Chronic Pain Assessment and Possible Treatments

Introduction

Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage” (12). Neuropathic pain is solely linked to damaged nerve or the nervous system. Similarly, Nociceptive is often an acute pain caused by a physical pressure or an inflammation which is detected by a nociceptor. Chronic pain can be perceived as a disease itself as it is an amalgam of nociceptive pains (such as visceral, somatic and chemical) and psychogenic pain that triggers or develops to a be persistent chronic pain. Hence it is pragmatic to acknowledge the strong correlation between nociceptive, psychogenic to chronic pain as one might trigger the other. It is also better to acknowledge and accept that some widespread, unidentifiable chronic pain is caused and generated by the central nervous system.

Moreover, assessing chronic pain has been a challenge and almost philosophical to scientist, pain researchers, patients and the public. This is because it is much easier to assess chronic pain as an output caused by a stimulus or an injury which is externally controlled by the peripheral nervous system. It becomes strenuous to peruse and denominate a cause to chronic pain that does not stem from damaged tissue nor a physical injury. Consequently, our study comprises of healthy subjects wearing a virtual reality headset responding to videos of a patients who show a visible chronic pain; as well as having a patient with chronic pain responding to healthy subject reaction or exposure to them. This allows us to explore and correlate the activation of the pain matrix in a health subject to a person experiencing chronic pain such as Fibromyalgia and arthritis. Both of these chronic pains are neither neuropathic nor nociceptive which makes them useful in exploring their potential causes. This is also useful in showing the foundation of chronic pain and its stimulation in the brain from the early stage, hence design treatment which reverses this brain stimulation.

The virtual reality headset has been used previously to reduce the level of pain on patients with acute pain (13). However, with my investigation I would like to deviate from attenuating acute pain to chronic pain. I would like to explore the effectiveness of using VR on patients with chronic pain and the possibility of reversing the brain stimulation of pain in them. Using VR is widely viable in various regions of the world, and could be used in various hospitals as a cheap effective method for pain management. This addresses the economic concerns of the study and its overall implementation.

This investigation is important because chronic pain is often pervasive and undertreated due to the lack of knowledge and scientific trace of the foundation or the causation of chronic pain. This has a huge economic impact, especially when statistics show that just in the UK nearly 50% of adults experience chronic pain (1). Additionally, the NHS spends £8000 per adolescent annually and “cost-of-illness to UK society of an approximately £3840 million” per year (2). In the USA 100 million experience chronic pain mostly untreated and unrecognised medically. Therefore, the economic impact of chronic pain is phenomenally too high and undoubtably a national economic burden. This outlines the desperation and the necessity to design a disease modifying drugs which target specific cells like glial cells (3) that are endemic in triggering pain. It is important to design an investigation which is embodies scientific knowledge and propound new opportunities for treatments and medicine that cures chronic pain itself rather than its symptoms, which reduced the economic impact. Overall, this investigation should obtain results that had ecological validity but also be devoid from ethical controversy and confounds.

To continue with this idea, as an investigator, we will conduct an experiment which uses an epidemiological methodology (1) rather than clinical and laboratory approaches. This is because using epidemiology aims to consider chronic pain’s variation, exposure intensity and prevalence in a population. This is also useful because understanding chronic pain requires the elimination of mutually exclusives probability which disregards various causes to chronic pain. Leading to a study which has ecological validity.

Additionally, the use of two neuroimaging techniques increases the reliability and accuracy of the data. This is very pragmatic because pain is a complex composition which involves and impacts several networks. This might be exploited to predict the behaviour and the intensity of pain, allowing for the invention of specific targeting treatments. chronic pain such as Fibromyalgia correlates much to the phantom pain theory which concludes that the unknown cause for widespread pain must be generated from the central nervous system. Evidently the outcomes of this investigation must indicate that chronic pain must not be caused or correlate to neuropathic (damaged tissue) all the time. Therefore, the investigation outcomes should present the limitations and travesty of Cartesian model of pain perception as the only role of the brain.

The Cartesian model simply claims that the brain is solely responsible for the perception of pain hence, cannot be a cause to chronic pain (4)(5).The complexity of chronic pain has endless impacts on discovered and undiscovered body mechanism such as on the peripheral nervous system, the central nervous system, endocrine, environment, immunity, cognitive process and the respiratory system (figure1). As part of investigating team, we would like to create a study which challenges incorrect theories such as the Cartesian model as well as completing previous studies with more intense research and evidence.

Rationale

Mainly, this study is important because it proposes theories and potential evidence which could affect families, patients and the future generation’s quality of lives. As an investigator, we hope to bring a new life to patients with chronic pain. In the same way DBS was able to control motor symptoms of Parkinson’s disease which brought a new life to patients (14). We know that Chronic pain is a disease which cannot be controlled mainly due to the lack of knowledge and successful studies. With our investigation we hope to achieve and establish a similar outcome to herd immunity vaccination. This research and study also impact medical education which could set a precedent for the exponential decline for patients who experience chronic pain not just in the UK but in the world. Therefore, it is our responsibility to address and resolve the NHS economic burden and stress in dealing with chronic pain. But also develop our current, sufficient knowledge of chronic pain. Therefore, this study has a significant value to everyone as well as ours.

Aim

The purpose of this investigation is to outline that the unknown cause of the chronic pain must be generated from the nervous system through a reliable neuroimaging technique. We will use both FMRI and EEG to investigate regions of the brain which generates pain and its relation with other regions. The FMRI will be used on the patients with chronic pain which measures the blood flow, glucose metabolism and oxygen (6). Typically, an increase glucose metabolism indicates an increase brain activity as active neurons require oxygenated blood. This oxygenated blood will be disproportional in parts of the brain according to the location of pain which will require more energy to activate and fire neurons (6). This shows the pain matrix of the patient and the origination of pain which will reveal the causes of pain. Similarly, the EGG will be conducted on healthy subjects which should show a change of pattern in order to indicate that the causes of chronic pain is due to the central nervous system networks. This is because if we can turn on and off pain, surely, its stimulation must be originated from the central nervous system.

There is a difference in brain stimulation in the health subject and the patient with chronic pain. Also, the patient with chronic pain must temporarily experience no or less pain. The positive outcomes of this investigation should allow us to visually see a stimulation in brain activity from health person at rest and when they are exposed though the virtually reality headset to patients expressing their chronic pain. This is acquired through the EEG exceptional time resolution which records the magnetic potential of activated neurones before and after the exposure. This should assimilate to the phantom pain explanation, in the sense that the health subject that has no association with no chronic pain stills experiences or feels (maybe be with different intensity) the same located pain when exposed to a patient with chronic pain. This would enforce the hypothesis with evidence that the nervous system is not only responsible for deciphering and perceiving pain but it is also a complex almost with its own entity network which can generate pain without a stimulus nor a damaged tissue.

The null hypothesis of this investigation would be that there is no difference in brain stimulation in the health subject hence the lack of sensory nervous system pain generation. This might assimilate to the Cartesian model which outlines that pain is either caused by a stimulus, damaged tissue or the peripheral nervous system. Hence, the negative outcomes of the investigation will indicate that the health subject will not react to the exposure of patients with chronic pain.

Participant

The participant will be health subjects and patients with chronic pain, aged from 20 to 40 years old. This is due to the fact that brain plasticity is affected by aging (8), so it is difficult to discern whether the obtained results is exclusively due to the independent variable or to health subjects being to old. Also, the sensitivity and age restriction from the age of 18 and under might limit and misrepresent the results as it alienated a large section of society. Especially when 20% to 35% of children experience chronic pain (9). Moreover, the number of participants will be 60 in total in different age groups: 30 health subjects and 30 patients who experience different chronic pain including fibromyalgia and arthritis; each evenly distributed male and female. All participant must have had a minimum of 4 hours sleep, a meal, no intake of antidepressant 24 hours before. This is to ensure sleep deprivation and starvation does not confound the obtained data. Also, scientifically antidepressant affect the neurotransmitters (10) which affect the obtained result’s reliability and accuracy. They also must have a good eyesight to view and immerse into the virtually reality headset hence responding to their video shown.

Procedure

In my experiment, my participants will be wearing virtual reality headset where they view the experience of patients with chronic pain whilst being connected to a net of electrodes on the scalp (EEG). Externally the patients will be viewing the healthy subject’s reaction to their pain and see if their real pain in inhibited and deflected temporarily whilst being neuroimaged on an FMRI scan.

Expected Outcome

This investigation should be useful in seeing what part(s) of the healthy subject brain is stimulated when it views a specific chronic pain. Additionally, the patient with chronic pain should postulate a change in their “sensory nervous system, cognition emotional aspects of pain” which might inhibit the central nervous system from generating pain or deflect and ameliorate pain (7).

Possible Directions

If the hypothesis of the investigation equated to the obtained positive results, as an investigator we would carry a series of FMRI on a varied of patients with chronic pain and measure and record the average brain plasticity over a period of time. This will help us to merge the brain plasticity set of results and brain stimulation of a healthy person to create medicine and treatment.

If the null hypothesis of the investigation equated to the obtained negative results. As an investigator this might implore us to carry another investigation which focuses on chronic pain transitions hence pinpoint the starting point. Also, by using SMRI it will help us see and explore how brain plasticity changes with patients with chronic pain, indicating the transition stage.

Ethical Consideration

The ethical consideration includes the rights of withdrawal because the health subject might view this investigation as an emotional burden surpassing the tolerance limit. Therefore, it is important to allow healthy subjects and patients to withdraw if it impacts their well beings. Neuroimaging precipitants from different age groups, gender and social life will although be a useful non-invasive it requires steadiness and patience for a maximum of an hour. This is because of the high sensitivity of FMRI and EEG which might impact the obtained results reducing its accuracy.

Additionally, the rights of anonymity will be taking into account and implemented in my investigation. The guidelines of any scientific experiment and investigation (11) is as follows written consent which comprises the nature and the purpose of the investigation the possible risks and future utilisation of the obtained data. This is important because the science of pain is limited and stagnated. Mainly because the term “human experimentation” is dissented in society. Hence reducing the likelihood of pain management which is achieved through experimentations, logical error and deviation from the Cartesian model for unidentifiable causes (3). Therefore, the lack of participant and assessment of patient who experience chronic pain has limited and impeded our understanding of pain.

Conclusion

In conclusion, chronic pain is a multidimensional disease which have many causes both known and unknown. The unknown causes tend to perplex pain scientist which leads to them being classified as idiopathic pain with no treatment (11). our study aims to explore a health subject exposed to chronic patient and a chronic patient exposed to the health subject’s reaction encountering their disease. This study might illustrate brain regions of the health subject being stimulated such as the sensory nervous system. As well as outlining that severity of the chronic pain can decline and ameliorate because if pain can be generated by something as complex as the nervous system it could also control its intensity and suspend it. The number of participants will 60 in total will the same number of females and males but a range of age groups. This is useful in addressing different structure in the whole population. Additionally, The FMRI and the EEG combined will produce a high spatial and temporal resolution which records where active neurons are firing to and originating from. This helps use to produce medicine which can deflect the active neurons from contacting other brain regions which leads to more pain in more regions of the body. As well as stop active neurones from originating themselves.