printer-friendly version (PDF) - Reflex Sympathetic Dystrophy ...

COMMENTARY | GIORDANO
Comprehending the complexity of …
suffering involves both scientific and
humanistic inquiry and is fundamental
to the provision of technically right
and morally good care.
what sterile and does not depict the potentiality of effects
elicited by a particular type of pain. However, if framed as
domains within the spectrum of pain, these classifications
impart insight to mechanism(s), manifestation(s), and broader
existential meaning.
Maldynia: The Illness of Pain as Suffering
I PROPOSE THAT MALDYNIA be reconsidered to be the multidimensional
constellation of symptoms and signs that represent the syndrome
of persistent pain as phenomenal illness. Thus, by its nature,
maldynia (irrespective of initiating cause and/or constituent
mechanisms) produces, and results from, functional and perhaps
structurally maladaptive changes in the nervous system that
evoke, and are reciprocally affected by, alterations in cognition,
emotion, and behavior. In this way, maldynia is both the conscious
state of pain and a consciousness of pain as a condition of
the internal domain of the lived body and existential disattunement
of the life world. 3 This definition compels a more thorough
consideration of the philosophical and pragmatic basis of pain
medicine, for if maldynia is the illness of pain experienced as suffering,
then the ethical obligations of the pain practitioner are
soundly-based upon an objective knowledge and subjective affirmation
that a patient’s pain and suffering are genuine. 4
Moskovitz describes CRPS as the quintessential maldynic
syndrome. This is well illustrated by Galer and Covington, who
note how multiple biological and psychosocial factors contribute
to, and are affected by, CRPS. The authors take steps to
reveal CRPS not as an unsolvable mystery or specious myth,
but as a complicated clinical problem that is explicable and
treatable. But complicated problems are rarely resolved through
simple means, and the diagnosis and treatment of CRPS
require an insightful, innovative approach that is wholly focal to
the varying pathologic bases and unique, needs of each patient.
The cornerstone of this approach is accurate diagnosis, (4, 5)
and Sherry addresses the differential diagnosis of persistent
musculoskeletal pain in adolescents as an example of how precise,
timely assessment is essential to establishing and implementing
what should be done to most effectively treat a particular
patient with a specific pain disorder. Diagnosis is built
from generalized and specifically contextual knowledge, and
Getson examines thermography as a novel technology and technique,
that, when utilized within an expanded objective and
subjective diagnostic framework, may afford improved evaluative
acumen, thereby determining the appropriate type and ultimate
trajectory of subsequent care. Manning, Webster, and
Fakata, as well as Prager each discuss this care, and their work
emphasizes the importance and viability of rational pharmacology
and new technologies, in an approach that reflects understanding
of the contributory neuropathic mechanism(s), as well
as the relational importance of how these mechanisms are
expressed in the patient.
I maintain that this latter point is particularly critical to
treatment. While there is considerable similarity in the underlying
neural mechanisms of CRPS, their manifestations can be
widely different, based upon the compound predispositions of
each person. The clinician must take this into account when
considering the prudential question of what should be done to
best meet the medical needs of a given patient at a particular
point in the disease-illness continuum (4, 6, 7). Such “customization”
of care allows for evaluation and therapeutics based
upon multiple levels and domains of evidence and is instrumental
in providing the right treatment(s) for the right reason(s) (8,
9). Instead of being inappropriately wedded to a singularly disease-based,
curative model, this approach embraces a larger,
more integrative paradigm, (10) that I feel acknowledges and
communicates to the patient that while cure may not be possible,
effective, ethical care is both achievable and obligatory.
Toward a Neurophilosophy of Pain
GIVEN THE NOTION THAT:
[1] maldynia induces functional and structural changes in
the neurological axis from periphery to brain;
[2] distinct regions in the brain are responsible for the conditions
and awareness of discriminable consciousness (e.g.,
the cingulate gyrus, parietal, prefrontal, and operculoinsular
cortex); and
[3] maldynia-induced changes in these brain regions are capable
of evoking alteration of the sensed internal state that is consciousness,
it becomes clear that maldynia (i.e., pain as suf-
2 There is considerable discussion in the neural sciences (i.e., neurobiology,
cognitive psychology, [neuro]philosophy) regarding the nature or existence
of the “self.” To gain insight into recent perspectives of some of the leading
scholars in this discourse, see: Blackmore S. Conversations on Consciousness:
What the Best Minds Think About the Brain, Free Will, and What It
Means to Be Human. Cambridge (UK), Oxford University Press, 2005.
3 I base this upon the model of levels of conscious processing, first detailed
in psychological terms by Ray Jackendoff (Consciousness and the Computational
Mind, Cambridge, MIT Press, 1990); and expanded by Jesse Prinz
(Furnishing the Mind: Concepts and Their Perceptual Basis, Cambridge, MIT
Press, 2004) to include neural substrates. I feel that this model fits well
within a complexity-based paradigm, and bridges neural mechanisms with
phenomenal experience(s). For further discussion of the phenomenological
approach to illness and pain, see: Gadamer HG. The Enigma of Health. Stanford,
Stanford University Press, 1996; Husserl E. Ideas: General Introduction
to a Pure Phenomenology. NY, Collier, 1962; Svenaeus F. The Hermeneutics of
Medicine and the Phenomenology of Health. Dordrecht, Kluwer, 2000; and
Zaner R. The Problem of Embodiment: Some Contributions to a Phenomenology
of the Body. The Hague, Nijhoff, 1964.
4 Suffering is an extensive topic of study. One of the leading scholars in this
field is Eric Cassell. For an overview of his work specific to a discussion of
suffering and the ethical obligations in caring for those who suffer, see: Cassell
E. The Healer’s Art, NY, Lippincott, 1976, and, Cassell E. The Nature of
Suffering, Oxford, Oxford University Press, 1991.
10 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6