Michael Vianin
The understanding of pain has been dominated by a brain-centric paradigm focused on nociceptive processing. This reductionist interpretation of pain needs to be balanced by the multiple processes outside of the central nervous system involved in the experience of pain. Assigning the whole experience of pain to one organ, the brain, fails to account for the complexity of the phenomenon. Pain is better understood when assigned to the whole itself and to the interactions of the components of the system. (1)
The fallacy of division currently prevalent in the pain field has been a hallmark of medical models for decades if not centuries. Both the biomedical and biopsychosocial models of care view the person as a whole, who is best understood by separately assessing and treating individual parts. (2) Complex biological systems are more than merely putting together individual parts to build a whole. They are best understood as parts that interact with each other in a way that also influences and alters the parts themselves in the process. (2)
Pain typically ascribed to central mechanisms often embodies alterations or involvement within peripheral systems. (1) The peripheral nervous system can play an essential role in the production and maintenance of pain. (1) Furthermore, other parts of the system play important roles in the perception of pain. For example, fibromyalgia can be linked to significant alterations in key brain regions associated with the pain experience, pathological changes in small nerve fibers, low-grade systemic inflammation, changes in gut microbiota, and microvascular alterations, among other factors. (1)
The binary discourse debating pain as a bottom-up or top-down process is not as straightforward, and the pivotal contribution of peripheral mechanisms to changes in cortical reorganization, among other factors, should not be underestimated. (1) Pain cannot merely be reduced to nociception but rather requires considering the subject’s subjective experience (1) and global context (2).
Clinicians must be cautious to not fall into the trap of oversimplified understanding of pain to avoid relying on treatment strategies targeting solely one component of the whole system. Such reductionist strategies have been dominating the pain management field producing less than optimal outcomes. The Dispositionalism Model of Care considers the multiple facets at play in pain, in particular the different contextual factors that influence the pain experience. Integration of these dispositions can positively impact the clinical encounter, foster therapeutic alliance, and improve outcomes. (2)
1. Párraga JP, Castellanos A. A Manifesto in Defense of Pain Complexity: A Critical Review of Essential Insights in Pain Neuroscience. Journal of Clinical Medicine. 2023; 12(22):7080. https://doi.org/10.3390/jcm12227080
2. VIANIN, M. Dispositionalism in Musculoskeletal Care: Understanding and Integrating Unique Characteristics of the Clinical Encounter to Optimize Patient Care. EVOLVE GLOBAL PUBLISHING. 2021