Volume 52, Issue 11, November 2023


Nagalaxmi Iyengar   
doi: 10.31128/AJGP-09-23-6966   |    Download article
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A painful discussion

Scientific and medical definitions are tools. Even when we recognize them as imperfect or provisional, awaiting replacement by an improved version, they perform work that cannot be accomplished by less precise instruments.1

One of the clinical hallmarks of musculoskeletal conditions is pain –difficult to express, difficult to define and often overlooked in consultations. General practitioners are well equipped to recognise the varied manifestations of pain in an individual. Pain can be physically and emotionally disempowering. We acknowledge the unique and personal pain experience and appreciate that injuries of similar aetiologies can inflict pain that differs in duration, character and intensity. Pain can also occur in the absence of an identifiable organic cause or be the harbinger of a malignant process. Emotional trauma can manifest as pain, where sometimes, paradoxically, self-inflicting physical pain can alleviate the psychological burden.

The International Association for the Study of Pain (IASP) defines pain as ‘An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’.2,3 This definition is instilled in medical curricula and widely accepted by medical professionals. Conceptualising pain is challenging, particularly for it to be universally transferable and translatable yet capture the personal experience of pain for the patient. The IASP has respectfully acknowledged this definition with accompanying key notes stating that pain is always a personal experience that is influenced by biological, psychological and social factors and that individuals learn the concept of pain through life experiences, therefore partially accounting for its variability.2,3 Pain affects an individual’s ability to thrive and, consequently, their social and psychological well-being. The IASP has also affirmed that pain cannot be solely inferred by activation of the sensory nervous system and an inability to express pain does not negate the concept of pain.3 An individual’s account of pain should be validated as per the Declaration of Montreal, which states that access to pain management is a fundamental human right.4

The physiological mechanisms of pain and transmission pathways have been extensively described; however, it is increasingly recognised that there is considerable overlap in the different types of pain mechanisms, both within and between patients.5 Perplexing entities include phantom limb pain, where an amputee continues to experience discomfort in the absence of actual or potential tissue damage, thought to be driven by neuropathic pathways2,6 and chronic pain conditions such as fibromyalgia, wherein pain is thought to occur via nociplastic pathways, likely attributed to altered sensory processing and modulation.7

Given that the biopsychosocial model of pain is the most comprehensive explanation of the aetiology of pain,8 general practice is ideally suited to manage pain and its unique and varied clinical manifestations. Embracing the interdisciplinary and sometimes obscure nature of pain and establishing a wholesome therapeutic relationship with patients is fundamental to relieve suffering and achieve patient-centred outcomes.

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EditorialMusculoskeletal conditionsPain

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