the guides who led me to the court of heaven. Returning to myself, I took up arms, and I made war upon Christ: I rode into His territory, and meeting Him, I engaged Him at once, and took my revenge on Him. Having had my revenge, I made a treaty with Him; for from the beginning Christ had loved me with a true love. And now my heart has become capable of the consolations of Christ." (St. Francis of Assisi)

51 weeks ago
51 weeks ago Link To Comment
It could still be abused. Even given the same objective amount of pain and suffering, people have far different subjective tolerances. Will life turn into a Monty Python skit?

Dr.: "Sorry, you're suffereing too much. I'm afraid we have to put you down?"

Patient: "No, I'm fine, really."

Dr.: "Who's the Dr. here, Mr. Smith? You're experiencing unbearable suffering. All our best machines say so!"

Patient: "No! I'm getting better! I feel like dancing!"

Dr.: "You're not fooling anyone, you know. Orderly, take him away!:

Patient: "I'm not dead yet!"

Orderly: *thump*

Dr.: "Much better."
1 year ago
1 year ago Link To Comment
"No more ethical agonizing."

Which would, truly, be a terrible thing.
1 year ago
1 year ago Link To Comment
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