Specificity to neuroplasticity and back again?

There is nothing like a good thinking session to kick off the new year. In their new paper, just published in Pain Medicine, the dulcet tones of A/Prof Milton Cohen and partners have been transformed to print in what is a very interesting critique of the theory of pain as a disease. Or, as they put it, ‘pain-as-a-disease’. It really is a tricky issue and my thoughts on it are on the record here, but Cohen et al take a more theoretical knife to the idea. They purport to test these three theories – specificity, neuroplasticity and disease theories – under what they call a framework of evolution of pain medicine theory. They conclude that the evolution from specificity to neuroplasticity was based on evidence and conceptual clarity, but that the subsequent evolution to pain-as-a-disease is faulty on the grounds that (i) pain is at once considered a symptom, a cause and a pathology, and (ii) the evidence concerning pathology is wishy washy.

1 Pain as a symptom, a cause and a pathology

Two tenets of ‘disease’ are that it is associated with abnormal structure or function of a body system and a characteristic clinical profile – the disease is a cause of the clinical presentation. This is the Catch 22 – chronic pain is considered a characteristic set of symptoms caused by the disease (pain). That is, chronic pain is caused by chronic pain. Confused?

2 Wishy washy evidence of pathology

Cohen et al argue that evidence of gray matter loss, which underpins the disease definition, is not that strong – and I tend to agree, especially in light of this new paper which argues that up to 95% of findings of abnormal gray matter density, using voxel based morphometry, are likely to be false positives (you read that right – check out our previous blog post on it here).  Rather than repeat Cohen et al’s coverage of the evidence, read their paper and see what you reckon.

Cohen et al won’t make any friends in high places with this paper, particularly with this assertion:

“By blurring the lines of cause and effect and of antecedent and consequent, taken together with the failure to propose an acceptable name for this “disease” other than the morally charged “maldynia” [24], this proclamation ultimately constitutes the philosophical error captured by Wittgenstein [25] in his aphorism #114: “One thinks that one is tracing the outline of the thing’s nature over and over again, and one is merely tracing round the frame through which we look at it.” The claim that pain is a disease is thus passed off as an assertion of certainty but only because that is demanded by the frame of reasoning through which it was conceived.”

However, I suspect that they are not driven by a need for friends. Rather they might be driven by a need for the right process, and that seems critical to this debate.

Perhaps it comes down to whether one is outcome-driven or process-driven. That is, an outcome-driven approach would render the technicalities emphasised by Cohen et al unimportant in comparison to what is at stake. If chronic pain needs funding, and our societies were ploughing money into fruit, would it be all that bad if we redefined chronic pain as a fruit, in order to get the money it deserves?

The alternative, process-driven approach, would be to call chronic pain the consequence of a disease to which we would have to give a very uncatchy name, for example “ongoing implicit perception of threat to body tissue as a result of multiple system sensitivity and inaccurate evaluative processes, in the absence of true threat to body tissue”. If we did that, what are the chances of getting it understood by the powers that be, and therefore funded? We would remain true to our modus operandus, but the problem would continue to fly under the societal radar. By taking a process-driven approach, Cohen et al are defenceless against outcome-driven criticisms, but the same is true in reverse – to define chronic pain as a disease hits up against the Catch 22 mentioned earlier and there is not really anywhere to go.

Is there a third way perhaps? Is it pie in the sky to hope that we might increase community understanding and acceptance of the multifactorial nature of chronic pain, and the huge burden it places on us as a society and on the individuals who suffer and their families, and then establish it as a problem that we might collectively invest in solving?

Time, I guess, will tell.

About Lorimer Moseley

Lorimer is NHMRC Senior Research Fellow with twenty years clinical experience working with people in pain. After spending some time as a Nuffield Medical Research Fellow at Oxford University he returned to Australia in 2009 to take up an NHMRC Senior Research Fellowship at Neuroscience Research Australia (NeuRA). In 2011, he was appointed Professor of Clinical Neurosciences & the Inaugural Chair in Physiotherapy at the University of South Australia, Adelaide. He runs the Body in Mind research groups. He is the only Clinical Scientist to have knocked over a water tank tower in Outback Australia.

Link to Lorimer’s published research here. Downloadable PDFs here.


Cohen, M., Quintner, J., & Buchanan, D. (2013). Is Chronic Pain a Disease? Pain Medicine DOI: 10.1111/pme.12025

Scarpazza, C., Sartori, G., De Simone, M., & Mechelli, A. (2013). When the single matters more than the group: Very high false positive rates in single case Voxel Based Morphometry NeuroImage, 70, 175-188 DOI: 10.1016/j.neuroimage.2012.12.045


  1. John Quintner says:

    Dr Rodrigues, in response to your comment, may I point out:

    1. It is “people” who need treatment and not “pain” per se.

    2. Seeking linear “cause and effect” relationships is doomed to fail. We now understand that living organisms are complex dynamic systems. That the link between input (treatment) and output (response) is a highly variable one was realized by Melzack and Wall when they proposed their revolutionary “gate theory” of pain.

    3. The various therapeutic options you mention are of questionable if any benefit. In particular, the “trigger point” hypothesis is a conjecture without scientific foundation. All the the research that has been conducted has been guided by belief systems, rather than on established scientific knowledge. Similarly, clinical practice that is based upon this flawed research has been exposed as ineffective.

    4. The concept of “spinal segment sensitization” may be a nice story for those who hold to the view that “pain” is punishment (i.e. “hellfire and brimstone”) but one that is non-scientific. But the word pain does in fact derive from the Latin “poena” = punishment.

    5. The very concept of bioplasticity is testament to the need for better theory to guide our clinical practice. Let us not revert to the outdated biomedical reductionist thinking that you appear to espouse.

  2. Pain can not be distilled into a finite word or entity. Pain as a “thing” that is itself capable of producing an effect.” It is an emotion and thus individual. My opinion, until proven otherwise pain is a “thing” that is capable of producing an effect and affect in the subject.
    Lets combine your “Three dominant theories” into a single concept and not waste time so we can begin to treat patients who are suffering in pain today while researchers debate.
    Yes pain is caused by multiple issues so it would make sense to treat all of those factors with multiple therapy options in a case by case comprehensive personalized manner.

    What do we know;
    Chronic pain needs treatment.
    Chronic pain can not be treated in a cause-effect manner like one would treat appendicitis, with invasive surgeries or medicated with a set of pills.
    Chronic pain should be treated with the multiple therapeutic options that are all safe and nontoxic first line — as soon as the diagnosis is considered.
    Chronic pain will responds to a lot of the therapy options of the last 100 yrs; Tissue manipulation, spine and joint manipulations, Traditional Acupuncture, and trigger point or substance injections.
    Chronic pain that is not treated with these options can potentially spread into surrounding zone and invade the small rotators of the vertebra to progress into a more sinister pain syndrome called “Spinal Segment Sensitization” which is the pain of hellfire and brimstone.

  3. John Quintner says:

    Dear Stephen. Travell, Rachlin and Gunn have all enjoyed popularity but their therapies were based upon a misinterpretation of the phenomena attributed to the Myofascial Trigger Point. I know that “dry” needling remains in vogue amongst some physical therapists but its scientific foundations are decidedly shaky and the published outcome data are singularly unimpressive. These days one needs evidence in order to justify calling any modality of treatment a “valuable therapy”. Simply issuing proclamations to this effect is no substitute for evidence.

  4. Complex discussion! I do miss the point of the words, definitions as these words related to pain and suffering. The “whys” are important but ignoring the fact that we have potent therapies to treat pain is just wrong. Travell, Rachlin, Gunn and many others have protocols to help pain. One major barrier is how naysayers in power will block valuable therapies in the hope of profits is wrong. Let the patient define pain and let them dictate what therapy is best for them.

    I notice a reference to ICD-10 … which is another barrier to therapy because there are not codes for some of the valuable therapy. If there are not codes doctors and providers will not perform them for no pay. (except a few of us who are considered … stupid)

  5. I think there are some pragmatic short-term advantages in pain being labelled as a disease – such as a potential boost in research funding once it is considered a “real” disease in itself in itself rather than a simple outcome of some structural tissue “pathology”, which is still unfortunately often the case with funding and governmental agencies.

    I am in the “pain is not a disease” camp however. I think as healthcare professionals when we see a person presenting with widespread, disabling pain, we tend to consider pain as the disease/disorder/symptom (delete whichever term you dislike for now)…….and we note the many other diseases/disorders/symptoms (insomnia, depression, anxiety) that person may present with as either (a) coincidental, or (b) secondary to the pain, or (c) causing the pain.
    Instead, it seems plausible that this person has a very real systemic “illness” which has altered their body’s physiology in many ways, and which results in many clinical phenomena – one of these alterations in their physiology leads to pain which is very real. But the altered physiology could also include leave them susceptible to sleep disorders, mood disorders, greater difficulty controlling emotions and anxieties…. In other words, the pain is very real, and is not closely related to tissue pathology, but it may be simply one manifestation of a systemic “illness” or “sickness” which affects multiple systems, and not just the nervous system. In that way, central sensitisation is just one manifestation of how this “illness” affects the nervous system, rather than being a disease in itself. While there is a whole lot of speculation in this, I think the recent Lyon et al paper by the authors of this paper is well worth a read, and has a lot more meat to it!

    As an aside, it is interesting to see that is far less debate on obesity being considered a disease, despite it being in many ways a symptom (with probably many contributing factors).

  6. John Quintner says:

    Suzanne, you are communicating perfectly. You may be at a disadvantage by not having read our paper on this topic. If you contact me at my email address (jqu33431@bigpond.net.au) I will send you an electronic copy of the paper. It has not yet been published in print form.

  7. Suzanne Newnham says:

    I became very despondent on the reply to my previous comments as once again circular arguments come into play. Is my wording clumsy? Am I not communicating properly? Since then I watched as my emails built up (still haven’t replied to similar discussions a couple of months ago). Then I read Daniel’s comments, my thoughts different wording, Daniel’s words concurred by Neil. Again the responses – well at least I can be reassured about the wording of my opinion. So here goes …

    As Daniel said, “Chronic pain is both normal and disease, symptom and cause, and every possible combination in between!” If you use the analogy of apple and orange: they are both fruit and can be described as such. But if you start describing an apple in terms of what an orange looks like, taste, texture etc you will be so far from being accurate. Chronic pain is (using the analogy) fruit; now for the descriptions of chronic pain as individual pieces of that fruit: chronic pain as a symptom of an underlying disease state is accurate; chronic pain without definable diagnosis, recognisable cause (to the current knowledge, technology or perhaps just not the right investigations done) and not just a symptom is also accurate. This latter type of chronic pain has to be considered in its own right – call it a disease or not, just identify it as separate from being a symptom and all the stigma, the disbelief of the intensity and impact when no “real” cause is found.

    I only used the fibromyalgia sequence of names to illustrate the change in names as research etc came to indicate a new level of understanding (not a comment on whether that new understanding, what it includes and discards is accurate or appropriate). It was not meant to get into a discussion about a specific medical condition (which in itself is hugely contentious).

    The type of chronic pain which is being discussed, the implications on every facet of one’s being, one’s life, the impact especially on people immediately around you, and the depths of existing that is experienced and lived daily because of that intense and persistent pain it is an insult to have the words/terms “good” pain and “bad” pain bandied about to try and compartmentalise a very damaging situation. Talk about the potential for creating greater stigma!

    I have said what I am going to say. There may be flaws in my understanding of medical intent behind the terminology and I just see the words and their literal meaning, however, more importantly for me I don’t have the energy or the inclination to continually defend my words written with the experience of what I have LIVED WITH for over 5 years.

    I wish you well with your continued discussion – which I will still be following.
    cheers Suzanne

  8. David Buchanan says:

    “We must allow chronic pain to be a disease to escape the dualism of “disease or normal”,” ? You see the problem…? Daniel – you simply cannot have your cake and eat it too! QED. There is a language game afoot here – not the nature of the thing (especially so when the thing ain’t a thing – but is a self-organising complexity). To get beyond a self-imposed and unnecessariy imposed disease/normal dualism – we simply need to stop muddying the waters by using the word disease. It cannot be a disease for it isn’t a disease – it is an experience of growing and unpredictable complexity. Otherwise we must call chronic pain bad pain (maldynia) and reflexive/nociceptive pain eudynia… And look at the morlaised dualism writ large. My point remains – let’s be careful about what language we use ove the nature of the complexity we are dealing with? Surely? Best d

  9. John Quintner says:

    Daniel, your proposition is reminiscent of the “good” pain (eudynia), “bad” pain (maldynia) dichotomy that we discuss in our paper.
    I think there is a way around this problem.
    You might like to read and comment upon our hypothesis paper – Lyon et al. 2011. An evolutionary stress-response hypothesis for chronic widespread pain (Fibromyalgia Syndrome).

  10. Hi David. Not all chronic pain can or should be characterised as disease. Your pain experience may be stress responses as you say, with minimal or no disease component.

    Similarly arthritis and cancer sufferers may have chronic pain that is predominantly a normal nociceptive response to ongoing inflammatory processes. They may however have some signs and symptoms of chronic pain as a disease, which could include hyperalgesia resulting from central sensitization, impaired sleep, depression, and pain related anxiety. Their chronic pain may be classified for argument sake as 80% normal pain 20% disease component.

    Another individual for example may have chronic limb pain with no initiating injury or infection. They may have gain-of-function ion channel mutations in the peripheral nervous system, which combined with certain environmental factors has led to the development of central sensitization in the spinal cord. Severe chronic pain has, over time, impaired activity, attention and learning and resulted in changes to brain structure. This individual’s chronic pain may be classified as 20% normal pain (pain resulting from limited physical activity, muscle weakness, and mild inflammation) and 80% chronic pain disease.

    I think you might be the one trapped in a dualistic narrative, believing that the argument here is “disease” or “not disease”.

    We must allow chronic pain to be a disease to escape the dualism of “disease or normal”, “symptom or cause”. This is precisely the problem with the tradition view of pain as a symptom. Chronic pain is both normal and disease, symptom and cause, and every possible combination in between! That is in my view the sophistication of the theory and the challenge for scientists and clinicians.

  11. David Buchanan says:

    I’m sorry – pain as a disease is simply a philosophical error. Atypical is simply another word for normal in this context. Chronic pain is atypical for us – not for the brain – nor the endocrine system – nor immune system. We asserted for hundreds of years a philosophical error over this complexity – it was/is called dualism. Then we find a self-organising, noncentred and wildly unpredictable neuro-immuno-endocrine systems that render dualism insupportable. Just because A) central sensitisation exists doesn’t follow that its association with B) chronic pain renders it necessarily C) a disease never mind if its experience is a symptom or a causality. This is classic post hoc ergo propter hoc: the fifth error of classical reasoning. I too, Daniel, suffer from chronic pain – and – i dislike being told I am diseased when what i suffer from may well be stress responses that are absolutely typical in all mamalian brains… I’m sorry – empiricism is simply not enough in the kind of complexity over which pain-as-a-disease would be imposed like a colonial flag over an unknown land. How many more times to we have to expend energy on a proclamation of certitude only to find that the proclamation met our needs before the actual thing’s nature? (Wittgenstein #114).

  12. John Quintner says:

    In our paper we admit that the argument turns on the definition of “disease” that we have quoted.
    Yes, the lived experience we call “love” is not usually considered a disease process, but “love-sick” might suggest the opposite. In the 19th century, “nostalgia” was awarded disease status. How about “shell shock” in the early 20th century?
    In philosophical terms we have encountered the “is-ought” gap (attributed to David Hume). Chronic pain OUGHT to be a disease, ergo it IS a disease.
    Daniel’s prediction may turn out to be accurate – “I am confident this theory will be increasingly developed and reaffirmed as science reveals more about the human nervous system.”
    However, as Lorimer has said, this is a tricky issue.

  13. Thinking more on this … Pain is a human experience.
    Our struggle with it is similar to what might occur should we endeavour to define other troublesome human experiences, such as love.
    Yup, I know that love isn’t usually considered a disease process, but we talk of it as both an experience and a state of being. I am in love, and I know it mainly because I feel love.
    (in case anyone should think I am invalidating the horrible nature of pain by comparing it to love, that is not my intention, and we can replace love with hate if that helps)

  14. Well written Daniel. I am curious how Lorimer, Michael and John will respond, especially to the idea that maybe one of the problems is that there is a flaw in thinking of pain as a symptom. Part of the argument has been that ‘chronic pain as a disease’ doesn’t make any sense because we cannot say the disease and the primary symptom are the same thing. We should consider that maybe accepting ‘chronic pain’ as a disease process name is more appropriate than accepting ‘chronic pain’ as a symptom.
    Pain is part of normal life. (yes I know I cannot define normal)
    Chronic pain is not. As best we know chronic pain is a result of atypical responses in the nervous systems (I am not blaming it all on this system, or saying other systems are not involved). … So, I like the direction that Daniel has steered us in here.

  15. As I mentioned in response to another of Lorimer’s posts, I have had chronic pain in my legs since I was a teenager and rely on a wheelchair for mobility. The concept of chronic pain as a disease in its own right was the only theory in medicine that explained my reality.

    I spent years going to doctors who looked for pathology with x-rays, MRIs, blood tests and a range of other investigations without success. After years of confusion and frustration I turned to the scientific literature and found Professor Cousins work. It explained to me that the intense pain that impaired my activity was not necessarily a symptom but the actual problem. It was an incorrect or exaggerated message in my nervous system, the disease itself and not the symptom.

    This was a revelation to me. It enabled me to stop searching for an elusive disease and begin combatting the pain directly. It gave me hope that scientist were on the right track and has been the source of my greatest strength and healing.

    Addressing the Cohen et al. article and Lorimer’s blog, both doubt the validity of pain being both a symptom and a cause. Lorimer ridicules the concept by stating “This is the catch 22…chronic pain is caused by chronic pain. Confused?” But this position overlooks large volumes of scientific literature describing central sensitisation and the potential for similar processes of self-reinforcement and amplification to be responsible for the pathology of chronic pain. It must be remembered that the majority of our knowledge in this area has been derived from animal studies. Given the diversity of human chronic pain conditions and the difficulty in accessing human nervous tissue, very few if any of the experimental models can be applied to human subjects with appropriate sample sizes and controls. Are you suggesting that the literature describing central sensitization and other nociception initiated neuropathology in animal models is irrelevant to the human condition?

    Furthermore “chronic pain as a disease” is not suggesting that the cause of chronic pain is limited to pain itself. Most importantly it acknowledges that chronic pain is likely to have multiple concurrent causes. It may for example involve initiating injuries or infections, which on their own are not sufficient, combined with a constellation of currently unknown genetic susceptibilities and neurophysiological processes. Even if our scientific knowledge was sufficiently advanced to understand every detail, will we give a seperate disease name to every individual condition, conditions that are likely to be significantly overlapping in constitution? Why not just call it what it is…chronic pain? Further characterisation can be ascribed under this disease umbrella as we better understand the infinite complexities of pain physiology, and pain pathophysiology.

    I think the Cohen et al. article was right in comparing the chronic pain as a disease theory with the preceeding specificity and neuroplasiticity theories. As far as I know throughout human history pain has been viewed solely as a symptom, signallying the presence of another distinct entity. To view chronic pain as a disease itself represents, like the theories before, a significant and progressive shift in our understanding of the human condition. I firmly believe this is the most sophisticated approach, which in its semantic simplicity most accurately reflects the science and the remarkably similar life experiences of those with chronic pain. I am confident this theory will be increasingly developed and reaffirmed as science reveals more about the human nervous system.

  16. John Quintner says:

    Suzanne, as far as I am aware, the proponents of chronic pain-as-a-disease have already presented their case to those who are deliberating on the new ICD-10. Lorimer did address this issue last year at a meeting of EFIC and may be in a position to report back on the outcome.
    Historically, there has been a progression from Neurasthenia as formulated in the 1860s by George Miller Beard to Fibromyalgia as constructed by the American College of Rheumatology in 1990. The latter classification/diagnosis rested upon the presence of chronic widespread pain and 11 or more of 18 anatomical points where a person was found to be more tender than was to be expected. The tender point criterion was abandoned in 2011 and the condition has since lacked this anchor for diagnostic purposes.
    So far, the only name that has been proposed for your “chronic/persistent pain without a definable diagnosis” has been Maldynia (“bad pain”) put forward by the American Academy of Pain Medicine. For obvious reasons people in pain might not wish to embrace such a label.
    My personal opinion, and I may be proven quite wrong, is that “chronic pain” cannot be slotted into a convenient pigeon hole in order to satisfy those who fund health care and provide income support etc.

  17. Suzanne Newnham says:

    I see “chronic pain as a disease” as 2 separate issues (not necessarily written in order of priority):
    1. correctly placed under the International Classification of Disease code so that people disabled by “chronic/persistent pain without a definable diagnosis” can actually have a more relevant box to tick in able to apply for health fund recognition, pensions, and other resources available to chronically ill or disabled people.
    2. not all people are the same when it comes to labels. Yes, a label can become a person in some instances (but then it wouldn’t matter what “disease” label that person was given they would wear it “with pride” so to speak). A label, and even “chronic pain without a definable diagnosis” is a recognition of that person’s current state of health and a platform from which can then be launched a multi-modality treatment plan. Some of these modalities can run concurrently, others will be a trial and error depending upon the abilities and finances of the person in pain. This discussion is for pain that is NOT a symptom of another classified disease, injury or trauma state. When further investigations whilst under a “chronic pain disease” label which leads to a recognised and known diagnosis then the chronic pain disease label is discontinued and replaced by the new diagnosis.

    Over the centuries how many pain states have remained that until research has identified the source and given it a name? This original name sometimes changed as further research and improvements in technology and knowledge have redefined source and/or different pathways/progression e.g. fibrositis-fibromyalgia-from rheumatological to ??or and neurological/immunological/endocrine basis???
    In all the discussions that I have been reading over the past 18 months or so, I have got the feeling the process rather than people have been the focus! Please remember people are all different, and different again when in constant pain – don’t be afraid and don’t allow the status quo to remain.

  18. David Buchanan says:

    Yes – in fact the argument is that pain-as-a-disease is conceptually confused neuroscience. Neuroscience actually points to the third way, marnie… and is in fact sooo complex that there is no acronym possible… Community education is vital – I agree… but let’s clarify what we want educated first? If we piss down the communitity’s neck and tell them it’s raining then when we actually have real natural water – they won’t wanna listen…???

  19. John Quintner says:

    Marnie, I am all for neuroscience education but this is not the main issue here. After all, some prominent neuroscientists have supported chronic pain-as-a-disease. If it is eventually decreed by those in high places (but not in the highest one, of course) that a disease by the name of “chronic pain” exists, upwards of 20% of the population could potentially attract this diagnosis. The implications for systems of income support and personal injury compensation are huge. We did not explore this issue in our paper but, at least in my opinion, it might be worth considering.

  20. “oipottbtaaromssaiepetaotttbt” even the acronym is impossible….I vote community education until they embrace it in the marrow of their bones. Lorimer – Commander and Chief of Operations – get out the word for Neuroscience Education!
    Keep it up -it pays every day with more than $$, some day that will come, it has to!

  21. David Buchanan says:

    I would suggest that ‘the third way’ can only occur in ‘the third space’ (the intersubjective) but wherein the clinician’s ‘expertise’ and the person-in-pain’s ‘subjectivity’ is renegotiated (that is not jetisoned – no babies are to be thrown out with the bathwater!!) to recover at 3 simultaneous levels: 1. medical illness (CRPS and whatever) 2. how the person thinks, feels and relates in their individual lives (sometimes errantly referred to as psyco-social disorder) and 3. how the social-self partcipates in the ocial determinants of health (connected to the community; included in the community; have access to income and social and economic participation and education).

    For mine this process ought to be the next step in conceptually clarifying the huge advances in scientific knowledge in this arena. There is much work to be done??

  22. David Buchanan says:

    Michael, thank you for this… I find your points very timely and I suspect will ultimately dictate a change in approach from one of the untenable task of assigning a disease (conceptually confused apropos of this paper) towards an approach that all the evidence and conceptual clarity seems to point: to an embodied intersubjective (negotiated) conceptual framework – wherein all involved engage in a mutual sense-making process?

  23. Michael Negraeff says:

    This has been a conundrum for me as both a physician and chair of an organization advocating for system change that seeks to help others understand what is at stake.
    I’ve never quite been comfortable telling people who make decisions or people that have pain that chronic pain is a disease. For people with pain, it is a bit of a label to call it a disease and I fear may lend a feeling of fatalism in them that actually disempowers them to do anything about it, even as it gives them a sense of a diagnosis and label they can latch onto. For policy people, it may be tempting to think it will catch their attention for funding in the current “chronic disease management” models and I think that is why we latched onto it. But there is risk if we can’t explain what we mean very clearly and especially if we harbour some doubts about calling it a disease. Also the same sense of fatalism can creep into policy – why do anything about a “disease” that the people who treat can hardly make me understand?
    So I’ve started to refrain from calling it that. Instead spending more time talking with patients what I really believe and focusing on hope and optimism and even allowing for some mystery that need not all be solved in order to be at peace with it. With policy folks, I need to boil it down to two or three talking points that can explain the conundrum, but again focus on what it is we can actually do to change outcomes for people and the system, again without needing to completely understand what parts of the multifunctional nature you are changing by how much – just that there is a measurable improvement.
    Thanks for the chance to discuss it! Michael

  24. The descriptor “pain without a cause” an oxymoron (and anathema to persons with chronic pain.) If it exists, some “thingamabob”, caused it, even if we know not what (yet). MHO. If you can’t touch it it doesn’t mean it doesn’t have a cause. Try touching radio waves….

  25. John Quintner says:

    Dear Lorimer. For the record, we do offer a third way at the conclusion of our paper. “By contrast, neuroplasticity theory, when seen as part of a broader manifestation of how an organism might survive in a hostile environment, offers both greater explanatory power for the observed phenomena and a platform for progressive research.” Is this “pie in the sky” stuff? Over to you.

  26. Well stated Lorimer, and Cohen et al.