Re the fibromyalgia thread and questions about its “realness” I wondered if there are any medical procedures like brain scans or other physiological scans where you could actually ‘see’ pain occurring in the human body via nerve signals firing or other indicators as the pain manifested itself and verify the pain was actually a physical manifestation.
Does this technology exist?
I wish there was. I don’t know about fibromyalgia, but it would revolutionize neurosurgery to be able to scan someone and be able to say “your back pain is being caused by this specific nerve” and then do whatever procedure is appropriate. A lot of pain control is based on traditional patterns and interpreting images such as MRI, but there’s often some “cross-wiring” of nerves - is the leg pain coming from the L4 or the L5 nerve? Could be either, so the doctor orders an MRI, and with luck, there will be a nice obvious disk herniation, etc.
Usually, they get it right, but occasionally, it turns out to be the non-obvious nerve root causing the problems. None of it is infallible, though. I recently had a cervical microdiskectomy, and afterward, my surgeon said there were some bone spurs that were not apparent on the MRI. Fortunately, he was able to remove them along with the disk fragment.
I have asked several doctors this same question. I have a child with Cerebral Palsy. He cannot speak or communicate in any way and when he seems to be in pain, there is no way to identify the source. There is no way that I have been able to learn about.
This would also cause much distress for the many people who are happily defrauding various establishments thanks to their “back pain.”
My sympathies to anyone with genuine back pain of any sort. I’ve had a taste of it, and don’t care to return for seconds :eek:
Several research articles on FM have the researchers using spinal blocks or double-blind placebo/analgesics to show that the pain is real and located where the patient identifies it. There does not seem to be much doubt to me that in formally diagnosed (as opposed to self-diagnosed) fibromyalgia, the pain is real and originates either in the skeletal muscles or surrounding nerves.
As for diagnostic approaches, I have seen some attempts to use fMRI to identify neural networks in the brain involved in intractable pain. The one I saw used fMRI to identify the brain region, then used transcranial magnetic stimulation to target the identified region, hopefully triggering neural plasticity and disrupting feedback networks. But it was very experimental, and transcranial magnetic stimulation is not hugely focusable (and fMRI isn’t very detailed, either). But new techniques will improve on both these things.
What about thermal imaging?
That’s something I’ve been wondering about. I assume if it was as easy as taking a snapshot it would already be widely used.
(emphasis added)
Not really what you were getting at, but there are some time honoured (but not really proven) “indicators” that are used to determine if a person who’s complaining of severe pain may be malingering - you simply check to see whether there are the expected associated findings.
So, for example, a person with pain that is truly excruciating should also demonstrate things like rapid heart rate (tachycardia), high blood pressure (hypertension), and sweating (diaphoresis). You’d be surprised at how many people can say, “Doc, on a scale out of 10, it’s an 11!”, who don’t show a hint of any such markers of the expected associated physical stress.
We’re now taught in nursing school that vital signs are not a reliable indicator of pain. This study was passed out in class to reinforce the lesson:
No Correlation Between Vital Signs and Self-Reported Pain Scores
Diane M. Birnbaumer, MD, FACEP reviewing Marco CA et al. Acad Emerg Med 2006 Sep.
Now, that’s not to say that people are always truthful or realistic, or that behavior isn’t useful to include in an assessment. When I say, “10 is the worst pain you can possibly imagine,” and you say 11 while calmly swinging your legs off the side of the bed while munching potato chips and playing Candy Crush, I’m going to think that my imagination is a bit bigger than yours and this isn’t really the worst pain ever. But I’m not asking for pain on a scale to see who’s worthy of intervention. A lot of people seem to think that if they tell me their pain is a 3, I won’t do anything about it, while if they say 11, they’ll get “the good drugs”. I’m quite often explaining that what I want to do is to see what makes it better or worse, and maybe get an idea of how much. If your 11 goes down to an 8 with some ibuprofen, that’s tells me we’re on the right track. If your roommate starts at a 3 and then after she walks it’s an 8, that tells me something about the origin of her pain (and to consider suggesting some medication before we have to walk again). Doesn’t matter if those two 8s are the same degree of pain across patients.
But, especially when dealing with chronic pain, I don’t have to see an elevated blood pressure or pulse to believe that there’s pain.
This is the point exactly. It wouldn’t help to simply identify whether or not pain receptors are firing. The degree of suffering secondary to pain receptors firing is a much more complex thing.
It is well shown that identical stimuli have disparate reactions in different individuals or different situations for the same individual. You might start hollering with pain if I pull off a fingernail while you are watching TV; if you lose the same nail during a bear attack you might not even notice it.
For this reason, as KG notes, patients are typically asked to rate their pain against their own scale. This helps us decide if pain is improving or worsening, but is almost useless as an absolute measurement. Many’s the time a diaphoretic, tachycardic stoic patient tells me their kidney stone is a 7 while a wimp describes their owie finger burn as a 10, where “10” is the worst pain they could imagine. (How many times my staff has wondered if their scale would changed should the family jewels be squeezed with a visegrip.) When you get to 11s and 12s, you know you are dealing with either a total weenie or possibly a drug abuser. The range of mental response to the same mechanical stimulus is remarkable.
Vital signs are definitely not a reliable indicator of self-reported pain scores. Personality is the best indicator of how you are going to self-report a number on a pain scale.
VS are not an absolute indicator of pain, period, although they are helpful. But it’s really not just vital signs. It’s an overall gestalt of the patient by a competent and experienced examiner who’s seen thousands of similar situations and has a good feel for the average response.
As a rule of thumb, it’s best to just treat pain generously, at least in an ED setting. What’s the big deal? Chronic pain is a whole other issue, but for acute pain I’m very happy to load you up with whatever you want even if you are a weenie. I don’t think my job as a physician is to be the Chief Arbiter of how you should react to minor stimuli, and most patients really appreciate their pain being taken seriously and treated preemptively and aggressively.
(bolding mine)
Absolutely. I mostly see it in behaviors and movement. Others may see it elsewhere, like in posture and facial expressions. But it’s hardly ever one or two convenient clicky boxes on a checklist. It’s, as you say, a gestalt.
Chronic pain is usually when I get them. And that’s a whole stinky smelly kettle of fish. I honestly don’t mind the addicts and dealers so much…it’s those who are in pain and always in pain and may always be in pain that I feel made helpless by. Those are the people who would really welcome an imaging or diagnostic test, if only to reassure themselves that they’re not malingering weenies - a secret fear many chronic pain patients have.
Two pain related stories about my recent bout with pancreatitis and pain.
I’m in the urgent care while the doctors tried to figure out the source of my pain. I HURT. A lot. Dr. Takes my blood pressure
Dr.: What do you do about your hypertension?
Me : I don’t have hypertension
Dr.: Your blood pressure is 178/98
Me: I’m in amazing amount of pain how bout we fix that and check it again
A while later they figure it out, give me morphine and pain leaves. Doc retakes BP
Dr.: 116/62
Me: told you 
Before the surgery surgeon comes in to discuss the surgery. He tells me I will have pain in my shoulder after the laparoscopic surgery.
OK whatever.
Sure enough after the surgery my right shoulder blade hurts like a mother. WTF?
At my follow up visit I ask the surgeon about the source of the pain. He explained it like this: They inflate the abdomen with CO2 to have room to work. The CO2 presses on the nerves in diaphragm, the pain from that pressure shows in the shoulder.
So where the pain is is not always the source.
Then there’s also how tolerant people are to the pain.
I’ve had back pain bad enough to warrant a doctors visit after it doesn’t go away for two weeks or so and when they ask me for a number I’ll say something like “Well, I guess it’s a 3, but I should mention that I’ve had debilitating migraines all my life” and I now get to add to that “Well, I guess it’s a 3, but I should add that I’ve had debilitating migraines and 2 kidney stones so my pain scale is a bit skewed I think”
IOW, if this was my first brush with pain, I’d probably pick a higher number, but I’ve been in a lot more pain then this plenty of times.
I hate that stupid scale. First off, I know even though I said all that all the doctor saw was “3”, trust me, if I’m in enough pain to drag my ass to your office and pay $200, something’s wrong.
Second, the last time I said “3” she said “Oh, they changed it, you can only use even numbers now” Are you kidding, no one liked the old scale and you just made it harder.
The only time I ever liked that scale is when I had my first kidney stone and they asked me for a number and showed me the scale. I was in waaay too much pain to think and just said “8, I’m an 8, I feel exactly like that guy looks”. At that point I still didn’t know what was wrong.
Having said all that, I do get it, I understand that they do need a way to standardize/quantitative the amount of pain you’re in and this is probably the best way for right now.
Only even numbers? They were messing with you or just plain obstinate. I think that top scale with the faces is more for kids or people who, for whatever reason, can’t articulate “it was a three this morning, but now it’s a six and feels like I’m being burned and stabbed.” I’ve got a plastic ruler at my office with those faces in a range of kid-friendly colors on one side and the 1-10 scale with notations like “no pain at all”, “awful” and “unbearable” on the other.
Faults and all, the VAS is probably going to be with us for a long time. One thing it’s very good for is tracking an individual’s progress. As far as an absolute scale, other then the “a ten is the worst pain imaginable” notion, it’s hard to calibrate people without actually injuring them.
ROFLMAO - amazing, isn’t it? Feels about like someone is trying to peel off a shoulder blade with a screwdriver.
I described my current gallbladder issues as the pain being ‘pinchy’ - you know how kids will do this little game where they do light pinches? The over all pain is rather like that, with a few instances of it feeling like someone is using a set of calipers so they sort of meet in the middle of my upper right quadrant, and one spectacular instance where I leaned back to stretch and it felt like someone stabbed me in pretty much that exact place. So my pain is in general extremely minor, more just a teaser. I know from the overall symptoms it will probably be the gallbladder [4 of 5 'F’s - female, fat, flatulent, fifties but no longer fecund] and I get the gastric emptying if I eat too much fat/oil in a single meal, and that quadrant tingle/pain.
And I am a chronic pain sufferer as well - migraines, assorted prior injuries, many involved joints with impingements and various levels of arthritis. I have an insanely high chronic pain tolerance. My 3 is most peoples 8 probably.
The best pain scale yet created: Hyperbole and a Half: Boyfriend Doesn't Have Ebola. Probably.
Bwhahahaha!
small voice because I rarely venture into this Forum
I think irritability can be an indicator, too.
