Abstract
Consciousness constitutes a fundamental prerequisite in the individual appraisal and experience of pain. In the same way, a person needs to be able to report on pain perception. Patients who suffered a severe brain injury with disorders of consciousness (DOC) represent a spectrum of pathologies affecting patients' capacity to interact with the external world. In these patients, the most relevant aspects in response to pain are physiologic and behavioral. The treatments and management of pain are challenging issues in these patients, arising serious ethical concerns and bringing emotional load among medical staff, caregivers, and relatives. In this review, we report the importance of having a correct pain management in DOC patients, to individuate the best pharmacological treatment that can make the difference in detecting a behavioral response, indicative of a change in the level of consciousness, and in planning a more effective rehabilitative approach.
Highlights
In 1979, the IASP approved the following definition of pain: "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" coupling the sensory and emotional dimensions of the experience, as well as the association between tissue injury and pain (IASP, 1979).The emotional experience can be described by a complex system of interacting processes characterized by affective, expressive, cognitive, and physiological components (Scherer et al, 2001).In 1999 McCaffrey and Pasero reported a similar definition: "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does" denoting the subjectivity of the pain experience (McCaffrey and Pasero, 1999, p 63)
Kassubek and colleagues, using the same PET technique in disorders of consciousness (DOC) patients, found the activation of the secondary somatosensory cortex, in the cingulate cortex contralateral to the stimulus, and the posterior insula ipsilateral to the stimulus (Kassubek et al, 2003). These findings suggest that DOC patients might have a residual perception and partial sensory-discriminative pain processing
Another fMRI study performed by Markl and colleagues (Markl et al, 2013), demonstrated the significant activation of the sensory and affective components of the pain matrix in patients clinically diagnosed as UWS/VS, suggesting the possibility of a painful experience in some of these patients
Summary
In 1979, the IASP approved the following definition of pain: "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" coupling the sensory and emotional dimensions of the experience, as well as the association between tissue injury and pain (IASP, 1979). In 1999 McCaffrey and Pasero reported a similar definition: "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does" denoting the subjectivity of the pain experience (McCaffrey and Pasero, 1999, p 63). Such definition implies that pain may be detected when a patient reports its manifestation but that consciousness constitutes a fundamental prerequisite in the individual appraisal and experience of pain. From a more accurate terminology, a key aspect of pain remains the subjective experience and the necessity to
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