Orthopaedic Surgery/Pain States

Pain States

RSD has a number of synonyms, the most common one being the eponymn Sudeck's Dystrophy. Others are Algodystrophy and the current term of art; complex regional pain syndome, type 1, a prefered term in that it omits the implied etiology involving the sympathetic nervous system, historical personages, and pedantic usage. In English, the word semantic means "of or relating to meaning." In the science of linguistics, semantics is more explicit: It's the study of meaning based on the historical and psychological significance of words and terms. This greater specificity in defining our semantics is helpful when our therapeutic efforts are organized around a disease name instead of the preferred organization around a specific symptom or better still the influencing of a specific known pathophysiologic mechanism.




Whatever we choose to call the problem this remains a controversial area which touches on the nature of pain itself, and the more general philosophical question of mind body and the nature of perception. It is probably well that we imply nothing by our nomenclature rather than imply something erroneous or which unduly restricts the scope of the problem.

Consider the sentence "I can't help feeling this way." Now consider the sentence "The feeling of which you speak is painful". It is evident from this comparison of usage for the word "feeling", that the very language we use to describe pain or any other feeling for that matter leaves ambiguous the issue of the feeling as a tangible entity unto itself or more of an internal habit of mind. Can we hope to fruitfully delve into such matters in a scientific manner or will our inquiries inevitably lead to a reduction to absurdity by tracing feeling back to its neurophysiologic underpinnings.

It is unusual to find pain that is purely somatic in its manifestations. All pain involves a central response and all pain associated with disability will effect the person as a whole whose normal connection to their place in the world is altered by their incapacity. The perception of pain distorts all aspects of reality as interpreted by the individual. The sentient being who has conscious self awareness, who is conscious of their own mortality, this is the essential distinguishing characteristic of an intelligent life form and we tend to presume it is the defining characteristic of our humanity.

Pain inherently reminds us of mortality. Pain deprives us of the transcendent bliss of dwelling in the present. The present is denied to the individual in pain, and the future is likewise denied as each moment in pain seems an eternity. The past becomes the only escape and in the case of an individual who has been traumatized, this constraining quality of pain prevents recovery from the trauma. This is stated better by Emily Dickinson in poem 650.Dickinson

Complex regional pain syndrome,shoulder hand syndrome, causalgia, minor trauma dystrophy, pain dysfunction syndrome,nonspecific upper extremity pain syndrome, fibromyalgia, we create categories of pain associated syndromes each with unknown pathophysiologic mechanisms. They seem to represent discrete categories and at other times they appear to morph, or oscillate. Could it be that the apparent discrepancy between the manifestations of a patient's pain from one clinic visit to the next reflects such an oscillation between pain states. Do these pain states have differing neurophysiological bases?

Pain states have a protean character; they share this quality with other neuropathologies. There is a sort of quantum tendency to shift states of being in a way that belies the normal logic of classical anatomically based explanations. The quandry might be likened to the inadequacy of Newtonian mechanics failing to account for the behavior of subatomic particles prior to the development of quantum mechanics and relativity.

Similar difficulties are encountered in defining neurophysiologic correlates for Anesthesia and Analgesia as these too represent related states of consciousness, at the opposite spectrum in a sense from that of pain.

It is proposed that the management of pain in association with surgical recovery may predispose to a chronic pain experience. The presumption is that the ideal would be a zero pain experience. The acceptance that some level of pain will be experienced is a prerequisite to consent for the present as completely pain free is infrequently the case for most surgical procedures. The afferent storm may be blunted. The afferents may go nowhere, hit the wall at consciousness unreceptive, they are is a sense forgotten if not unseen. So the effect of ideal anesthetic is one which dissociates recognition as adverse and harmful, detachment from reality without full loss of awareness, this would be Ketamine. Then there is the complete detachment to the point of sleep, changed respirations, often suppressing, then there is complete dissociation of brain control on the maintenance of physiology warranting complete control of respirations and blood pressure by pressors and ventilatory support. So anaesthesia is a variable proposition, depending upon what is being undertaken favoring the less is more approach, retaining a flexible response, or it could be more cookie cutter. The consistency of the anesthesia, the appropriateness to the level of expected pain in the immediate post operative period, these are challenges made better by the experience of the crew, their awareness and familiarity with similar cases. Much of this is undiscussed, relationship driven in some cases, it is helpful if the anesthesiologist knows his surgeon, and knows how to make him look good by getting the cocktail just right. Who can really know in advance how much pain they can take. So a patients prior experience with pain successful or otherwise would be well to know in advance of any procedure. A patient may have a pretty good idea of how much they can take. Others will recoil at the least amount of pain as if an old terror was awakened, the sight of a needle nearly qualifying as painful in itself.

While impossible to quantify one has a sense for what level of pain a person is experiencing.  

Competing scales include a one to ten verbal report, or a facial response scale. As a guide this is imperfect but it is just one more tool of communication. The human is ultimately deciding and interpreting. If pain is to be called a thing, it would consist of three parts. That which can be observed by facial expression and posture. That which can be observed on the basis of physiologic monitoring including pulse blood pressure and respirations. Thirdly that which can be ascertained by the patients utterances, or directed responses. How the patient says it and what is said may be considered but ideally the patient reporting 10/10 pain is taken at face value. Together these three observations are what we can empirically call pain. All the rest is what we ourselves have experienced, currently experience or can imagine. So we are all influenced by our personal knowledge of pain and our cultural acumen with regard to what humans are capable of experiencing and surviving. Do we have a generational or cultural bias that influences our responses, and our responses to pain in another. Do we react the same to a stoic or one who from their background, ethnicity sex, we expect may amplify their outward manifestation of pain, be more likely to verbalize it, One who is like us or unlike us. Since the human judgement is in the loop with regard to the response to pain, individually and as health care providers these questions are relevant. Empirically another view of pain might be that which can be observed via imaging. What does a brain look like that is in pain? What would the monitoring of the spinal cord tell us as to the intraoperative experience of pain. Is the spine also asleep when the brain is asleep?

One could imagine artificial intelligence being enlisted. A computer delivered data including facial recognition

inputs, auditory tonal cues, and physiologic feeds.  All of these brought together and the computer spits out a number corresponding to the patients pain score and advising the right response.  

How much? What form.

That being unavailable, the decision making is made between nurses and doctors, doctors ordering, adjusting their orders based on nursing observations. The role of the nurse in mediating this through the course of the night, is a separate battle ground. How acceptable is level of pain, how quickly are adjustments made,

The doctor and nurse and patient are all in three different places while these decisions are made. While this is understandable it begs the question of why this could not be alleviated by the ubiquitous availability of wifi based video conferencing. The nurse and doctor could quickly concur agreeing about how much pain a patient is in and whether to provide as much as might be demanded. The answer is that such a capacity would infringe upon privacy.

Ordering without video input or some other means, remote communication with the patient is a condition we accept to preserve privacy. How much video scrutiny of the pain experience would be acceptable and what amount would be a problematic, violation of privacy etc might be answered in advance, with none. None without permission. What tacit provision is already presumed. How frequently is a doctor currently called to the bedside to evaluate pain? Does this have as much to do with the relationship of the nurse and doctor. Certainly a doctor getting short or angry or not fully coherent might dissuade a nurse from calling. The nurse may not like speaking with the doctor. She has to rely on professionalism and duty to the patient to overcome that, or she may find a way to take more on herself, but this is severely limited.

Currently, how accessible is a doctor to a nurses call is determined by how much love and hate, CYA, experience or other characteristics of the doctor nurse working relationship might influence the current decision making and treatment delivery train. The doctors pen, the nurses phone this is the point of the sword in cost of care. The more that is ordered the higher the cost. Are there cost considerations, between PCA vs intermittent dosing. How much autonomy can be exercised by a nurse, in recovery vs ICU vs the floor

There is currently no assent to such intrusion even though every other intrusion has been accepted, ones personal integrity put at risk giving every access to every orifice, but then there is the expectation of some privacy.  The conditions in the post recovery state, how to deliver care and support while retaining privacy encouraging autonomy.  Our present hospital rooms are static, hospital environments are compartmentalized, lounging areas, where autonomy is grown, patients rarely moving about unescorted, and hopefully not inappropriately so.  Safety being paramount a hospital is a highly regulated environment in which privacy and personal autonomy is dictated.  A matter of policy.   

Privacy may be sacrificed to the purpose of recovery, such as a built in semipublic experience of a group therapy session. To what extent does this come into play. Will a patient in the course of recovery be amidst others also recovering. This could be good or bad of course, generally good though. A patient may not know how much they can take but they may be darn sure they can take as much as that schmuck. So attitudes, competitive or even prejudicial may become prorecovery. To what extent can a hospital provide a personalized response knowing what would be most helpful for a given patient. Lots of reassurance and presence, or more personal privacy with less interaction. There are formal and informal ways in which the patient may tailor the environment, doors, their own clothing rather than gowns, A recent bill board advertises the front opening robe they offer as an alternative to the back opening gown. All and all, if you ask patients they will say they want as much privacy as possible. Presumably, that may not be what is best for them. They may need lots of frequent interaction and prodding.

There may be other reasons for a particular choice of management, respiratory difficulties, orientation limitations very sensitive to the side effect of any analgesic resulting in disorientation, a detachment from the external accompanying the emancipation from the nociceptive reality. The storm of afferents warning of recent or impending injury.  The fear of the possibility of life threatening or eternal disability.  The fear that the present course was a bad one and things are never getting better, something wrong was done or is this normal.  So over a particular period of time the afferent storm is interpreted and either amplified in significance or dismissed.  This division is clear when two patients undergo the same operation one doing well and another poorly. How are they different, both middle aged men working at the same job same problem carpal tunnel syndrome.  The surgeons can tell you with high reliability that one will do well and the other poorly.  Their differing phases of recovery, one rapid and one slow.  One dismissive of symptoms, focused on the improvements, optimistic that taking on more is good and not bad, ready to do the other hand sooner.  The other patient taking too long to reach a state of capability, enabling a return to one handed duty, and ultimately undertaking the second operation never really getting pinned down to its state of improvement relative to its previous state of dis-ease.  And slow to recover all the more after the second operation.  The symptoms then becoming commodities like playing cards more than symptoms.  More pain means lighter work.  That is all that I need report.  Then there is the question of whether the patient is consciously playing the cards or whether the brain is playing without the mind being aware.  This may be the level at which psychiatric theory would be expected to work.  To point out the disjunction. Analysis of the type of cognitive dissonance that may be involved.  The social psychology of the recovery process is generally not formally addressed, but argely[check spelling] the domain of the work comp nurse.  What factors of the patients overall life may be detrimental to recovery, which may need to be addressed proactively, in advance of surgery.  

To make the person acknowledge that their brain is playing this zero sum game. Gaining advantage through the perpetuation of pain or disability and without consulting you. Psychiatry would suggest this autonomous layering whereby inner motivation and even happiness may be hostage to this disconnect. The extent to which behavior is determined by unconscious motivations is largely underestimated. In the case of patient B. The unpleasantness of the work environment, conflicts with coworkers, peers and well as superiors are all potential obstacles to recovery. Then there is a culture of entitlement. A correlation between the duration of recovery and the ultimate settlement. If it took a long time coming back then it must have been pretty bad and more compensation is due.

The person either owns the pain, or is controlled by it.  All that is a stretch to even contemplate let alone make a difference with therapeutically, using conversation, mostly listening it may seem to some but observation as well.  Reflecting back to the person who is opening up.  Hard to standardize this process, it is as varied as there are individuals.  In fact such interactions are also at large within every persons experience, in net work with family and friends and coworkers.  The interaction of a patient in pain within himself may be determined by the expectations and encouragement of those around him.  An atmosphere that is prorecovery, sometimes shaming into recovery as might be seen as a chiding yet supportive band or brothers helping you through.  These factors must be enlisted in order to overcome what seem otherwise to be the forgone conclusion that the second patient will do poorly.  Knowing this in advance and preparing for the difficulty, may hopefully result in a better than expected outcome.  

Pain assessment on a chronic basis has a larger overall cost impact than does the management of acute pain. The question remains as to whether the latter influences the former. As with acute pain, the empirical description would be defined by one who takes medication to control pain. One who appears to avoid certain activities because they are painful. One who is weakened or dysfunctional due to pain. One who has atrophy of disuse or skin changes associated with maximal contact avoidance. Sweat pattern, and other vasomotor manifestation would also be included in the empirical description of chronic pain. So when is a patient who is still in pain to be encouraged or compelled to resume unrestricted work.

Is the pain being managed in a fashion compatible with work.   Narcotics dependency is a handicap which cannot be accommodated safely in the work place, where the actions or inaction of one may lead to injury of another.    So societal norms and obligations become central to the question of pain management in the chronic phase.  What benefit has been agreed to.  A job will be provided which I can do with no experience of pain.  Is there a level of pain experienced on the job which is considered allowable.  Are some jobs inherently associated with somatic pain.  Pain that resolves, in which case how reliably and how fully?  Is there a normative value that can be ascribed to an allowable standard for break in pain.  Is it possible to adjust the pain threshold through conditioning.  Does an employer have a right to expect fitness from a worker, sleep yes, nutritional balance maybe not.  What of smoking?  Currently no expectation that a worker will observe a program of strength or endurance training like an athlete.  But when the patient is recovering from a procedure from a covered injury or malady is it appropriate that employer may expect diet and exercise compliance beyond the norm for an uninjured employee.  At any given time what percentage of a corporate work force has an affliction under care?  What percentage of the current and retired work force is in that category?  

What is the usefulness of a pain log. This would consist of two daily entries. The morning entry would describe the events of the evening and night. The evening entry would describe the events of the day. The AM entry would include Pain, Restfulness and success of sleep, and evening emotive communication, anxiety, depression, TV watching, isolation. The evening entry would describe pain episodes or severity over the course of the day of pain. Secondly, the level of energy fatigue and stiffness over the course of the day. Thirdly, emotive communication, how much Driving, Sitting, Walking or other exercise. So with the benefit of a months log one might have the ability to make a comment about the persons chronic pain state. Such a detailed set of information even if imperfectly recorded could improve decision making with regard to intervention.

Problematic patterns in the log would include negative emotive communications in both AM and PM. No social interaction in the AM log. No positive feedback on performance or tangible accomplishment, jobs or tasks completed, High levels of financial anxiety. Lack of restful sleep. Any number of patterns may be noted and each might call for a different therapeutic response.

The hospital record is not unlike a series of ships logs. The rather uneventful observation of wind sea state and ships encountered. In the hospital record is reams of data regarding vital signs, laboratory data. There is the maintenance log which in the hospital record would be surgeries and procedures, separately dictated, entries concerning the planning for the preparation for the decision to proceed with one or another course of action, a change in course which in a ships log would be recorded in the smooth log. There is no directly corresponding document to a captains log. It is something held privately and only sourced in the event of calamity. So the medical record is largely tabular and smooth ships logs, and maintenance log. We generally do not have a similar document for outpatient and aftercare. The office record has features which mirror the hospital record, similarly bland entries regarding progress and how things are going. then in the smooth log the occasional untoward unexpected event. Again we see the suppression of any tendency to make a captains log. No running commentary of thoughts about a patient worries, conflicts. These are absent from the record largely out of concern for potential litigation. At the same time certain entries seem to anticipate the potential for negative scrutiny after the fact. So the chart over the last 40 years has changed quite a bit. The log on a ship is alive and well, still recommended practice and usually ignored.

The reason to maintain a log in each case is that there is danger, it is possible to lose ones way and something of value life or ship could be lost in the process. Both exist because a person is needing to get from point a to point b. No one is in the hospital for an adventure. For adventure travel the log becomes more a journal. On a passage it is about safety. Keeping a record allows for the noting of trends. Trends are empirical confirmation of improvement. Empirical confirmation conveyed to the patient is the stuff of psychological healing. The perpetuation of pain being linked to the expectation of a protracted or eternal pain experience, a known negative prognostic indicator when encountered and best met with objective verification of improvement.

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