Talk:Pain/Archive 4

Archive 1

Archive 2

Archive 3

Archive 4

Archive 5

Removed intensity, location and duration from intro'

I removed "Typically, pain is characterized by its intensity, location and duration" because it is incomplete and, without context, its pretty meaningless. I shall soon add a section on description or classification of pain which will cover these and more. Without this sentence, I think the intro' is much friendlier. Anthony (talk) 22:43, 28 December 2009 (UTC)

Warehousing

I removed the section Mechanism. The first two paragraphs were redundant. Bits of this one belong in a section on the neural mechanisms (coming) and others in a discussion of autonomic response (coming) Anthony (talk) 10:05, 3 January 2010 (UTC)

Nociception is the unconscious afferent activity produced in the peripheral and central nervous system by stimuli that have the potential to damage tissue. It should not be confused with pain, which is a conscious experience. Nociception or noxious stimuli usually cause pain, but not always, and sometimes pain occurs without them. It is initiated by nociceptors that can detect mechanical, thermal or chemical changes above a certain threshold. All nociceptors are free nerve endings of slow-conducting, thinly myelinated A delta fibers or even slower-conducting, unmyelinated C fibers, respectively responsible for fast, localized, sharp pain and slow, poorly-localized, dull pain. Once stimulated, they transmit signals that travel to the spinal cord and up to and within the brain. Nociception, even in the absence of pain, may trigger withdrawal reflexes and a variety of autonomic responses such as pallor, diaphoresis, bradycardia, hypotension, lightheadedness, nausea and fainting. The brain contains no nociceptors, and hence cannot sense pain inside itself.

This one is a bit chaotic and belongs in a discussion of threshold and tolerance (coming)

Pain may be experienced differently depending on genotype. For example, individuals with red hair may be more susceptible to pain caused by heat, but redheads with a non-functional melanocortin 1 receptor (MC1R) gene are less sensitive to pain from electric shock. Gene Nav1.7 has been identified as a major factor in the development of the pain-perception systems within the body. A rare genetic mutation in this area causes non-functional development of certain sodium channels in the nervous system, which prevents the brain from receiving messages of physical damage, resulting in congenital insensitivity to pain. The same gene also appears to mediate a form of pain hypersensitivity, while other mutations may be the root of paroxysmal extreme pain disorder.

Pain versus suffering

An anon, 174.1.116.207, has been removing without discussion all references to "suffering" from animal related articles. It seems to me that this issue needs a wider discussion, which is why I have brought the matter here. --Epipelagic (talk) 04:15, 19 November 2009 (UTC)

It doesn't need discussion, it needs a block. I've filed a report at WP:AIV. Looie496 (talk) 04:29, 19 November 2009 (UTC)

Our friend is back, this time as IP 70.70.188.14. Both IPs operate from Shaw Communications, Canada. I still think the issue of pain verses suffering needs clarification. --Epipelagic (talk) 06:07, 18 February 2010 (UTC)

What clarification, Epipelagic? --Robert Daoust (talk) 16:30, 18 February 2010 (UTC)

In the first round of vandalism, the IP was focused on replacing the word "suffering" with "pain" in articles which referred to pain in animals. Though I didn't like the way the IP was going about it, I thought there was a reasonable point there. Looie496 abruptly terminated the matter, so I assumed that, from the vantage point of neuroscience, my uncertainty was naive confusion, not worth wasting time on.

However, the cited sources in those articles had referred to pain and not to suffering. It was a Wikipedia editor who had introduced the word "suffering". Pain and suffering are not quite the same. If someone is in pain, it is usually appropriate to ask "Where does it hurt?" If someone is suffering, like a mother who has lost a son, that question may not be appropriate. It may be possible to clinically observe pain, whereas suffering can be more private, and not something the sufferer thinks of as a physical pain. An analgesic may work for a pain, but not for suffering.

The distinction is relevant in the context of articles on pain in animals. Those articles are describing scientific attempts at establishing whether animals feel pain. Animals can be observed to exhibit physical behaviours, including chemical changes and neurological patterns, similar to those associated with pain in humans. From this, it is reasonable to say the animal is in pain. However, it is not the same thing to then take a running jump, with echoes ringing from Descartes, Ryle, and whole philosophical traditions, and say the animal is also suffering.

This is the talk page for the main article on pain, so I thought maybe there might be some guidance on how the distinction should be handled. --Epipelagic (talk) 20:26, 18 February 2010 (UTC)

This is certainly the right place for dealing with such matters! Your concern is quite appropriate, and it has been discussed here before. As far as I can see, what you are saying above does not bring questions that have not been examined previously, so I will just try to tell you how I see the pain-suffering confusion-clarification.

First, the words pain and suffering are used in various ways, as explained at the article Suffering. This may bring about equivocity or confusion. To be clear, it has been decided with time that the article Pain would be about physical pain, and the article Suffering about pain in the broad sense. Suffering, thus, includes physical suffering, of which physical pain is one kind, and mental suffering, which has an entry that is still a stub.

Now, you are talking about articles on pain in animals. Like in other articles on whatever topics, the meanings of the words pain and suffering may vary, and thus each instance has to be judged individually. For instance, it is quite possible that a cited source uses the word pain but refers actually to suffering. In another instance, a scientific article may be using the word pain to refer to physical pain, and then it would not be appropriate for an editor to let think that it refers to suffering. The last time I checked, there was no problem with the use of the words pain and suffering in articles on pain in animals. But that was some time ago. If you find such problematic uses of words, please change them, or if you are not sure, please let us know. Nota bene: the article Pain in animals, for instance, is about suffering, in general, and about physical pain, in particular. --Robert Daoust (talk) 00:41, 19 February 2010 (UTC)

I removed all mention of suffering from this article during a big rewrite a few months ago, and have not gotten round to replacing it. Sorry. I could use some help. The functional neuroanatomy POV on this is: suffering is activity in part of the anterior cingulate cortex. This region is active during physical pain (possibly during all types of aversive homeostatic emotion) and active during social trauma (rejection, exclusion, empathy). The insula is thought to embody the unpleasant feeling that distinguishes pain from other aversive homeostatic emotions such as nausea and itch. Sense of the intensity and location of pain are represented in the primary and secondary somatosensory cortices. The orbitofrontal cortex, associated among other things with inhibition of emotion, is often active in pain. Suffering, whether from an aversive homeostatic emotion or social trauma/deprivation, also negatively impacts various cognitive faculties that depend on healthy frontal lobe function, such as working memory, control of attention, and impulse inhibition. Anthony (talk) 10:44, 19 February 2010 (UTC)

A quite peculiar, limited, and questionable neuroscientific POV on suffering, methinks, Anthony... --Robert Daoust (talk) 07:22, 20 February 2010 (UTC)

Simple, I know. I was trying to be clear. What have I missed and what do you question? Anthony (talk) 09:14, 20 February 2010 (UTC)

Just a sentence by someone on Facebook today: "...the subjective unpleasantness of pain isn't limited to just the anterior cingulate cortex, and depression and anxiety/fear stems from somewhere else entirely (basal ganglia and amygdala, I believe)..." I question, for instance, Craig's theory of suffering, and I believe that a sufficiently complete overview of the neural bases of suffering is a big task... Your beginning is not to blame, but... --Robert Daoust (talk) 18:11, 20 February 2010 (UTC)

Anthony's summary accords pretty well with my (limited) understanding. Of course all of this stuff is controversial, and it would be inappropriate to explain it without getting that point across. It would be dangerous to conflate depression and anxiety with suffering -- they include suffering as one aspect but they also include other motivational features. Looie496 (talk) 18:19, 20 February 2010 (UTC)

Well that takes my confusion to a different level. Would it be correct to say that the neurology of suffering in humans is at an early stage and is incompletely understood. So it is too early to establish whether, say, fish "suffer". However it may be possible to establish whether fish feel pain. The principal opponent to the notion that fish feel pain (Rose) ultimately argues that we can't say fish feel pain until we can show that they are conscious of the pain. I think that raises the bar too high, since there's a hurdle there with humans too, isn't there? At least humans can self report. I would quite like to have a go at bringing the article pain in fish to GA, but would definitely need help. Would you guys be okay with making it a collaborative effort? --Epipelagic (talk) 19:03, 20 February 2010 (UTC)

That's intriguing, Robert. I wonder what they can have been referring to. Keep me informed if you hear more, I'm doing no reading on this at the moment. Yes, Epipelagic, neurology of suffering in humans is at an early stage and is incompletely understood. Pain science includes suffering (unpleasantness) as a dimension of pain, though you can experience a thing like "pain without suffering" if important parts of the anterior cingulate cortex are surgically removed. This is occasionally done for cases of extreme and incurable pain; usually at end of life. Patients say they feel the pain but it doesn't bother them any more. Antonio Damasio describes a dramatic case towards the back of Descarte's Error.

To suffer from pain, a human must be conscious of pain. In pain the anterior cingulate cortex and the anterior and mid insula are active. It seems that pain-related activity in the anterior insula indicates conscious awareness of pain. If you are completely distracted from the pain, pain-related activity in the anterior insula ceases, as does pain-related activity in the anterior cingulate cortex; and you cease to suffer. When distracted from pain, the pain continues to be represented by activity in the mid-insula, but it is no longer "re-represented" (AD Craig's term) to consciousness in the anterior insula, and so no longer activates the anterior cingulate. So, in humans, consciousness of pain (re-representation of pain in the anterior insula) is necessary for pain to cause suffering (activity in the anterior cingulate). If this "re-representation" in the anterior insula can't happen in a "lower" animal, then their analogue of our anterior cingulate (if they have such a thing) is not activated by pain, so they don't suffer from pain, as we do. Robert is following Craig's neural mapping of consciousness closer than I am, so correct me if I'm wrong Robert. Anthony (talk) 06:33, 21 February 2010 (UTC)

So is it appropriate to try and tighten pain in fish and bring it to GA level, or should the possibility be revisited in ten years time? --Epipelagic (talk) 08:12, 21 February 2010 (UTC)

I'll share my thoughts on Pain in fish if you like, but I can't give it due attention straight away. I would consult that article to find out if fish feel pain and, if so, whether they suffer. So it should explain "feel", "pain" and "suffer" in this context. I would guess that should include input from psychology, neuroscience and philosophy. If Philosophy of mind is active you might invite collaboration from its discussion page. Anthony (talk) 09:37, 21 February 2010 (UTC)

I don't see anything that would prevent bringing Pain in fish to GA level, but it would take a lot of background reading to be able to work on the article at an expert level. The main thing is to realize that the article won't be able to give a definitive answer to the question of whether fish have pain -- the best it will be able to do is to review the literature and explain the views that have been expressed and the reasons for them. Looie496 (talk) 17:13, 21 February 2010 (UTC)

I concur with what Looie and Anthony are saying, and hope it responds to your questions, Epipelagic. --Robert Daoust (talk) 15:40, 22 February 2010 (UTC)

I invited input from Philosophy project a couple of days ago. Anthony (talk) 15:49, 18 March 2010 (UTC)

Anthony's paragraph above that begins with "To suffer from pain, a human must be conscious of pain" seems to imply that there may be unconscious pain or that pain may be without unpleasantness. According to the IASP definition, pain IS always a conscious experience, and pain IS always an unpleasant experience. Asymbolic pain is another phenomenon than normal or usual pain: asymbolic pain is not pain. Without an agreed upon definiton, the term pain becomes equivocal and well focused discussion on pain becomes impossible... But we might question IASP definition, we might choose another definition of pain. Some, not numerous, philosophers, and scientists, are doing this. Personally I believe that pain is a particular sensory phenomenon, not necessarily conscious or unpleasant. Besides, I believe that (at least vertebrate) animals are conscious and able to suffer, with or without pain. --Robert Daoust (talk) 01:54, 19 March 2010 (UTC)

1. "...there may be unconscious pain..." I didn't mean to imply that.
2. "...pain may be without unpleasantness..." Ditto, hence "like" and the scare quotes around "pain without suffering". Whatever cingulotomy patients feel, because it lacks the affective/motivational dimension, it's not pain by IASP definition. We lack a word for that feeling. The phrase "the feeling that distinguishes pain from other homeostatic emotions such as itch, nausea, or hunger" is as close as I can get to it.
3. "...I believe that (at least vertebrate) animals are conscious..." Prove it and I'll nominate you for a Nobel prize! Anthony (talk) 10:55, 20 March 2010 (UTC)

If re-representation of pain does not happen (in a 'lower' animal, like a mouse), the individual does not suffer from pain (feel it as unpleasant): reading this, I feel inclined to read that there is pain but it is not unpleasant. Further down, Craig's theory is mentioned, which says that if there is no re-representation, there is no consciousness, and there being no consciousness, there is no pain either. I remain under the impression, probably wrong, that Anthony means, as I understood above, that there is pain, i.e. there is no re-representation of (a present) pain, but then, in accordance with Craig's theory of consciousness, it is not a conscious pain. I must be confused. As to animal consciousness, the prevalent view currently among bioscientists is that a mouse or a frog are conscious, whilst for Craig they are not. --Robert Daoust (talk) 18:17, 21 March 2010 (UTC)

Thanks for these comments guys. And thanks particularly, Anthony, for your comments on the Pain in fish talk page. The Norwegian Research Council is funding a three-year research project, scheduled to end in December 2011, into whether cod can feel pain. Ii might be useful to wait, and see what that brings up, before trying to get the article to GA. --Epipelagic (talk) 03:15, 17 April 2010 (UTC)

Psychology of pain

Also coming is a section (an article) (a section here, and an article) on the psychology of pain. Anthony (talk) 10:05, 3 January 2010 (UTC)

I have drawn up a skeleton for the article on the psychology of pain. If you have an interest or expertise in this area, please add to or edit it at will. I'd like to see every sentence supported by a review published in an important peer-reviewed lournal, or at least by a recent, university-level textbook. Either source, page numbers should be cited. Anthony (talk) 10:00, 29 January 2010 (UTC)

Does that mean you're basically done with the current article? I haven't been tracking every change here, but if it has reached stability, I would like to do a "peer review" of it, and then I think it would be nice to submit it for GA. Regards, Looie496 (talk) 16:15, 29 January 2010 (UTC)

Not quite. I intend to include a psychology section in this article, as well as something on philosophy, physiology, biochemistry and genetics. Unless you have concerns about veracity, it may be best to leave peer review a few more months. I will distill Psychology of pain into a subsection for here before publishing.. Can I take a rain check on that peer review offer? Anthony (talk) 00:53, 30 January 2010 (UTC)

Name the sensation

Is there a name for the sensation a person has, when some hair or dust etc. penetrates the urethra? It seems like some nociception as different from pain, itching, or nausea as they are from one another, though not excessively severe. It is the sensation produced by suction within the navel up until perhaps the age of twenty, or of handling an aroused genital before one reaches puberty. But I've never seen a word for it. I wonder whether this sensation is one of those associated with kidney stones, or if those produce strictly the abundance of pain in the ordinary sense. Wnt (talk) 07:21, 18 March 2010 (UTC)

I don't know that feeling. Anthony (talk) 10:05, 18 March 2010 (UTC)

Merge proposal

Pain in babies appears to have been imported from Citizendium, which may introduce copyright issues. Perhaps even more importantly, it is an under-cited, over-simplified essay. I think the best thing to do with it is to merge the verifiable parts into this article. In particular, I think that the diagnosis and management of pain in pediatric patients is highly suitable subject, and that the historical changes in professional views of physical pain in neonates is valuable here. WhatamIdoing (talk) 21:46, 16 April 2010 (UTC)

I like the article. It could be more encyclopedic in tone but it covers the issue well and the medical aspects are mostly supported by reliable sources. I've asked about copyright at Media copyright questions. This article, Pain needs a section on pediatric pain, and a digest of Pain in babies could be imported here for that. But I incline toward leaving Pain in babies as an article too, until someone composes Pediatric pain. Anthony (talk) 03:20, 17 April 2010 (UTC) Media copyright questions referred me on, and I found this at Citizendium "Citizendium has differing content policies than Wikipedia, but, after their recent switch to Creative Commons licensing, all Citizendium articles may be copied or merged to Wikipedia, if they fit Wikipedia's policies." They require attribution, which has been done under References. Anthony (talk) 03:45, 17 April 2010 (UTC)

• Oppose merge - Pain in babies is a specialized topic that could be developed based on reliable sources beyond the level of detail that would be appropriate for this article. I recommend a one paragraph summary here with a {{Main}} link to the more specific article. Regarding the content from Citizendium, that is not a problem, as noted by Anthony. --Jack-A-Roe (talk) 05:12, 17 April 2010 (UTC)
• I would like to see the article kept separate, too. This subtopic is hearty with ample references available and is definitely a source of interest to the general reader. The recent clean up is a good start towards a comprehensive well balanced article. FloNight♥♥♥♥ 10:14, 17 April 2010 (UTC)

Pain in Medpedia

It would be useful for our article here to have a look at Medpedia about pain. --Robert Daoust (talk) 21:50, 3 May 2010 (UTC)

More on the introductory sentence

The introductory sentence provides a poor definition, in that it merely cites examples, and sounds distinctly unscientific. Why couldn't the definition be something along the lines of Pain is an unpleasant physical feeling associated with minor to severe physiological damage endured by an organism? Certainly it could be reworded or redefined--I'm not claiming that my definition is the best. But the current one strikes me as inadequate. --N-k (talk) 21:59, 5 May 2010 (UTC)

The examples seem simplistic, I know, and the IASP definition seems a bit tortured, but there is some thought behind it above at Introductory definition and Introduction II. Have a look at those discussions (they're not very long by Wikipedia standards), and any improvement you can suggest would be carefully considered. Re examples (from above):

Examples of pain-evoking stimuli are as necessary to the definition of pain as examples of red- and yellow-evoking stimuli are to the definition of red or yellow. It is how qualia are defined.

Anthony (talk) 23:04, 5 May 2010 (UTC)

I lean toward N-k opinion, on this thorny matter. Examples are good, but they should not take the place of a definition. It seems that pain can be 'described', while yellow cannot. I suggested before: "...a typical sensory experience that may be described as the unpleasant awareness of a noxious stimulus or a bodily harm." I am not claiming it is the best definition either... --Robert Daoust (talk) 00:16, 6 May 2010 (UTC)

Indeed. While pain may be a subjective experience, it has a common sense, easy to understand cause. The examples could come after the definition--I'm not saying we should necessarily eliminate them. --N-k (talk) 12:55, 6 May 2010 (UTC)

I am loathe to displace the IASP definition, it's the one all the reliable sources use. How about this:

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is the feeling common to such experiences as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone".

Anthony (talk) 16:28, 6 May 2010 (UTC)

That looks good to me. --N-k (talk) 16:45, 6 May 2010 (UTC)

Done. Anthony (talk) 21:52, 6 May 2010 (UTC)

Temporary free access to IASP journal Pain

I just saw this For a limited time, this title is open to the public in a free trial period.. Anthony (talk) 02:13, 7 May 2010 (UTC)

Time Magazine

About this link: Did you read the Time Magazine "article"? I thought it very much lay-oriented (not a proper medical source), and that it illustrated the primary problem with relying exclusively on self-reports: some patients, whether because they're macho or because they're drug addicts or because of some other reason, sometimes tell lies about their pain. I don't think that it's a good source for building article content, but I think that it is an accessible, simple source for further information for interested readers. WhatamIdoing (talk) 01:59, 10 May 2010 (UTC)

I read the article. The ER doctor explained you can't believe patient report of pain intensity and must rely on your own judgment when prescribing drugs. This is arrogant nonsense, the kind of attitude that has left millions of patients suffering every year because doctor knows best. Individual pain threshold and tolerance, and ability or willingness to suppress pain expression all vary widely. Health care providers routinely underestimate patients' pain intensity. Though there are occasional drug-seeking addicts and people too stoic for their own good, the vast majority of patients rate their pain honestly and consistently. Because of this, and until there is an objective measure of pain intensity, best practice is to believe the patient. This doctor is saying nothing new, in fact he is dangerously out of date.

Rupp, T; Delaney, KA (2004). "Inadequate analgesia in emergency medicine" Annals of emergency medicine 43 (4): 504–6. Anthony (talk) 07:43, 10 May 2010 (UTC)

Yes, chronic pain is often badly treated. This fact has nothing to do with the fact that some people misreport their pain. There's one opiate addict for every 20 people with significant chronic pain in the US (and the ratio is much higher for young adults). We should not pretend that the 5% doesn't exist just because the 95% also exists. One of the problems with defining pain 100% by self-report means that it is—by definition—impossible for people with certain kinds of brain damage to have pain. Blind acceptance of patient report means that a person who has suffered for years with an obvious organic disease can have his or her debilitating pain problems miraculously "solved" overnight by having a stroke or a lobotomy. But surely you wouldn't look at a mentally incompetent patient, who is guarding an obviously damaged limb, and say that because the patient can't connect the unpleasant sensation with the concept of pain, that the patient is incapable of benefiting from pain management? WhatamIdoing (talk) 03:05, 23 May 2010 (UTC)

You are touching on important issues, Whatamidoing. I'm sorry if I sounded dismissive. Most of what you raise is covered, to some degree, in the article but needs to be expressed more clearly. Please make all changes you think are appropriate. I believe the prescription dilemma has a better fit in pain management, with, maybe, a short summary here; and probably, ultimately, deserves an article of its own. If you're interested, right now, while Pain is free online, would be an ideal time to attack that worthy project. Anthony (talk) 05:09, 23 May 2010 (UTC)

Edit by Jmh649

Thanks for the excellent contribtion. I have made a couple of minor changes. I changed a section heading from "Diagnostics approach" back to "In health care" because its meaning is clearer. I changed "Management" back to "Treatment and management" because the section discusses both. Reshuffled a few sections for logical flow. Anthony (talk) 09:36, 19 May 2010 (UTC)

This page should be organized as per the condition section of WP:MEDMOS. Treatment and management are synonymous and therefore only one is needed. To get this to article to GA compliance with this guidelines is useful. Cheers Doc James (talk · contribs · email) 15:13, 19 May 2010 (UTC)

Cool. Thanks again for your attention. More suggestions would be very welcome. Anthony (talk) 00:57, 20 May 2010 (UTC)

I do not understand what "in health care" means. This section is about how pain is diagnosed ( ie. based on verbal severity ). How one diagnosis pain in those who are none verbal ( physiological parameters). I agree that the bit about the use of pain characteristic to make a diagnosis does not fit as well but still think "diagnosis" is a better heading.Doc James (talk · contribs · email) 18:35, 26 May 2010 (UTC)

I concur. Moving "As an aid to diagnosis" was good, and "Diagnosis" is better than "Diagnostics approach." Thanks. Anthony (talk) 19:12, 26 May 2010 (UTC)

Under the section: In animals

"Opioids and opiate receptors occur naturally in crustaceans and, although at present no certain conclusion can be drawn, 83 their presence indicates that lobsters may be able to experience pain" 83 84 Specifically: "their presence indicates that lobsters may be able to experience pain"

Reference 83 is for: Sentience and pain in invertebrates: Report to Norwegian Scientific Committee for Food Safety

A copy in engligh can be reviewed here: http://www.vkm.no/dav/d1bfe88cf5.pdf

The first part of the statement in question, "Opioids and opiate receptors occur naturally in crustaceans and, although at present no certain conclusion can be drawn..." is supported from page 5 paragraph 1; "The function of opioids in invertebrates is not known, but the production of such substances reduces pain in vertebrates."

However, the full report does not support the assertion that lobsters feel pain. The findings published in that report opposes that assumtion outright. From page 5 paragraph 4; "Lobsters and crabs have some capacity of learning, but it is unlikely that they can feel pain."

The pdf for reference 84 redirects to the home page of, onekind.org, and so this may be a dead link.

Request rewrite, or updated reference for the claim. 99.30.54.30 (talk) 20:41, 22 May 2010 (UTC)

I haven't read the source but, if you're confident, go ahead. Anthony (talk) 23:07, 22 May 2010 (UTC)

Epidemiology

We need a section discussing the prevalence of pain. This paper for example says 30% of people who present to there FP have pain.[1]Doc James (talk · contribs · email) 01:47, 27 May 2010 (UTC)

I favor an epidemiology section. There is some good work on it. I'll get round to it in a few days if no one else has. Anthony (talk) 14:29, 27 May 2010 (UTC)

In other animals/in animals

I'm okay with either. But this article is all about humans... of necessity. Presently, almost nothing is known about whether and, if so, how other animals experience pain. Anthony (talk) 14:19, 27 May 2010 (UTC)

We are all animals thus it should be in other animals to make sure we conform with mainstream scientific ideas. Without the other it seems to imply that we humans are somehow different. This is the wording recommended by WP:MEDMOS. Also virtually all the rest of the article applies to human animals. Doc James (talk · contribs · email) 18:44, 27 May 2010 (UTC)

Organization

This article should follow WP:MEDMOS. Doc James (talk · contribs · email) 17:58, 7 June 2010 (UTC)

Yes. That is why I suggest to organize sections in a manner that is appropriate to the topic and to the development level of the article, in conformity with WP:MEDMOS: "Some sections will necessarily be absent or may be better merged, especially if the article is not (yet) fully comprehensive." In the current state of the article, 'odd' sections are a factor of disorganization, and in the recent weeks I brought them under larger sections for the sake of a more (esthetically and logically) balanced organization. Imagine that the present article is published: I would prefer seeing cognition and epidemiology under diagnosis (retitled "Diagnosis, signs and symptoms, epidemiology") than alone by themselves... --Robert Daoust (talk) 19:12, 7 June 2010 (UTC)

I disagree with this organization. If you at other articles such as strep throat, ect. you will notice them organized how it was before. Doc James (talk · contribs · email) 22:02, 7 June 2010 (UTC)

Sorry, I am not sure of what you mean with articles such as Strep throat organized how it was before. Perhaps you mean Strep throat is organized as Pain was organized before my edits. Well, Strep throat's present organization looks fine to me, but it is clear that pain could not be organized like that since it is not a simple disease, but a complex everyday experience. In any case, you may organize this article as you wish, as far as I am concerned, because you are doing a very good job, but please try to minimize oddities. Perhaps all odd sections could be grouped together: cf. "The given order of sections is also encouraged but may be varied". --Robert Daoust (talk) 00:01, 8 June 2010 (UTC)

In Our Time

The BBC programme In Our Time presented by Melvyn Bragg has an episode which may be about this subject (if not moving this note to the appropriate talk page earns cookies). You can add it to "External links" by pasting * {{In Our Time|Pain|p00545m1}}. Rich Farmbrough, 03:18, 16 September 2010 (UTC).

Wikipedia:Invitation to edit

I'm working on a project aimed at streamlining the transition from reader to editor. Would anybody mind if I trialled it on Pain? Anthony (talk) 11:38, 5 October 2010 (UTC)

That seems a good initiative. I cannot see why one would mind, as long as the trial does not harm the article in any way. --Robert Daoust (talk) 13:53, 5 October 2010 (UTC)

Thanks Robert. Here goes! Anthony (talk) 10:21, 6 October 2010 (UTC)

Sorry about that. Can you describe for me what was happening to the table of contents please Robert? Anthony (talk) 19:01, 6 October 2010 (UTC)

Ahh. I see. It is listing the sections of the tutorial in the article table of contents. I'll see what I can do. Anthony (talk) 19:08, 6 October 2010 (UTC)

Sorry, I've removed the template from the page. It was the very first thing that I did when I landed here (I still haven't read the article). There is a very clear consensus that this style of template does not belong in the mainspace. Feel free to add the templates to talk pages, but all uses within the mainspace should be removed. To me, this isn't an issue even worth discussing, so I doubt that I'll check back here on the talk page. I'm not planning on edit warring over this, but I'll look at the template's usage every few days and go around and remove all mainspace uses. I support the project, and the template itself is generally fine, but the effort is slightly misguided is all. I hope that you don't get discouraged, but I feel that I must stick to my guns on this issue (there's certainly nothing personal to this). I regularly remove "maintenance templates" as well, when their not blatantly needed, which I mention in order to make clear that it's not just thi particular template that is problematic. Regards,
— V = IR (Talk • Contribs) 21:47, 4 November 2010 (UTC)

Can you provide a link to that "very clear consensus"? WhatamIdoing (talk) 22:34, 4 November 2010 (UTC)

Personally I find the threat to check transclusions and remove uses "every few days" combined with the unwillingness to discuss the issue, quite disturbing and verging on disruptive. — Martin (MSGJ · talk) 14:06, 5 November 2010 (UTC)

Bundling citations

Mainly in order to avoid a long row of footnote markers in this paragraph:

Inadequate treatment of pain is widespread throughout surgical wards, intensive care units, accident and emergency departments, in general practice, in the management of all forms of chronic pain including cancer pain, and in end of life care.^{[53][54][55][56][57][58][59][60]} This neglect is extended to all ages, from neonates to the frail elderly.^[61][62][63] African and Hispanic Americans are more likely to suffer needlessly in the hands of a physician than whites;^[64][65] and women's pain is more likely to be undertreated than men's.^[66]

I have bundled most multiple citations. I have also handwritten the citations, as the citation templates were adding 50–100% to the page opening time. To see the difference, clear browser cache each time before clicking 7 September 2010 and 13 October 2010. Anthony (talk) 11:27, 13 October 2010 (UTC)

An even better solution might be to get rid of some of those citations. One or two citations to recent authoritative sources ought to be sufficient to establish any given point. Looie496 (talk) 16:14, 13 October 2010 (UTC)

Hi Looie. I removed 2 cites from the above paragraph which were both primary studies and redundant. The rest are textbook chapters or reviews, each addressing a different population. I know it looks sus, but this is neither synthesis, since it reports only the conclusions of authoritative secondary sources, nor duplication. Anthony (talk) 16:45, 13 October 2010 (UTC)

Theory

This is sort of the same as cause / pathophysiology and IMO should be higher up in the article per WP:MEDMOS Doc James (talk · contribs · email) 18:10, 7 November 2010 (UTC)

I moved it down the page out of consideration to the average reader, who will be much more interested in diagnosis and management, and the difficult theory section might act as a barrier to them reaching those more relevant sections. Other than the present configuration conforming better to MEDMOS, is there an actual advantage to the reader in having it where it is? Anthony (talk) 19:32, 7 November 2010 (UTC)

Picture

Aches and pains

I was a bit amused to see the picture in the infobox. My first impression on seeing a soccer player lying on the ground holding his ankle is that he's probably faking it. Looie496 (talk) 00:39, 24 October 2010 (UTC)

To me, who am not very visual, he might as well be dead or sleeping! A more expressive picture would be welcome. --Robert Daoust (talk) 03:13, 24 October 2010 (UTC)

Yes. He was no doubt sprinting on it 10 seconds after getting the penalty. I put it there just because it's not gory, and doesn't actually hurt to look at. Anthony (talk) 16:44, 24 October 2010 (UTC)

The illustration at right has been added to the lead. Any thoughts? --Anthonyhcole (talk) 08:18, 24 January 2011 (UTC)

Serves no purpose, removed. JFW | T@lk 08:33, 24 January 2011 (UTC)

I was thinking it might adorn Low back pain but they've already got a couple of appropriate medical illustrations. --Anthonyhcole (talk) 13:37, 24 January 2011 (UTC)

"You can edit this article"

I've never seen this on any other article and I'm wondering, is there consensus to maintain it? I've never seen instructions like this in mainspace. --Golbez (talk) 21:16, 3 February 2011 (UTC)

{{Invitation to edit}} is apparently being piloted. It is also up for deletion here. JFW | T@lk 21:43, 3 February 2011 (UTC)

Can pain kill?

I read of an instance once where someone was suffering from pain so intense it killed them. Is that possible (with the pain presumably creating so much noise in the brain to screw up its function)? —Preceding unsigned comment added by 64.231.28.113 (talk) 03:48, 5 December 2010 (UTC)

I heard that years ago, as a kid. But I've done a bit of reading in this area and never seen it in the literature. Thanks for reminding me. Anthony (talk) 08:11, 5 December 2010 (UTC)

I can't find any such instance either...but it does seem possible, at least theoretically. Am I being an idiot in saying this? —Preceding unsigned comment added by 70.26.71.233 (talk) 00:45, 6 December 2010 (UTC)

Not a dumb question. Heart rate and blood pressure are impacted by acute pain, so intense acute pain could trigger a heart attack. But I don't think the pleasure/pain systems are vital, so my guess is the state of those systems isn't going to directly cause death. Anthony (talk) 07:37, 11 December 2010 (UTC)

Pain cannot kill directly, but the acute severe stress on the organism leads to the release of hormones such as catecholamines and cortisol (known as "stress hormones"). Catecholamines are implicated in conditions such as Takotsubo cardiomyopathy, which can cause cardiac arrhythmias and theoretically lead to death. Stress is also known to be a precipitant for arrhythmias in people with long QT syndrome (LQTS2 in particular). Most of these reports are anecdotal, and I would not necessarily include this concept in the article without a very tight secondary source. JFW | T@lk 10:46, 12 December 2010 (UTC)

Thank you for those links, JFW. That was very informative. So, people do die of a broken heart. You're not across the biochemistry of pain by any chance, are you? :) Anthony (talk) 12:42, 17 December 2010 (UTC)

Ah, no, sorry. JFW | T@lk 21:01, 8 January 2011 (UTC)

I hate having to actually say this, but non- or poorly-managed pain is a frequent reason that people self-medicate with alcohol and/or narcotics (both pharmaceutical and street). It'd be pretty hard to argue that doesn't kill. LeadSongDog come howl! 17:23, 17 January 2011 (UTC)

And then there's suicide. --Anthonyhcole (talk) 20:02, 11 February 2011 (UTC)

Insensitivity to pain

Excellent section, especially with recent additions by jfdwolff. However, the various congenital conditions are confusing, they are not enough clearly differentiated or categorized, in my opinion. --Robert Daoust (talk) 12:17, 4 February 2011 (UTC)

I know nothing about this topic but will start reading in a week or so, if no one's addressed this. --Anthonyhcole (talk) 14:53, 4 February 2011 (UTC)

It needs more work, and I am prepared to help out here. Could you tell me exactly what you find confusing?

Insensitivty to pain is either acquired (through nerve damage) or inborn/congenital. Acquired insensitivity is a major problem in people with diabetes, who develop neuropathic foot ulcers partially because they do not notice pain e.g. from stepping on a pushpin. The inborn syndromes of insensitivity to pain are much rarer. They occur together with autonomic neuropathy in a cluster of conditions known as HSAN (hereditary sensory and autonomic neuropathy). Finally, exceedingly rare conditions have a lack of pain sensation without any other neurological problems; in this group of people, sodium channel mutations have been described.

Interestingly, different mutations in the same channel have been associated with erythromelalgia, a very painful skin condition. Clearly this sodium channel is a major player in sensitivity to pain. JFW | T@lk 19:41, 5 February 2011 (UTC)

I find confusing what is said about congenital insensitivity to pain (CIP), because there are several kinds of it, and they are not clearly differentiated or categorized. Reading the section, I cannot tell how many kinds there are. If I look elsewhere for more info, I am still more confused. The article Congenital insensitivity to pain seems to describe only one kind of CIP: for clarity sake I am going to call it "CIP per se". Hereditary_sensory_and_autonomic_neuropathy seems to group 5 kinds, but not CIP per se. Which of those 5 types include CIP? Which of those 5 include insensitivity to pain but not CIP? Which of those 5 types (if any) does not include insensitivity to pain at all? Finally, if "A very rare syndrome with isolated congenital insensitivity to pain has been linked with mutations in the SCN9A gene", then does that kind of CIP belong to CIP per se, or to HSAN, or is it a kind of CIP by itself? --Robert Daoust (talk) 00:11, 7 February 2011 (UTC)

Looking at a recent review (doi:10.1007/s10286-009-0024-3), CIP is an umbrella term of people who do not feel pain since infancy. Usually this is in the context of one of the five forms of HSAN, some of which have "insensitivity to pain" in their name but others do not. Riley-Day syndrome/familial dysautonomia (HSAN 3) also features insensitivity to pain despite the name not containing any mention of pain! The CIP that occurs in SCN9A mutations seems to be independent of this. JFW | T@lk 15:36, 7 February 2011 (UTC)

The lead of the CIP article says that HSAN are separate, unrelated disorders. It sounds like that is wrong, and may be the source of the confusion. WhatamIdoing (talk) 17:05, 7 February 2011 (UTC)

Firstly, the entire November 2010 edition of the Journal of Clinical Investigation is stuffed with review articles about the biology of pain. Very technical, but great reference material!

Secondly, I have been looking for more sources, and doi:10.1016/S0304-3959(02)00482-7 (PMID 12583863, 2003) seems to be the best there is. It seems that congenital insensitivity to pain is to be divided into those with a detectable polyneuropathy and those without. In the latter, "indifference to pain" seems to be the better term. In the former, there are usually other neurological abnormalities and the diagnosis ends up being one of the five types of HSAN.

What I don't know yet is whether SCN9A mutations cause indifference or insensitivity to pain, and whether there is clinically detectable neuropathy. JFW | T@lk 20:26, 7 February 2011 (UTC)

The new section looks fine. Kinds of CIP are more clearly presented. However, the confusion has now been somewhat displaced toward the kinds of non-sensitivity to pain. It is tricky to distinguish between asymbolia (pain is felt, but without unpleasantness), indifference (pain is felt and is unpleasant, but without aversion -- or is it that aversion is felt but there is no behavioral avoidance?), and insensitivity (pain is not felt). Decreased sensitivity is also mentioned, and that is a surprise for me: are there cases of congenital insensitivity to pain in which there is sensitivity, although 'decreased'? Would such a decreased sensitivity be considered a kind of 'hypoalgesia' (as it is called in IASP pain terminology)? --Robert Daoust (talk) 22:50, 7 February 2011 (UTC)

I know too little about these conditions to say whether the loss of sensation is absolute or relative. I can have another look at the sources if you wish.

The 2003 source is clear that those with pain asymbolia process the painful stimulus identically but this does not translate to behaviour. They have a functionally normal nervous system on clinical examination and neurophysiological investigation. Those with neuropathies have neurophysiological abnormalities that can be detected with a nerve conduction study. JFW | T@lk 23:21, 7 February 2011 (UTC)

Fossil sources

I am a little bit troubled by the fact that this article frequently seems to be relying on sources from the 1950s and 1960s. Does this indicate that no more recent sources are available? JFW | T@lk 21:13, 7 February 2011 (UTC)

There are four sources from the 50's and 60's.

• Beecher, HK (1959). Measurement of subjective responses. New York: Oxford University Press. cited in Melzack, R; Wall, PD (1996). The challenge of pain (2 ed.). London: Penguin. p. 7. ISBN 978-0-14-025670-3.

• Melzack, R; Wall. PD (November 1965). "Pain mechanisms: a new theory". Science 150 (699): 971–979. doi:10.1126/science.150.3699.971 PMID 5320816.

• Melzack, R; Casey, KL (1968). "Sensory, motivational and central control determinants of chronic pain: A new conceptual model". In Kenshalo, DR. The Skin Senses. Springfield, Illinois: Thomas. p. 432.

• McCaffery M. (1968). Nursing practice theories related to cognition, bodily pain, and man-environment interactions. LosAngeles: UCLA Students Store.

Beecher's (1959) work on episodic endogenous analgesia on the battlefield was seminal, and an impetus for Melzack and Wall's gate control theory. Our article refers to Melzack and Wall (1996), which cites it.

Melzack and Wall's (1965) gate control theory is the most significant piece of theory in pain science since Descartes, and our reference to it is historical. Our section on the gate control theory relies on Melzack and Katz (2003), and Skevington (1995).

Melzack and Casey's (1968) carving of the pain experience into sensory-discriminative, motivational-affective, and cognitive dimensions, is the current model, but the section on this is my summary of that paper. We need a secondary source. Because of its historical impact, though, I believe our article should also cite the original paper.

McCaffery (1968) marks the beginning of the shift towards humility on the part of the medical profession regarding the assessment of patients' pain. It is a pivotal moment in pain medicine so I believe it should be cited here, but needs a secondary source.

--Anthonyhcole (talk) 19:46, 11 February 2011 (UTC)

Cite ref

Wondering why the page is being moved away from the Cite journal format? If it is a speed issue maybe we need to approach Wikipedia and see if they can put more computing power into dealing with this. Doc James (talk · contribs · email) 18:10, 7 November 2010 (UTC)

I hand wrote all the ref's because the page opens 50% faster that way. They present and function exactly as template citations, only faster. To see the difference, clear browser cache each time before clicking 7 September 2010 and 13 October 2010. Anthony (talk) 19:36, 7 November 2010 (UTC)

I think this is not a valid reason to use non-templated references. So what if the page loads a bit faster - use of citation templates is de rigeur even on large heavily-visited topics such as myocardial infarction. Please reconsider your position. I have opened a thread on the the village pump policy page to see what others think.[2] JFW | T@lk 08:53, 12 December 2010 (UTC)

Following on from comments on the Village Pump page, would you care to have a look at WP:PERFORMANCE? JFW | T@lk 10:43, 12 December 2010 (UTC)

Can you please explain to me the down side to the present hand written format? Anthony (talk) 12:34, 12 December 2010 (UTC)

There are several. DOI-based links will be automated. Other contributors adding references will not need to replicate your formatting in fine detail. The DOI/Citation bots will update references automatically... JFW | T@lk 13:21, 12 December 2010 (UTC)

Can you explain the doi business for me? "DOI-based links will be automated." I don't understand what that means. "The DOI/Citation bots will update references automatically" What kind of updating will they do? I thought references were pretty stable.

As for other editors' citations, if the code stays as it is, I'm happy to handwrite their citations if they edit using {{cite}}. Anthony (talk) 15:45, 12 December 2010 (UTC)

Citation bot (talk · contribs) should be a start. JFW | T@lk 16:43, 12 December 2010 (UTC)

The article shouldn't be changed from one style to another (templates to non-templates or vice-versa); our cardinal rule is to preserve the style that is established, rather than unilaterally changing it. Looking at the page history, by 2008 the article seems to have stabilized on a reference style that includes cite templates (e.g. [3]). It seems to me that, after two years like that, it's clear the article does have an established style that uses cite templates. (Figuring out what style is established can be a tricky issue for very short, under-referenced articles, but in this case it seems pretty straightforward.) — Carl (CBM · talk) 22:20, 12 December 2010 (UTC)

Thanks. From my reading of Citation bot (talk · contribs), it appears there is no practical benefit, whatever, to using {{cite}} over handwritten citations, provided I'm happy to update the citations with their doi's and hand write new {{cite}} citations. Am I right? Anthony (talk) 02:12, 13 December 2010 (UTC)

I'm aware of that procedural tradition you describe, Carl. I'm arguing in favor of ignoring it on this occasion for the benefit of the article and the project. If it is shown that to do so would do harm, I'll respect the convention, of course, but for now I can only see an improvement (in access and usability for those with slow connections). Anthony (talk) 02:18, 13 December 2010 (UTC)

I think of it as a sort of armistice. There are arguments on each side, and no general agreement. By agreeing to leave things mostly as they are, we can avoid hostilities. — Carl (CBM · talk) 02:27, 13 December 2010 (UTC)

I think it's worth persevering with discussion. I can see an obvious benefit (loading time) from hand-written citations, I'm worried that there must be a benefit to template citations but I'm just not seeing it. Until I see the benefit of template citations, I can't decide which is best for the article. Anthony (talk) 03:11, 13 December 2010 (UTC)

I'm not taking sides here - I have never edited this article and don't plan to - but I can summarize the benefits people claim for templated references. The first is that they are easier to manipulate via scripts, to allow editors to add additional reference information in an automated way and to allow others to extract reference information in an automated way. The second is that they allow editors to ignore "how" to format a reference, letting the template to do it for them. So the same reference information could be used to generate formatted references in different formats.

On the other hand, there are definitely long load times that the current template system, particularly for articles with large numbers of references. And manually formatted references allow more flexibility to handle different types of references, especially esoteric ones.

I think comfort is a commonly unacknowledged factor. Personally, in all my published mathematics papers, I have never formatted a reference by hand – BibTeX does that for me, and every journal I published in has a BibTeX style file to put the reference in its own format. That makes me comfortable with citation templates. But I'm sure other people have always formatted references manually in their published work, so that's what they're used to. — Carl (CBM · talk) 03:36, 13 December 2010 (UTC)

I've just read some of the back story around this issue including this discussion. Whether (with a cleared cache) I open the template version and the hand written version logged in (as an editor) or logged out (as a typical reader), the hand written version always opens 50% faster. Anthony (talk) 08:23, 13 December 2010 (UTC)

WP:PERFORMANCE. It's not an issue. --Errant ^(chat!) 18:54, 13 December 2010 (UTC)

I don't fully understand your comment, but WP:PERFORMANCE specifically allows for this.

Also, you can worry about performance if you can tell the difference yourself. If you find that a page takes ten seconds to load, and takes only one second to load if you remove a particular template, and you can reliably reproduce this and other editors confirm they can too, then obviously the template is slowing down that page. If you would like the page to load faster, then by all means remove or simplify the template. (Bold in original)

Anthony (talk) 09:17, 14 December 2010 (UTC)

For the record I object to the removal of citation templates. This is just making the citations harder to maintain and index. Rjwilmsi 15:19, 8 January 2011 (UTC)

I second Rjwilmsi. The use of templates insures that the citations will be displayed in a consistent manner and makes it easier for bots such as Citation bot maintain these citations. Boghog (talk) 16:31, 8 January 2011 (UTC)

What does "maintain citations" mean? --Anthonyhcole (talk) 17:10, 8 January 2011 (UTC)

Usually, it means that they worry that someone will screw up the formatting (by hand) and that then the formatting will need to be fixed (by hand/by the complainer).

Additionally, there are a couple of bots that seem to be able to fix dois and such; perhaps those don't work on non-template citations. WhatamIdoing (talk) 18:45, 8 January 2011 (UTC)

Oh. Thanks. I've just been through all the ref's down as far as Pain#Society and culture and found a couple that needed doi's and put them in. All ref's that have an assigned doi, PMID or ISBN down to that section now have them. I'll check the remainder later. Anthonyhcole (talk) 19:18, 8 January 2011 (UTC)

If the citations were formatted, Citation bot would be able to do this for you. This (in part) is what maintenance means. Boghog (talk) 21:13, 8 January 2011 (UTC)

A compromise might be to use the {{vcite journal}} template. The load times are at least 2X as fast compared to {{cite journal}}. Boghog (talk) 21:45, 8 January 2011 (UTC)

Great suggestion. I'll give it a shot. Does {{vcite book}} have the same speed advantage? --Anthonyhcole (talk) 03:28, 9 January 2011 (UTC)

As I understand it, the entire vcite series of templates have similar speed advantages. There is one minor complication however: Citation bot doesn't seem to support vcite templates at the moment. I have put in a request to the bot owner to add this functionality. This in principle should be trivial to implement, so I am optimistic that Citation bot will in the future support the vcite template. Boghog (talk) 09:56, 9 January 2011 (UTC)

Thanks Boghog. --Anthonyhcole (talk) 11:26, 9 January 2011 (UTC)

Boghog, if you're still watching this, can you let me know when citation bot starts updating vcite templates? --Anthonyhcole (talk) 13:41, 24 January 2011 (UTC)

I asked the maintainer of the Citation Bot about adding vcite support. He was reluctant to do so since he was worried about who was going to maintain the vcite templates. A workaround is to temporarily use the normal citation templates, run the bot on the article, and then replace the cite with the corresponding vcite templates. (See here for a discussion.) This is bit of a kludge, but it does work (for an example, see Nuclear receptor). If no one objects, I would be willing to do the same for this article.

Performance? Quite aside from the impropriety of arbitrarily switching citation styles, and of the definite advantages of using the cite/citation templates, I am curious about the one advantage claimed here for handwriting citations: "because the page opens 50% faster that way." I am curious because I have an article that is nearly twice as long is this one, and I don't see any noticeable performance problems. I am not saying that there wasn't (isn't?) a problem here, on this article. (Would love to see it documented.) But I have begun to suspect that these claimed speed issues are not due to use of cite per se, but of use of cite templates in the text. E.g., in Puget Sound faults all of the citation templates are in the References section; citation of sources in the text is via Harv templates. I suspect this is more efficient to process. Anyone have any pertinent information about this? - J. Johnson (JJ) (talk) 22:40, 12 February 2011 (UTC)

I was also skeptical about performance differences. However after replacing cite with vcite templates on the nuclear receptor article, I did notice a substantial decrease in the time it takes to load the page. Concerning the Puget Sound faults article, it uses Harvard style referencing that combines both in-line citations plus {{citation}} templates. Furthermore both the {{citation}} and {{cite journal}} templates transclude the same {{citation/core}} template which is responsible for much of the slow down. Hence I do not see why the Harvard style referencing system would load any faster. Finally I am not sure everyone would agree to switching to the Harvard style. To me, it seems unnecessarily complex. Boghog (talk) 00:20, 13 February 2011 (UTC)

I certainly don't object to you converting this article to vcite, Boghog. Thank you so much for that kind offer. It 99&oldid=401912738] [[User:Jfdwo

For those skeptical that there is a speed advantage to handwritten references, clear your cache, open the template version of Pain and time how long it takes. Clear your cache again and open the hand written version. Whether you are logged in (as an editor) or logged out (as a typical reader), the hand written version always opens 50% faster. Several other editors have confirmed since this discussion began that vcite confers the same speed advantage. One of the best editors in medicine took the trouble to convert Autism to vcite a year or so back, for this reason.--Anthonyhcole (talk) 04:14, 13 February 2011 (UTC)

I tried clearing my cache and downloading each version, and got 13 and 15 seconds. Not a really significant difference, but I don't think this result is really valid. I wish someone would do a valid technical test on this. And I would like to see a version that puts all the citation templates in the references section to see (as I suggested above) whether the problem is not the templates as such, but processing the templates in the text.

Someone clarify for me: is {{vcite}} not subject to this supposed performance problem? - J. Johnson (JJ) (talk) 23:28, 13 February 2011 (UTC)

Thanks for the feedback, JJ. I've tested loading times for "cite" template and manual citations on this article on my laptop at home, at university and in an internet cafe, about 10 times each. The average for each was 50% faster loading for hand-written references. This section in WP:MEDMOS makes the claim that pages with lots of citations load faster with vcite than cite. --Anthonyhcole (talk) 03:18, 14 February 2011 (UTC)

Replacing cite with vcite templates reduces page-generation time by ~2X. More detail on the performance advantages of the {{vcite journal}} template (and related vcite family of templates) may be found here. The Harvard style referencing system can use the same templates to display the full citations, but the full citation are no longer included in-line. I have not been able to find any information to confirm or refute that page-generation times are slower when cite templates are included in-line compared to the same templates that are not included in-line. In any case, I would not be in favor of implementing the Harvard system in this article since in my opinion the system is overly complex. Boghog (talk) 06:11, 14 February 2011 (UTC)

I also think Harvard is overly complex. Let's make good editing easier not harder. --Anthonyhcole (talk) 07:57, 14 February 2011 (UTC)

These results certainly are a prima facie case for a speed difference. But I still have doubts as to the details of just what is the cause, and what other factors might be involved. E.g., these results suggest that "loading times" and "page-generation time" (are these equivalent?) for vcite vs. hand-written should be about the same. Which would say that the problem is not templates per se, but certain templates. Also, even though {{citation}} and {{cite journal}} share the same core, has anyone tested whether they perform the same? - J. Johnson (JJ) (talk) 23:11, 14 February 2011 (UTC)

It sounds like the speed advantage on hand-written is the same as on vcite. Boghog's "vcite templates reduce page-generation time by ~2X" above, which I've seen somewhere else, seems to be saying a 50% reduction, which is what I'm finding here with handwritten. Boghog is converting this article to vcite, so we'll be able to compare the speeds of the three versions: cite journal, vcite, and handwritten. The underlying cause? I haven't a clue, though I haven't followed Boghog's links above. --Anthonyhcole (talk) 03:23, 15 February 2011 (UTC)

This link explains in detail why vcite templates are faster than the corresponding cite templates. This applies to all the cite and vcite templates (cite book, journal, web, etc.). The biggest single difference why the "page-generation time" of cite templates is longer than vcite template is that the cite templates (including the {{citation}} template) generate Wikipedia:COinS metadata while vcite templates do not. "Page-generation time" is the length of time it takes the Wikipedia server to generate a page, "loading times" are what the end user experiences ("page-generation time" + time it takes to transmit the data from the Wikipedia sever to your computer + time it takes for your browser to render the page). Boghog (talk) 06:59, 15 February 2011 (UTC)

Thanks. That link (Template:Vcite_journal#Rationale) lists several items, but I gather that generating the COinS metadata is the most significant. Which is the kind of thing I am concerned about: is a major objection to using citation templates generally turn out to be a problem not with the templates generally, but with a certain feature of a certain template? In which case why don't we ditch this dubious feature? Or (if some editors insist on it) have optionable COinS-nonCOinS versions of the templates? (Well, we do, but I find {{vcite journal}} irksome in the other features it drops.)

These different times are one aspect of why I tend to be skeptical of most casual tests. What we could use is a formal experimental protocol, vetted by the technical wonks to address all these possibly confounding factors, and then some rigorous testing. (Don't wake me up till it's ready. :-) J. Johnson (JJ) (talk) 00:09, 16 February 2011 (UTC)

It is a significant problem, which no one is addressing. Someone with time, energy and who knows what a template is should take it to Village pump (technical) or Wikipedia talk:Citation templates. But my feeling is it will take considerable push to get any movement. In earlier discussions I've read, there are a number of defenders of the status quo who are adamant that page opening time doesn't matter. --Anthonyhcole (talk) 12:52, 16 February 2011 (UTC)

To bring this discussion back to where it started ("Wondering why the page is being moved away from the Cite journal format?") I think it is fair summary to say: there was a performance problem as the article was. Now some folks don't think that's a significant problem, just as some folks don't think citation templates are useful. I would like to suggest that, for the sake of this discussion, both of these views be accepted: that citation templates are useful (even if you don't like templates, please accept that others do), and that the use of citation templates in this article was a problem. Now this certainly suggests a conflict (templates "good" vs. templates "bad"), but please note what developed in this discussion: the performance problem is not all inherent in all citation templates, but only the {cite} family. It appears that {vcite} is "good" in this respect. So I ask: would conversion to {vcite} been a better option? Sure, many of us don't like vcite, but manually applied style can be just as unliked, and I say that is a different issue. The question is: where use of {cite} is found unacceptable, is conversion to {vcite} better than manual formatting? - J. Johnson (JJ) (talk) 22:16, 17 February 2011 (UTC)

That is the ideal solution JJ. Boghog has, amazingly (thank you so much Boghog), offered to translate the handwritten cites to vcite. --Anthonyhcole (talk) 10:55, 24 February 2011 (UTC)

Review

[4] Doc James (talk · contribs · email) 15:41, 23 February 2011 (UTC)

Evolutionary and behavioral role

I can't see the relevence of it to this section, and it seems kind of speculative, so have removed this paragraph:

Interestingly, the brain itself has no nociceptive tissue, and hence cannot sense pain inside itself. Thus, a headache is not due to stimulation of pain fibers in the brain itself. Rather, the membrane surrounding the brain and spinal cord, called the dura mater, is innervated with pain receptors, and stimulation of these dural nociceptors is thought to be involved to some extent in producing headache pain. The vasoconstriction of pain-innervated blood vessels in the head is another common cause. Some evolutionary biologists have speculated that this lack of nociceptive tissue in the brain might be because any injury of sufficient magnitude to cause pain in the brain has a sufficiently high probability of being fatal that development of nociceptive tissue therein would have little to no survival benefit.

Anthony (talk) 16:47, 5 October 2009 (UTC)

Agree, although I think the article ought to contain some material somewhere about headache and the brain's lack of pain receptors. Maybe moving the material before "Some evolutionary biologists..." into a special section on headache would be a reasonable thing to do? Looie496 (talk) 17:23, 5 October 2009 (UTC)

O.K. I've moved "brain has no nociceptors" to Mechanism. We'll need to have the conversation about whether to include a section on the various pain conditions. I think it should include you, Robert, me and several other editors. But perhaps a little later. For now, I'm trying to shape what we've got into a trimmer, more coherent essay. Next I shall attempt to create a bridge between Mechanism and Evolution of the Theory. Thanks for your feedback. You probably know how important that is in this endeavour.Anthony (talk) 02:43, 6 October 2009 (UTC)

I'm worried about this:

However, it is likely that the significant pain levels experienced in these situations are related to the high sensitivity of nerves in these parts of the body. For instance, the nerves in the roots of teeth need to be particularly sensitive in order for the subject to be aware of the sensation of eating, since teeth move very little during this process.

There is no reference and it seems not to make scientific sense. Low-threshold mechanoreceptors (those receptors recruited for awareness "of the sensation of eating") are not nociceptors, and so a proliferation of these would have no effect on pain. O.K. if I delete? Anthony (talk) 05:33, 15 October 2009 (UTC)

Seems okay to me. I changed, for a reason that is obvious (to me at least), "In other species" for "In other than human beings" (which I had put there before), but wonder whether it is a correct English phrase at that place. --Robert Daoust (talk) 15:12, 15 October 2009 (UTC)

Can you defend it though? My problem is: it is (1) unreferenced (2) conjecture which (3) does not agree with current theory. Every textbook I've seen published after 1990 says something like the following:

Somatosensory afferents are modality specific. Some, "low-threshold mechanoreceptors" (LTMs), respond to gentle touch and vibration. Others, "nociceptors", respond only to strong stimuli. (...) Within each modality, firing frequency encodes stimulus strength. LTMs, for example, respond to increasing pressure by accelerating their firing rate. LTMs also respond to noxious pinch but since their firing rate saturates below the noxious range, they do not encode the intensity of noxious stimuli. Arbib (2003), page 845.

If periodontal ligament and fingertips demand sensitivity to low-intensity mechanical stimulation, all that is required is lots of very low-threshold mechanoreceptors. The need for low threshold mechanosensitivity does not explain the presence of lots of low-threshold nociceptors.

I like "In Other than Human Beings". Is your problem with "species" the ambiguity of the term? Anthony (talk) 08:01, 16 October 2009 (UTC)

Anthony, I agree with your suggestion of deleting the paragraph. I am glad you like "In other than human beings". For discussion on the use of species, see Talk:Pain/Archive_2#Impossible_to_prove_that_any_individual_feels_pain.3F. Computers, gods, or mountains are not 'species'. --Robert Daoust (talk) 17:57, 19 October 2009 (UTC)

Cool Anthony (talk) 05:54, 20 October 2009 (UTC)

Areas of the body which can be affected by severe pain are also areas which are sensitive to touch (eg, mouth, toes, fingers, genitals, etc) - this seems more than coincidence. Is it possible that evolution has resulted in an increase in all sensory receptors where an increased touch sensation is required, because it is not possible for the receptors to evolve independently? Is there any research which confirms this?Tjandspallan (talk) 17:56, 21 February 2011 (UTC)

Latest revision answers my point - chronic or severe pain is simply an accidental side-effect of having the ability to feel pain, resulting in the signals being wrong or exaggerated.Tjandspallan (talk) 20:20, 25 April 2011 (UTC)

Haha I'm glad that helped. I just finished Dawkins' book and I thought that was a curious, but brilliant point.-Tesseract²(talk) 20:43, 25 April 2011 (UTC)

Yes. Thanks Tesseract2. The imperfection of evolution explains this nicely. --Anthonyhcole (talk) 05:52, 27 April 2011 (UTC)

Mancini et al (2011)?

Here’s a summary of a recent BBC news report at [5] entitled "Pain reduced by changing what you look at" by Rebecca Morelle at bbc.co.uk. If anyone has access to Psychological Science, the primary journal source, perhaps they could add something to the article?

In a study published in the journal Psychological Science, researchers from University College London and from the University of Milan-Bicocca found that looking at one's body - in this case the hand - reduces the pain experienced. The team also showed that magnifying the hand to make it appear larger reduced pain levels further still.

The research involved Patrick Haggard, Professor of cognitive neuroscience from UCL, was funded by the Biotechnology and Biological Sciences Research Council (BBSRC) and used of 18 volunteers. Scientists applied a heat probe to each participant's hand, gradually increasing the temperature. As soon as this began to feel painful, the probe was removed and the temperature was recorded. This gave a measure of the pain threshold, in a safe and reliable way. The scientists then used a set of mirrors to manipulate what the volunteers saw. The team found that volunteers could tolerate on average 3C more heat when they were looking at their hand in the mirror, compared with when their hand was obscured by a block of wood.

In another experiment, the researchers used convex mirrors to enlarge the appearance of the participant's hand. They found that doing so meant the volunteers were able to tolerate higher temperatures. Conversely, when the team made the volunteers' hands look smaller, their pain threshold decreased. The researchers hope that understanding more about the science that underpins pain could one day help to lead to new treatments for chronic conditions.

Professor Haggard said: "We know quite a lot about the pathways that carry pain signals from the body to the brain, but we know rather less about how the brain processes these signals once they arrive. Our interest has been in the relationship between the experience of pain and the representation that your brain makes of your own body. And we've shown there is an interesting interaction between the brain's visual networks and the brain's pain networks."

Dr Flavia Mancini, lead author of the paper, said: "Psychological therapies for pain usually focus on the source of pain, for example by changing expectations or attention. However, thinking beyond the pain stimulus, to our body itself, may lead to novel clinical treatments." Martinevans123 (talk) 18:50, 10 February 2011 (UTC)

Reference for the actual article?

This is a primary research study. I would prefer for content to be based on WP:MEDRS-compatible secondary sources. JFW | T@lk 20:20, 10 February 2011 (UTC)

I see this listed at the site of one of the authors [6]: "Mancini, F., Longo, M. R., Kammers, M. P. M., & Haggard, P. (in press). Visual distortion of body size modulates pain perception. Psychological Science". So looks like we'll have to wait. Not sure that any secondary source can be used if the primary one doesn't yet exist (regardless of the number or quality of popular press news articles)? Martinevans123 (talk) 20:42, 10 February 2011 (UTC)

Not everything that hits the popular press is notable in the long run. Ideally the results should be replicated etc etc. JFW | T@lk 22:01, 10 February 2011 (UTC)

Quite agree that one study with only 18 volunteer subjects is probably not enough to include yet. But this looks like genuinely novel, counter-intuitive and interesting work. It might also have real implications for care. Yet in apparent contradiction to the work of Hoffman and Patterson at UW Seattle, wrt attentional saturation. Obviously several mechanisms at work. Martinevans123 (talk) 22:22, 10 February 2011 (UTC)

It seems to go in the same direction as Ramachandran's work with phantom limb pain -- he found that if you give people the illusion of seeing their phantom limb and being able to move it, the pain associated with it can be made to practically vanish. Looie496 (talk) 17:25, 11 February 2011 (UTC)

Yes, it does seem to, doesn't it. I had a look at Vilayanur S. Ramachandran and I think he should certainly get a mention in this article. Or at least phantom limb pain in general? Martinevans123 (talk) 17:40, 11 February 2011 (UTC)

Is Ramachandsan's technique being used in the clinic? This article touches on phantom pain at Pain#Phantom pain, but doesn't mention mirror box therapy. The main article Phantom pain devotes several paragraphs to it. --Anthonyhcole (talk) 03:16, 12 February 2011 (UTC)

I could find no evidence that Ramachandran's mirror box technique is being used in any clinic. But I think at least a brief note is justified by these links to the other articles. So have imported from the same source. Please revert is you think this is not justified. Some evidence of application in a clinical setting would be needed for any addition to Pain Management, I suppose. Thanks. Martinevans123 (talk) 09:19, 12 February 2011 (UTC)

The paper is now published: Mancini, F., Longo, M. R., Kammers, M., Haggard, P. (2011) Visual distortion of body size modulates pain perception. Psychological Science, 22, 325-330. Mirrorbox illusion is currently used in many pain management centres for the treatment of chronic pain. —Preceding unsigned comment added by 128.40.254.91 (talk) 10:39, 30 March 2011 (UTC)

Thanks for that, 128. PMID 21303990 Can you point to a systematic review or similar that confirms how many centres are using mirrorbox therapy, so we can mention it in the article? Is it mentioned in Mancini et al.? --Anthonyhcole (talk) 09:12, 27 April 2011 (UTC)

Pain is a homeostatic emotion

The IASP defines pain as "an unpleasant sensory and emotional experience." Bud Craig has named this class of feeling (the "sensory and emotional experience") "the homeostatic emotion." Derek Denton calls them the "primordial emotions." They include among their number, hunger, thirst, fatigue, pain, air hunger, salt hunger and sleepiness. They are feelings that tell us the state of our many homeostatic systems and motivate our behaviour so as to maintain the ideal physical state.

These researchers and theorists distinguish these emotions from those caused by the state of the environment, such as love, hate and fear. Denton points to lust as a kind of hybrid of the two.

I would like to include "Pain is a homeostatic emotion." somewhere in the lead. Thoughts?

• Derek A. Denton (8 June 2006). The primordial emotions: the dawning of consciousness. Oxford University Press.
• Craig, A.D. (Bud) (2003). "Interoception: The sense of the physiological condition of the body". Current Opinion in Neurobiology 13 (4): 500–505. PMID 12965300.
• Craig, A.D. (Bud) (2008). "Interoception and emotion: A neuroanatomical perspective". In Lewis, M.; Haviland-Jones, J.M.; Feldman Barrett, L.. Handbook of Emotion (3 ed.). New York: The Guildford Press. pp. 272–288. ISBN 978-1-59385-650-2.

--Anthonyhcole (talk) 13:16, 1 May 2011 (UTC)

A mention under "Theory Today" section seems enough for me, given that viewing pain as a homeostatic emotion is still not mainstream even in pain science... --Robert Daoust (talk) 16:17, 1 May 2011 (UTC)

I agree with Robert -- these views may be worth discussing somewhere in the article (though personally I don't see pain as either homeostatic or an emotion), but they are not mainstream enough to belong in the lead. Looie496 (talk) 16:28, 1 May 2011 (UTC)

Fair enough. How's this? --Anthonyhcole (talk) 02:45, 2 May 2011 (UTC)

Analgesic effects of multisensory illusions in osteoarthritis

This also looks relevant: [7].

This is a letter from Catherine Preston and Roger Newport to the journal Rheumatology accepted 2 February 2011. Although the full text is pay-to-view, the abstract says this:

• "Sir, There is increasing evidence that drug-free illusion therapies can be beneficial for the amelioration of chronic pain, particularly so for conditions in which some of the pain is thought to have a cortical origin. For example, mirror therapy and size reduction illusions can reduce pain in complex regional pain syndrome type 1 (CRPS1) patients, the majority of whom have disturbed body representations with some reporting their hand as larger than in reality [1] and others describing parts of their hand as foreshortened [2]. If cortical misrepresentation of body parts contributes to pain, then manipulating the appearance of those body parts might be a useful tool in the reduction of pain. This letter describes an exploratory experiment using unique visuo-proprioceptive illusions that manipulated the perceived size of painful and non-painful parts of the hand in an attempt to modulate pain experienced in OA.

• "Illusions were applied using a MIRAGE system [3] that presents real-time video capture of the actual hand from the same position and perspective as if viewing the real hand directly."

I understand that a full article is to be published in the next issue of Rheumatology. Martinevans123 (talk) 19:03, 14 April 2011 (UTC)

This sounds preliminary, and needs to be covered in a secondary source before being suitable for inclusion. JFW | T@lk 19:41, 14 April 2011 (UTC)

This source has a video: [8]. Thanks. Martinevans123 (talk) 19:55, 14 April 2011 (UTC)

Yup. They wrote a press release and it was picked up by the BBC. Please have a look at WP:MEDRS. JFW | T@lk 20:03, 14 April 2011 (UTC)

Yup. A few years yet then. Martinevans123 (talk) 20:08, 14 April 2011 (UTC)

Is there gating in the spinal dorsal horn? If so, how much?

I am not a subject expert but I'm aware there is a mildly vitriolic debate in pain neuroscience as to whether any elements of Melzack and Wall's gate control theory can now be taken seriously. User:Tzores has just added "The inhibitory gates originally postulated by Melzack and Wall have also been demonstrated recently in the spinal dorsal horn." citing

Takazawa T, McDermott AB. Synaptic pathways and inhibitory gates in the spinal cord dorsal horn. Ann. NY Acad. Sci.. 2010;1198:153-158. PMID 20536929.

a primary source. The next paragraph begins with "One study has found that pain reduction due to non-noxious touch or vibration can result from activity within the cerebral cortex, with minimal contribution at the spinal level." citing

Inui K, Tsuji T, Kakigi R. Temporal analysis of cortical mechanisms for pain relief by tactile stimuli in humans. Cereb. Cortex. 2006;16(3):355–65. PMID 15901650.

another primary source.

I'd love for this article to illuminate this question but the primary sources are an issue. It's contentious and I don't think we should be taking a position on this until a good recent authoritative review tells us what to say. (There may be one, I don't know.) I propose deleting both statements for now. --Anthonyhcole (talk) 17:16, 17 April 2011 (UTC)

OK. I've deleted both statements for now. --Anthonyhcole (talk) 06:16, 19 April 2011 (UTC)

First sentence take 2

I was thinking of this, what do you guys think? Pain is a feeling triggered in the nervous system. Pain may be sharp or dull. It may come and go, or it may be constant. You may feel pain in one area of your body, such as your back, abdomen or chest or you may feel pain all over, such as when your muscles ache from the flu.

Pain can be helpful in diagnosing a problem. Without pain, you might seriously hurt yourself without knowing it, or you might not realize you have a medical problem that needs treatment. Once you take care of the problem, pain usually goes away. However, sometimes pain goes on for weeks, months or even years. This is called chronic pain. Sometimes chronic pain is due to an ongoing cause, such as cancer or arthritis. Sometimes the cause is unknown. — Preceding unsigned comment added by Bananas 77 (talk • contribs) 17:46, 4 October 2011 (UTC)

The material above is taken from MedlinePlus: health topics: pain . While this material does not appear to be copyrighted (see MedlinePlus copyright), there is another problem. Wikipedia purpose, like other encyclopedias, is to inform not instruct and to present facts, not to teach subject matter (see WP:NOTGUIDE). The MedlinePlus text reads too much like a guide and therefore in my opinion is not appropriate for Wikipedia. Boghog (talk) 20:51, 4 October 2011 (UTC)

We really can't just copy and paste stuff in any case. But regarding whether that's the right kind of thing, my feeling is that it's a good introduction for a person who is experiencing pain and looking for resources that might be helpful, but not such a good introduction for a reader who basically wants to know what pain is. Looie496 (talk) 21:42, 4 October 2011 (UTC)

Actually you can use material that is in the public domain as long as proper attribution is provided (see for example articles that transclude the {{NLM content}} or {{InterPro content}} templates). However I think in this particular case, it is very bad style to replace text that was agreed upon after extensive discussion and that is unique to Wikipedia with material that is copy and pasted from another web site. Boghog (talk) 06:26, 5 October 2011 (UTC)

The lead should define the topic and summarize the body of the article with appropriate weight. The IASP definition is difficult for most people to understand on first reading, so I changed it to simply "Unpleasant sensation often caused by body damage" - not exactly a precise definition but everyone should recognise it - followed by examples of the three "modes" of nociceptive pain (thermal, mechanical and chemical) and an example of neuropathic pain. What else to include in the lead? WP:LEAD says "The lead serves as an introduction to the article and a summary of its most important aspects."

Presently the lead mentions pain's usefulness (withdrawal, protection and avoidance), chronic vs. acute, idiopathic pain, a little epidemiology (most common reason for GP visit), impact on QOL and function, and its modulation by higher processes (cognitive and social) - some of which is covered in the Medline quote. What we don't cover and the Medline quote does is:

Pain is a feeling triggered in the nervous system. Pain may be sharp or dull. It may come and go, or it may be constant. You may feel pain in one area of your body, such as your back, abdomen or chest or you may feel pain all over, such as when your muscles ache from the flu.

I removed mention of the nervous system mechanism because it was thought to be too detailed for the lead, but we could mention that pain involves the nervous system. Temporal profile (recurring, constant), Quality (sharp, dull, burning, crushing, etc.) and localization add depth to the characterization of pain, and could follow the first sentence. This lead has mentioned quality before. --Anthonyhcole (talk) 22:16, 4 October 2011 (UTC)

Can we please have a universal neuroscience view and not a human-centric POV? elle _{vécut heureuse} ^{à jamais} (be free) 04:52, 5 October 2011 (UTC)

What's needed?

Moved to bottom so new visitors are more likely to notice. Undo if this is impertinent. --Anthonyhcole (talk) 06:55, 19 April 2011 (UTC)

(Feel free to add. Many of the following actually need a good dedicated article.)

• central sensitization
• allodynia.
• congenital insensitivity to pain. (done)
• pain and consciousness.
• pain's neurological kinship with social pain.
• the theory/mechanism section is turgid and a barrier that will put people off reading the article. It either needs to be made easy reading, or moved to the bottom.
• Pain#Assessment_in_nonverbal_patients needs the attention of an expert, or someone willing to read up on the protocols.
• the relationship between pain and inflammation.
• central pain.
• cancer pain. (done)
• the chemistry of pain.
• the functional neuroanatomy of acute and chronic pain.
• is pain a homeostatic emotion? If so, should that be included in the definition? (done)
• relationship to pleasure.
• suicide and self-medication.
• current status of Melzack & Wall's gate control theory of pain.
• effect of sleep deprivation on pain
• psychology of pain

If you can help with any of the above, that would be much appreciated. Some of the conventions here take a little getting used to, I can help you with advice on Wikipedia policy and how to make changes to an article, or start a new one. If you have any queries, ask here, or at the medicine project. To edit a page, click the "edit" tab at the top of the page and type into the box near the bottom. Anthony (talk) 15:46, 15 December 2010 (UTC)

It is good to see that the article continues to get better. The to-do list at the top of this page could be updated. --Robert Daoust (talk) 16:54, 16 December 2010 (UTC)

I never noticed that before! (I ignore boxes) Anthony (talk) 18:57, 16 December 2010 (UTC)