It’s April and time for a change of season, sadly. For us in the southern hemisphere it means we’re moving swiftly into autumn, with the leaves outside my house becoming yellow and fluttering to the ground, and the hint of chill in the air at night and early morning. After a weekend away, it’s a bit hard to sit down and write!
And what a weekend it was – I had an absolutely wonderful time at PainLang in Brisbane. A four-hour forum of discussion and dialogue between a couple of really wonderful people including Professor Harold Merskey, originator of the now internationally-adopted definition of ‘pain’, Professor Jenny Strong from Queensland University, Professor Roland Sussex also from Queensland University, and a range of other researchers and clinicians who all were able to contribute to a wide-ranging discussion about the language of pain.
For me, a highlight had to be hearing Professor Merksey talking about how the definition of pain was first adopted, and his ongoing work in the medicolegal field of defining pain and disability, and establishing that there is a widespread but probably false impression that musculoskeletal pain such as whiplash is short-lived. Some of his research and particularly his re-analysis of several studies, demonstrated that due to inadequate outcome measures and methodological limitations, there is an impression that all but a small percentage of people completely recover within three months – but in fact, somewhat closer to the truth is that around 10% of people take longer than 12 months to completely recover. What confounds the assessment of outcome is lack of a consistent measure, and indeed it’s common for measures of:
- pain intensity
- return to work
- case closure based on ‘end of rehabilitation’
- cessation of compensation
all to be used at different times to establish an ‘outcome’ that is then used to determine how long it takes to recover from a musculoskeletal injury. This creates problems when respected organisations quote figures drawn from studies without rigorous methodology and use the results from these studies to dictate policy such as duration figures for rehabilitation, types of treatments funded, or to establish whether compensation will be continued.
Another person that I listened to and think of as a kindred spirit is Professor Roland Sussex. He is a linguistics professor and he and Professor Jenny Strong are working together to review the very commonly-used and well-known McGill Pain Questionnaire. This is the instrument that provides a list of words, and asked the person with pain to identify the words that apply to him/her. It was developed in the mid-1970’s, and reflects both the language and the concepts of pain from that time and the culture of North American middle-class white professionals. Why do I think of Prof Sussex as a kindred spirit? Well, he’s a magpie for bits and pieces of information which he gleefully collects and notes down, and pulls out in conversation which is erudite, ranges over an enormous range of topics, and is entertaining and thoughtful. While I can’t profess to achieve the level of knowledge of Prof Sussex, I too have that tendency to collect and pick over a range of tidbits of information that seems to scatter around me – and lo! and behold, it comes out on this blog!!
So, what did he have to say? Well, the poor McGill, which is an instrument I have never found useful and have rarely used, has some linguistic features that make it a product of its time, and one which needs some thoughtful consideration before deciding to use. There are several words in the instrument that are rarely found in the conversations of the people I see in my clinical practice: lacinating (which according to a number of on-line dictionaries means characterized by a sensation of cutting, piercing, or stabbing), torturing, gruelling, searing – to name a few. The instrument also categorises these words, but the categories are not necessarily mutually exclusive, and although each category apparently ranges from less severe to very severe, this isn’t particularly clear.
Some other concerns I’ve had with the McGill also came up – the cultural bias of an instrument developed in the US for english speakers means that people from other cultures are disadvantaged by it. We simply don’t know whether it’s possible for someone who doesn’t speak english as a first language would think of these words when describing their pain. There are some words that are very specific to pain (eg lancinating), while there are other words that are used far more generally for many other things (eg hot, cold, burning), and this makes it especially difficult for people from other cultures to translate.
I’m not sure whether the McGill was ever meant to be a substitute for simply talking about pain, but I’ve seen it used for a wide range of things in the pain literature – from ‘diagnosing’ pain sub-types (eg neuropathic pain), to measuring outcomes of treatment, to simply being part of a battery of tests to ‘understand’ someone’s pain. There are always concerns when we try to understand another’s pain – we can never know the qualia of another’s pain (just as we can never know whether we each see the same ‘blue’, although we use the word about the same/similar wavelength of light). Constraining someone to a tool like the McGill doesn’t seem especially helpful for me clinically, so I’ve preferred to talk and come to some sense of understanding, albeit filtered through my own language filters, and through the filters of the person I’m talking with.
Any assessment we use will be subject to certain other ‘cultural’ aspects of communication. This is because in order to understand another’s pain, we rely on communication, and communication is social and cultural. Communication involves at least two people, some shared communication conventions (folkways or mores), it relies on the ability of each participant to have a message to communicate, a method to encode it, transmit it, for that message to be received, decoded and comprehended. Lots of opportunity for error to creep in!
Think about some of the features that are present in any conversation about pain:
- the person with pain needs to decide whether their pain is something they wish to communicate about
- once they decided to communicate about it, they consider/process the aspect they wish to project – and we are quite selective about what we communicate. For example, do we want to demonstrate stoicism? martyrdom? bravery? anxiety?
- the actual process of determing what to communicate is filtered through often subconscious processes – how many of us from a Judeo-Christian background really think about the way our Judeo-Christian heritage conceptualises pain? Of heroes, and saints suffering, and pain as punishment, and retribution and how it was visited on Job to ‘test’ him, and removed only with God’s will?
- And what about our own family’s view on pain? Are we from a family where pain is discussed? or one where we were told to ‘put up or shut up’? Was one parent very vocal about pain, and what impact does that have on us? Like the child of an alcoholic, who may ‘blame’ the parent for either abstinence or alcoholism, we too may be reacting to situations in our early life…
- And culturally, we may be from a culture where certain pains are NEVER discussed (vulvodynia, painful periods), or we may be of an age or in a state such as pregnancy where every horror story of childbirth is discussed in intimate detail.
- Our gender makes an impact on what we will discuss, with whom and in what detail…
- Our power in a relationship as interrogator, subject or equal makes an impact on what is asked, by whom and when – and what is answered, by whom and when
- and finally, once a decision is made to communicate about pain, it is moderated by the response of the other person in that conversation to either increase the frequency of ‘pain talk’ or decrease it.
I’ve talked before about the words that we use when talking about pain – the importance, to me at least, of the ‘social’ in ‘psychosocial’ assessment, for fear that the interaction between the person and his or her environment (both social and nonhuman environment) will become lost. I’ve also talked about the language of ‘injury’ being used in some circumstances, but not in others (the head’ache’ is different from the back ‘injury’???).
So, a fruitful weekend, one that I will recall very fondly indeed – a toast to Jenny and colleagues for organising such a rich and enjoyable feast for me and the others who attended!