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Teacher's guide
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Teacher's guide
About the Guide The following teacher’s guide assists instructors in helping students engage thoughtfully in their own learning process. The method is action-based, aiming to encourage participants to understand various perspectives' truths in a given situation beyond the scientific, privileged viewpoint. It takes into account, and sometimes challanges our common sense on different topics, which is not usual in the context of medical studies. It is based on reflecting on and sometimes citicising our everyday experiences. For instance, it asks participants to reflect on their everyday expressions about pain to understand what kinds of hidden concepts about pain might exist without our reflection. Most of the tasks, using various techniques, urge participants to critically examine the "accepted," generally unquestioned knowledge. For example, we may ask them to imagine themselves in others' roles and argue from their perspective, or to gather their everyday knowledge, assumptions, and cultural biases, which are often difficult to see due to their familiarity. The exercises can be used flexibly, depending on the presenter's style. It is advisable to use a flip chart or board to clearly note and display the thoughts raised by the students for the entire group to see. It is also advisable to lead the discussions as openly as possible because, in these tasks—perhaps unlike the usual format of lectures and exercises—many good and unexpected responses come from the group. The exercises were created in alignment with the slides, directly following the topics of the presentation. Before showing the slides Before showing the slides, ask the students to write down their definitions of pain as precisely as possible, according to their best understanding. After the definitions are completed, some can be read aloud, and then it is worth assessing the community's views on the nature of pain through the following questions: 1. Who defined pain exclusively from a biological perspective? (Raise your hand) 2. Who included aspects other than biological ones in their definitions? What are these aspects? (Note the answers on the board and try to categorize them with the students) What are the difficulties in defining pain? After completing the task, display the slide showing the content, and based on it, consider which aspects of pain the group addressed and which they did not in their definitions. INTRODUCTION This presentation explores the evolution of how pain is understood as a psychological, physical, and cultural phenomenon, using endometriosis as a central example. It begins with an overview of endometriosis, a chronic condition affecting about 10% of women of reproductive age, characterized by the presence of endometrial-like tissue outside the uterus, leading to significant pain and infertility. The presentation then transitions to discussing current pain definitions, providing a historical context of pain theories and focusing on the biopsychosocial model. This model is examined in depth, highlighting the interrelated biological, psychological, and cultural aspects of pain. The presentation also addresses the impact of factors like racism, vulnerability, and social responsibility on pain perception and expression. Lastly, it emphasizes the critical role of effective communication between doctors and patients in managing chronic pain conditions like endometriosis within this comprehensive framework. Slide 4-6 - WHAT IS PAIN? This section explains the International Association for the Study of Pain's (IASP) 2020 definition of pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." The IASP expands on this definition with six key points that highlight pain as a complex, personal experience shaped by biological, psychological, and social factors. It distinguishes pain from nociception, emphasizes the role of life experiences in shaping pain perception, and underscores the importance of respecting individuals' reports of pain. The notes also address pain's potential adverse effects on well-being and acknowledge that pain can be expressed in ways beyond verbal communication. This definition reflects an evolved understanding of pain, emphasizing aspects that were not previously recognized. Slide 7 - 9 – HISTORY OF PAIN THEORIES Slide 10 – BIOPSYCHOSOCIAL PAIN Slide 11 -16 - BIOLOGICAL & PSYCHOLOGICAL DOMAIN OF PAIN Before projecting the slide, ask the students to think of someone they know who has an unusual attitude toward their own pain (or illness). Taking that person's perspective, have them write in the first person what that person thinks about their pain (e.g., 'My life is broken in two'; 'This will always be like this from now on'; 'It's not worth mentioning, I'll just take a painkiller and that's it,' etc.). After the students have completed the task, let's compare a few responses: someone reads their response aloud, and then ask who wrote down a very different perspective. Let's compare the different concepts of pain (or illness) and try to name them with a single word (e.g., 'the Self-pitying'; 'the Denying'; 'the Desperate'; 'the Self-punishing,' etc.). Ask the students to imagine how the person they recalled in the previous task feels when they are ill. Try to express this feeling through that person’s body posture. After completing the task, it is worth looking around the room and asking the participants who they think is in a better situation and why. Ask the students to name something they find particularly painful, to the point of even fearing it (e.g., injection, shin kick, earache, etc.). Have them explain how they think this affects their perception of pain: who thinks it doesn't affect them at all, and who believes they experience much more pain from something they fear. The goal of this task is for students to understand, based on their own experiences, that various concepts and feelings can be associated with pain. This is important because the further course material will demonstrate how these are related to the perception of pain, our preconceptions, concepts, feelings, and coping strategies. This section emphasizes the importance of treating pain by addressing three interconnected domains: biology, psychology, and social functioning. The biological aspect includes factors like genetics, hormones, tissue damage, and neuropsychology, with pain perception involving both peripheral and central nervous systems. The psychological domain covers thoughts, beliefs, coping behaviors, prior experiences, and emotions, all of which significantly influence pain perception and management. Pain is bidirectional, where pain affects emotions and cognition, and these factors, in turn, influence pain. Effective treatment requires a holistic approach that considers all three domains to address chronic pain comprehensively. Slide 17 - 22 – SOCIAL DOMAIN OF PAIN The "gender pain gap" highlights disparities in pain perception and treatment between men and women, leading to inadequate care for many women. Racial biases, particularly misconceptions about biological differences, contribute to disparities in pain treatment for minorities. Vulnerable groups, including those who cannot verbally express pain, often face significant challenges in receiving appropriate care. Tools like the FLACC Pain Scale help address these challenges by assessing pain in non-verbal patients. Pain management is recognized as a fundamental human right, yet millions globally lack access to adequate pain treatment, emphasizing the need for continued advocacy and action to address these inequities. Have the students collect common expressions in their native language that people use to downplay pain (e.g., "no big deal"; "you will survive"; "man up"; "shake it off"; don’t be such a baby). In pairs, have the participants collect experiences where, to their knowledge, someone's pain was not taken seriously due to racism or gender exclusion. Read together the account on slide 17! Slide 23 – COMMUNICATION Have the students come up with a tool for expressing pain non-verbally (e.g., measuring grip strength, colors' intensity, shapes). Students can search for example the Reimagining Pain Communication Project, which is a student's thesis project at the University of Bergen. https://ifdesign.com/en/winner-ranking/project/re-imagining-pain-communication/567583) Slide 24 - 26 - SOCIAL CRITICAL PERSPECTIVE Collect arguments, fictional cases on whether withholding pain relief could be considered torture. Yes, if... (e.g., intentional infliction of pain; sending soldiers into war without ensuring pain relief for injuries; denying pain relief to a laboring woman, claiming it will be over soon, etc.); No, if... Slide 27 –TAKE HOME MESSAGE BIBLIOGRAPHY Baird and Sheffield (2016) The Relationship between Pain Beliefs and Physical and Mental Health Outcome Measures in Chronic Low Back Pain: Direct and Indirect Effects. Healthcare (Basel). 2016 Aug 19;4(3):58. doi: 10.3390/healthcare4030058. PMID: 27548244; PMCID: PMC5041059. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5041059/ Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci. 2013 Jul;14(7):502-11. doi: 10.1038/nrn3516. Epub 2013 May 30. PMID: 23719569; PMCID: PMC4465351. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465351/ De Sario, Gioacchino D., et al. "Using AI to Detect Pain through Facial Expressions: A Review." Bioengineering 10.5 (2023): 548. Henry SG, Matthias MS. Patient-Clinician Communication About Pain: A Conceptual Model and Narrative Review. Pain Med. 2018 Nov 1;19(11):2154-2165. doi: 10.1093/pm/pny003. PMID: 29401356; PMCID: PMC6454797. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016 Apr 19;113(16):4296-301. doi: 10.1073/pnas.1516047113. Epub 2016 Apr 4. PMID: 27044069; PMCID: PMC4843483. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/ Human Rights Council (2013) Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Juan E. Méndez https://www.ohchr.org/sites/default/files/Documents/HRBodies/HRCouncil/RegularSession/Session22/A.HRC.22.53_English.pdf IASP: Pain in Women. https://www.iasp-pain.org/advocacy/global-year/pain-in-women/ IASP (2007) IASP declares the Global Year Against Pain in Women. https://www.eurekalert.org/news-releases/630641 Jensen, M. P. (2011). Hypnosis for chronic pain management: Therapist guide. Oxford University Press. Prell T, Liebermann JD, Mendorf S, Lehmann T, Zipprich HM. Pain coping strategies and their association with quality of life in people with Parkinson's disease: A cross-sectional study. PLoS One. 2021 Nov 1;16(11):e0257966. doi: 10.1371/journal.pone.0257966. PMID: 34723975; PMCID: PMC8559924. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8559924/ Oláh, Mara (1997) Önéletrajz. Magánkiadás. Trachel and Cascella (2019) Pain Theory van Rysewyk, Simon, ed. Meanings of Pain: Volume 1. Springer Nature, 2016. van Rysewyk, Simon, ed. Meanings of Pain: Volume 2: Common Types of Pain and Language. Springer Nature, 2019. Zoffness, Rachel (2019) Think Pain Is Purely Medical? Think Again.Psychology Today (October 25, 2019) https://www.psychologytoday.com/intl/blog/pain-explained/201910/think-pain-is-purely-medical-think-again
2021-1-HU01-KA220-HED-000027613 - COHRICE
Teachers Guide
8. Endometriosis and Pain
(Basic)
Read the IASP’s definition of pain, and ask the students which elements of the definition seem progressive or strange to them and why.
Here describe the evolution of pain theories, highlighting the gradual understanding that pain is not solely a physical sensation. Early theories, such as the Intensity Theory, Cartesian Dualism, and Specificity Theory, laid the groundwork for modern pain research but were limited in their explanations of chronic pain and the role of psychological factors. The Gate Control Theory, introduced in 1965, was groundbreaking in recognizing the interaction between physical and psychological elements in pain perception, proposing a "gate" in the spinal cord that regulates pain signals. Later, the Neuromatrix Model expanded on this by emphasizing the central nervous system's role in generating pain, acknowledging the influence of cognitive and emotional factors. However, despite these advancements, these theories do not fully address the social aspects of pain, indicating the need for continued research and the development of more comprehensive models, leading to the biopsychosocial approach.
The Biopsychosocial Model offers a holistic approach to understanding pain by emphasizing the complex interplay between biological, psychological, and sociological factors. It highlights that any pain theory neglecting these dimensions is insufficient. Although the term "biopsychosocial" was coined in 1954 by Roy Grinker, the approach was earlier promoted by physicians like John Joseph Bonica, who advocated for interdisciplinary pain clinics post-World War II. George Engle's 1977 work on multidimensional disease management and John D. Loeser's contributions to pain assessment further developed this model. Together, these elements provide a comprehensive framework for effectively understanding and managing chronic pain.
These slides introduce students to the biological domain of pain. This aspect is the closest to the students. It is worth presenting these in a simple lecture format.
For these slides talk about the social aspects of pain, which are complex and multifaceted, encompassing issues like gender, race, ethnicity, and social responsibility.
Effective communication between patients and clinicians is crucial for successful pain management. However, research shows that discussing pain can be challenging, indicating a need for improvement in this area. Good communication not only enhances patient satisfaction and treatment adherence but also improves clinical outcomes. When patients feel acknowledged and validated by their clinician, they are more likely to follow treatment recommendations, including non-pharmacological pain management techniques, leading to better pain outcomes. Given that pain is a subjective experience, it's essential for doctors to trust and accept the patient's self-reported pain levels unconditionally.
In a provocative conclusion, we explore the thoughts of social critic Ivan Illich, who challenges the conventional understanding of pain and pain relief in modern society. Illich, an Austrian Roman Catholic priest and philosopher, critiqued the overmedicalization of life in his 1975 book "Medical Nemesis." He argued that industrialized society distorts the experience of pain by turning it into a technical issue, stripping suffering of its personal and cultural meaning. According to Illich, this shift leads people to see pain as something to be managed or eliminated rather than a part of the human experience that requires individual response and resilience. On the final slide, we summarize Illich's views on how societal structures influence and, in his view, diminish the natural experience of pain, emphasizing independence, human competence, context, and responsibility.
When studying endometriosis, it's essential to understand that pain is not merely a physical sensation but a complex experience shaped by biological, psychological, and social factors. These aspects are closely interrelated, meaning effective treatment requires addressing all three. Healthcare providers must consider and integrate these dimensions to provide holistic care, ensuring that the diverse needs of individuals living with endometriosis are met. This approach leads to more effective pain management and better overall outcomes for patients.
Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or the Foundation for the Development of the Education System. Neither the European Union nor entity providing the grant can be held responsible for them.