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 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.

A critical evaluation of the trigger point phenomenon.

The theory of myofascial pain syndrome (MPS) caused by trigger points (TrPs) seeks to explain the phenomena of muscle pain and tenderness in the absence of evidence for local nociception. Although it lacks external validity, many practitioners have uncritically accepted the diagnosis of MPS and its system of treatment. Furthermore, rheumatologists have implicated TrPs in the pathogenesis of chronic widespread pain (FM syndrome). We have critically examined the evidence for the existence of myofascial TrPs as putative pathological entities and for the vicious cycles that are said to maintain them. We find that both are inventions that have no scientific basis, whether from experimental approaches that interrogate the suspect tissue or empirical approaches that assess the outcome of treatments predicated on presumed pathology. Therefore, the theory of MPS caused by TrPs has been refuted. This is not to deny the existence of the clinical phenomena themselves, for which scientifically sound and logically plausible explanations based on known neurophysiological phenomena can be advanced.

Implementing evidence-informed policy into practice for health care professionals managing people with low back pain in Australian rural settings: a preliminary prospective single-cohort study.

OBJECTIVE: To provide access to professional development opportunities for health care professionals, especially in rural Australian regions, consistent with recommendations in the Australian National Pain Strategy and state government policy. DESIGN AND SETTING: A preliminary prospective, single-cohort study design, which aligned health policy with evidence-informed clinical practice, evaluated the implementation and effectiveness of an interprofessional, health care provider pain education program (hPEP) for management of nonspecific low back pain (nsLBP) in rural Western Australia. INTERVENTION: The 6.5-hour hPEP intervention was delivered to 60 care providers (caseload nsLBP 19.8% ± 22.5) at four rural WA regions. OUTCOME MEASURES: Outcomes were recorded at baseline and 2 months post-intervention regarding attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale [HC-PAIRS]), Back Pain Beliefs Questionnaire [BBQ]), and self-reported evidence-based clinical practice (knowledge and skills regarding nsLBP, rated on a 5-point Likert scale with 1 = nil and 5 = excellent). RESULTS: hPEP was feasible to implement. At 2 months post-hPEP, responders' (response rate 53%) improved evidence-based beliefs were indicated by HC-PAIRS scores: baseline mean (SD) [43.2 (9.3)]; mean difference (95% CI) [-5.9 (-8.6 to -3.1)]; and BBQ baseline [34.3 (6.8)]; mean difference [2.1 (0.5 to 3.6)]. Positive shifts were observed for all measures of clinical knowledge and skills (P < 0.001) and increased assistance with planning lifestyle changes (P < 0.001), advice on self-management (P = 0.010), and for decreased referrals for spinal imaging (P = 0.03). CONCLUSIONS: This policy-into-practice educational program is feasible to implement in rural Western Australia (WA). While preliminary data are encouraging, a further randomized controlled trial is recommended.

Is chronic pain a disease?

OBJECTIVE: The discovery of neuroplastic phenomena such as central sensitization of nociception has challenged pain theory to evolve, to encompass unpredictable and unlikely chronic pain states, and to cope with the emerging complexity of the brain. Recently, the proposition that chronic pain is a disease in its own right has gained currency, based upon functional and structural changes in the brain constituting a distinctive pathology. Proponents have expanded the theory to identify "eudynia" ("good" pain) and "maldynia" ("bad" pain). METHODS: A critical examination of the proposition that chronic pain is a disease was conducted within the framework of evolution of pain medicine theory. RESULTS: Three dominant theories were identified: specificity theory (the "hard-wired" nervous system); neuroplasticity theory (the "soft-wired" nervous system); and pain-as-a-disease. The progression from specificity theory to neuroplasticity theory was based upon empirical evidence and conceptual clarity. The latter theory confronts the uncertainty and the unpredictability of pain, and offers explanations for conditions where ongoing noxious input is not discernible. However, not only does pain-as-a-disease elevate the neurophysiological mechanisms underlying the experience of chronic pain to the status of a disease, but also it conceives of pain as a "thing" that is itself capable of producing an effect. This reasoning is found to be faulty on two grounds: the confusion of pain as a symptom, a cause, and a pathology; and the fallacy that can arise when an interpretation is claimed to be a truth. CONCLUSIONS: The proposition that chronic pain is a disease cannot be supported on clinical and pathological grounds, as well as in terms of ways of knowing. The promulgation of "good" and "bad" pain has the potential to obstruct necessary dialogue for advancing the science and treatment of pain. We suggest a way forward to resolve this impasse.

"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.

Consumers' experiences of back pain in rural Western Australia: access to information and services, and self-management behaviours.

BACKGROUND: Coordinated, interdisciplinary services, supported by self-management underpin effective management for chronic low back pain (CLBP). However, a combination of system, provider and consumer-based barriers exist which limit the implementation of such models into practice, particularly in rural areas where unique access issues exist. In order to improve health service delivery for consumers with CLBP, policymakers and service providers require a more in depth understanding of these issues. The objective of this qualitative study was to explore barriers experienced by consumers in rural settings in Western Australia (WA) to accessing information and services and implementing effective self-management behaviours for CLBP. METHODS: Fourteen consumers with a history of CLBP from three rural sites in WA participated. Maximum variation sampling was employed to ensure a range of experiences were captured. An interviewer, blinded to quantitative pain history data, conducted semi-structured telephone interviews using a standardised schedule to explore individuals' access to information and services for CLBP, and self-management behaviours. Interviews were digitally recorded and transcribed verbatim. Inductive analysis techniques were used to derive and refine key themes. RESULTS: Five key themes were identified that affected individuals' experiences of managing CLBP in a rural setting, including: 1) poor access to information and services in rural settings; 2) inadequate knowledge and skills among local practitioners; 3) feelings of isolation and frustration; 4) psychological burden associated with CLBP; and 5) competing lifestyle demands hindering effective self-management for CLBP. CONCLUSIONS: Consumers in rural WA experienced difficulties in knowing where to access relevant information for CLBP and expressed frustration with the lack of service delivery options to access interdisciplinary and specialist services for CLBP. Competing lifestyle demands such as work and family commitments were cited as key barriers to adopting regular self-management practices. Consumer expectations for improved health service coordination and a workforce skilled in pain management are relevant to future service planning, particularly in the contexts of workforce capacity, community health services, and enablers to effective service delivery in primary care.

Engaging consumers living in remote areas of Western Australia in the self-management of back pain: a prospective cohort study.

BACKGROUND: In Western Australia (WA), health policy recommends encouraging the use of active self-management strategies as part of the co-care of consumers with persistent low back pain (LBP). As many areas in WA are geographically isolated and health services are limited, implementing this policy into practice is critical if health outcomes for consumers living in geographically-isolated areas are to be improved. METHODS: In this prospective cohort study, 51 consumers (mean (SD) age 62.3 (± 15.1) years) participated in an evidence-based interdisciplinary pain education program (modified Self Training Educative Pain Sessions: mSTEPS) delivered at three geographically isolated WA sites. Self report measures included LBP beliefs and attitudes (Back Pain Beliefs Questionnaire (BBQ); Fear Avoidance Beliefs Questionnaire (FABQ)), use of active and passive self-management strategies, and health literacy, and global perceived impression of usefulness (GPIU) recorded immediately pre-intervention (n = 51), same day post-intervention (BBQ; GPIU, n = 49) and 3 months post-intervention (n = 25). RESULTS: At baseline, consumers demonstrated adequate health literacy and elements of positive health behaviours, reflected by the use of more active than passive strategies in self-managing their persistent LBP. Immediately post-intervention, there was strong evidence for improvement in consumers' general beliefs about LBP as demonstrated by an increase in BBQ scores (baseline [mean (SD): 25.8 (7.6)] to same day post-intervention [28.8 (7.2); P < 0.005], however this improvement was not sustained at 3 months post-intervention. The majority of consumers (86.4%) reported the intervention as very useful [rated on NRS as 7-10]. CONCLUSIONS: To sustain improved consumer beliefs regarding LBP and encourage the adoption of more positive health behaviours, additional reinforcement strategies for consumers living in remote areas where service access and skilled workforce are limited are recommended. This study highlights the need for aligning health services and skilled workforce to improve the delivery of co-care for consumers living in geographically isolated areas.

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.

System plasticity and integrated care: informed consumers guide clinical reorientation and system reorganization.

SETTING: Two Australian public hospital multidisciplinary pain centers (MPCs) situated on opposite sides of the country. OBJECTIVE: Restructuring our services to become patient-centred and patient-driven by enabling entry to our MPCs through an education portal, inclusive of both knowledge and self-management skills, and to then be free to select particular treatment options on the basis of evidence of known efficacy (risk/benefit). DESIGN: Group-based education to inform our patients of the current state of uncertainty that exists in Pain Medicine, both in regard to diagnostic and therapeutic practices. Using an interprofessional team approach, we aimed to present practical and evidence-based advice on techniques of pain self-management and existing traditional medical options. RESULTS: Early, resource efficient, group intervention provides many patients with sufficient information to make informed decisions and enables them to partner us in engaging a whole person approach to their care. We have implemented routine comprehensive audits of clinical services to better inform the planning and provision of health care across health services. CONCLUSIONS: System plasticity is as important to the process of integrated health care as it is to our understanding of the complexity of the lived experience of pain. Better-informed consumers partnered with responsive health professionals drive the proposed paradigm shift in service delivery. The changes better align the needs of consumers with the ability of health care providers to meet them, thus achieving the twin goals of patient empowerment and system efficiency.

An evolutionary stress-response hypothesis for chronic widespread pain (fibromyalgia syndrome).

OBJECTIVE: The study aimed to seek a unifying biological basis for the phenomena encompassed in fibromyalgia syndrome (chronic widespread pain and associated morbidities). SETTING: While much progress has been made in the last decade in understanding chronic widespread pain, its pathogenesis remains stubbornly obscure and its treatment difficult. Two themes are gaining currency in the field: that chronic widespread pain is the result of central sensitization of nociception, and that chronic pain is somehow related to activation of a global stress response. DESIGN: In this article we merge these two ideas within the perspective of evolutionary biology to generate a hypothesis about the critical molecular pathway involved in chronic stress response activation, namely substance P and its preferred receptor, neurokinin-1 (NK-1R), which has many empirically testable implications. CONCLUSION: Drawing on diverse findings in neurobiology, immunology, physiology, and comparative biology, we suggest that the form of central sensitization that leads to the profound phenomenological features of chronic widespread pain is part of a whole-organism stress response, which is evolutionarily conserved, following a general pattern found in the simplest living systems.

Stigmatization of patients with chronic pain: the extinction of empathy.

OBJECTIVE: To address how health professionals may inadvertently contribute to the stigmatization of patients with chronic pain. SETTING: Formulation and implementation of the Australian National Pain Strategy. DESIGN: Review of current concepts of stereotyping and stigma, consideration of their relationship to empathy, and how they might impinge upon the clinical encounter. FINDINGS: The extinction of empathy, which we refer to as "negative empathy," can overwhelm health professionals, allowing the entry of negative community stereotypes of chronic pain sufferers and add to their stigmatization. Prevailing dualistic frames of reference encourage this process. CONCLUSION: Greater awareness by health professionals of their own potential, often inadvertent, contribution to the stigmatization of their patients with chronic pain may serve as a basis for an expanded model of clinical engagement.

Preclinic group education sessions reduce waiting times and costs at public pain medicine units.

OBJECTIVE: To assess the effects of preclinic group education sessions and system redesign on tertiary pain medicine units and patient outcomes. DESIGN: Prospective cohort study. SETTING: Two public hospital multidisciplinary pain medicine units. PATIENTS: People with persistent pain. INTERVENTIONS: A system redesign from a "traditional" model (initial individual medical appointments) to a model that delivers group education sessions prior to individual appointments. Based on Patient Triage Questionnaires patients were scheduled to attend Self-Training Educative Pain Sessions (STEPS), a two day eight hour group education program, followed by optional patient-initiated clinic appointments. OUTCOME MEASURES: Number of patients completing STEPS who subsequently requested individual outpatient clinic appointment(s); wait-times; unit cost per new patient referred; recurrent health care utilization; patient satisfaction; Global Perceived Impression of Change (GPIC); and utilized pain management strategies. RESULTS: Following STEPS 48% of attendees requested individual outpatient appointments. Wait times reduced from 105.6 to 16.1 weeks at one pain unit and 37.3 to 15.2 weeks at the second. Unit cost per new patient appointed reduced from $1,805 Australian Dollars (AUD) to AUD$541 (for STEPS). At 3 months, patients scored their satisfaction with "the treatment received for their pain" more positively than at baseline (change score=0.88; P=0.0003), GPIC improved (change score=0.46; P<0.0001) and mean number of active strategies utilized increased by 4.12 per patient (P=0.0004). CONCLUSIONS: The introduction of STEPS was associated with reduced wait-times and costs at public pain medicine units and increased both the use of active pain management strategies and patient satisfaction.

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.

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.