Pain is a private percept that arises in a conscious brain, typically in response to a noxious provoking stimulus, but sometimes in the absence of a stimulus. The relation of the percept to the stimulus is variable, and depends on the individual's prior expectations and beliefs, and on his/her cognitive and emotional state, not just on the nature of the stimulus itself. The nervous system may react to noxious stimuli with autonomic changes (e.g. in blood pressure), and even with adaptive behavioral responses, in the absence of a conscious pain percept. Likewise, there are circumstances in which the presence of pain is ambiguous, such as when the individual is unable to report on his/her conscious percept, or with reference to animals. In these situations, the word "nociception" is used instead of the word "pain" to express that the nervous system has detected the noxious stimulus without necessarily implying that a pain percept was evoked.
The European Pain Federation (EFIC) has declared pain as a major health problem, a disease in its own right: "Pain is a major healthcare problem in Europe. Although acute pain may reasonably be considered a symptom of disease or injury, chronic and recurrent pain is a specific healthcare problem, a disease in its own right".
Acute pain, such as that following trauma or surgery, constitutes a signal to a conscious brain about the presence of noxious stimuli and/or ongoing tissue damage. This acute pain signal is useful and adaptive, warning the individual of danger and the need to escape or seek help. Acute pain is a direct outcome of the noxious event, and is reasonably classified as a symptom of underlying tissue damage or disease. However, in many patients pain persists long after its usefulness as an alarm signal has passed, and indeed, often long after the tissue damage has healed. Chronic pain in these patients is probably not directly related to their initial injury or disease condition, but rather to secondary changes including ones that occur in the pain detection system itself.
In addition to being due to different physiological mechanisms than acute pain, chronic pain often sets the stage for the emergence of a complex set of physical and psychosocial changes that are an integral part of the chronic pain problem and that add greatly to the burden of the pain patient. These include:
1. immobility and consequent wasting of muscle, joints etc.
2. depression of the immune system and increased susceptibility to disease
3. disturbed sleep
4. poor appetite and nutrition
5. dependence on medication
6. over-dependence on family and other caregivers
7. overuse and inappropriate use of professional healthcare systems
8. poor performance on the job or inability to work, disability
9. isolation from society and family, turning inwards
10. anxiety, fear
11. bitterness, frustration, depression, suicide
Although comprehensive epidemiological data for the European Union are not available, chronic pain is clearly a very widespread condition. Several recent community-based surveys, for example, found that about 50% of adults sampled suffered from one or more types of pain at any given point in time. In a substantial proportion of those surveyed, the pain was both chronic and severe -the numbers increasing considerably in older age groups. The most widespread chronic pain conditions, low back pain, arthritis and recurrent headache (including migraine) are so common that they are often seen as a normal and unavoidable part of life. Although few people die of pain, many die in pain, and even more live in pain.
While acute pain is by definition a brief and self-limiting process, chronic pain comes to dominate the life and concerns of the patient, and often also family, friends and other caregivers. In addition to the severe erosion in quality of life of the pain sufferer and those around him/her, chronic pain imposes severe financial burdens on many levels. These include:
1. costs of healthcare services and medication
2. job absenteeism and disruption in the workplace
3. loss of income
4. non-productivity in the economy and in the home
5. financial burden on family, friends and employers
6. worker compensation costs and welfare payments
Authoritative sources place the overall financial costs of chronic pain to society in the same range as cancer and cardiovascular disease.
Detailed information on this subject is available from the following sources:
1. Wall P.D. and R. Melzack (eds.) Textbook on Pain, 6th Edition. Edited By Stephen McMahon, FMedSci, FSB, Martin Koltzenburg, MD, FRCP, Irene Tracey, MA (Oxon.), PhD, FRCA and Dennis C. Turk, PhD. Saunders 2013, 1184pp.
2. J. D. Loeser (ed.) Bonica's Management of Pain, Third Edition, Lea and Febiger, 2000. (Harcourt). New edition will be released on October 13, 2018.
3. Practical Management of Pain, Fifth Edition, Honorio Benzon James Rathmel Christopher L. Wu Dennis Turk Charles Argoff Robert Hurley.Mosby 2013.
4. Orofacial pain and Headache. Edited by Yair Sharav and Rafael Benoliel. Chicago Quintessence Publishing Co, Inc, [2015]
5. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine. 2011.
6. Raj's Practical Management of Pain. 4th Edition. Authors: Honorio Benzon James Rathmell Christopher L. Wu Dennis Turk Charles Argoff. Mosby 2008,1344pp.
7. http://www.iasp-pain.org
8. http://www.jr2.ox.ac.uk/Bandolier/index.html
9.http://www.cochrane.org/
First development
In Israel, as in the USA, Europe and elsewhere, Pain Medicine emerged as an academic field largely through the efforts of anesthesiologists, with the collaboration of physicians from other fields, and of basic scientists from physiology, pharmacology, psychology and neuroscience.
The first dedicated Pain Clinics were organized in the United States as a result of the inspiration of John Bonica. Some of the early clinics offered special courses on pain management techniques, particularly nerve blocks. In 1960 Florella Magora, after training in the Pain Clinic set up by Emory Rowenstine in the Bellevue Hospital, New York University, began to use nerve blocks for the relief of pain at the Department of Anesthesia of the Hadassah-Hebrew University Hospital in Jerusalem. At about the same time Jesmond Birkhan, director of the Department of Anesthesiology at Rambam Hospital (Technion Medical School) in Haifa, and Mark Chayen, director of the Department Anesthesiology at Ichilov Hospital (Tel Aviv University Medical School), became active in the treatment of pain in their respective institutions. Chayen was sensitized to the need to relieve pain by his experiences in World War II; he was among the first troops to enter and liberate the camps. Birkhan, too, became interested in pain through personal clinical experiences, fortified by a seminal mail correspondence with Bonica. All three groups began to train residents in pain management. Consultations and treatments mainly took place in the hospital emergency room or operating theatre.
During the Six Day War in 1967 large numbers of soldiers were treated for traumatic wounds, and a great deal of experience was gained in the diagnosis and management of patients suffering from causalgic pain and from spasticity of peripheral and central neural origin. Pain patients were investigated and treated by anesthesiologists in close collaboration with neurosurgeons, orthopedists and specialists in rehabilitation. Special mention should be made of Aaron Beller, head of the Department of Neurosurgery at Hadassah, and later dean of the Hebrew University Medical School, and Alex. Magora, head of Hadassah’s Department of Physical Medicine and Rehabilitation. During this period joint meetings often took place among physicians of these departments at Hadassah in order to discuss difficult pain problems. Soon these ad hoc meetings became formalized, and increasingly multidisciplinary with the inclusion, for example, of Eli Edelstein and colleagues from the Department of Psychiatry. The pain “Clinical think tank” group, organized by F. Magora, and later by Yoram Shir and Eliad Davidson, met at Hadassah on a regular basis since the mid-1970s, and continues to do so.
The first formal Pain Clinic in Israel was established by Chayen at Ichilov; the clinic’s first patient record was dated Jan. 23, 1967. The Ichilov clinic, which became a full-service multidisciplinary unit in 1990, is currently operated by David Niv. Shortly after the establishment of the Ichilov clinic, Pain Clinics were set up by Birkhan at Rambam (currently operated by Eilon Eisenberg) and by F. Magora (with Leoni Alajemoff) at Hadassah (later operated by Shir and now by Davidson). A few years later, in 1974, a specialty Clinic for Orofacial Pain was established by Yair Sharav at the Hebrew University Faculty of Dental Medicine. All of these were outpatient clinics operated as referral centers for patients with difficult, chronic pain problems, and as sites for the training of residents and fellows. Teaching of the pathophysiology and treatment of pain was introduced soon after into the curriculum of 5th year medical students at the Hadassah-University Medical School, and on diagnosis and treatment of orofacial pain to 5th year dental students. A short sequence on pain is also part of the specialty training in Anesthesia. A one-semester elective course on pain was also offered in the 4th year of medical studies at the Technion Medical School, and at Tel Aviv University Niv organized a lecture series on pain within the framework of continuing medical education. Overall, more needs to be done in the arena of education on pain. In the 1970s “alternative” healing methods started to be introduced into Israel. An early pioneer of the use of acupuncture was Rafi Carrasso. Birkhan was also an early proponent of acupuncture, hypnosis, and related healing arts.
These developments, and particularly the training efforts, triggered the foundation of Pain Clinics in other major medical centers in Israel: at Tel Hashomer in Ramat Gan (founded by Radu Manulescu), in Safed (by Mark Tverskoy), in Nahariya (by Kurt Simon), in Beer Sheva (by Gabriel Gurman), in Afula (by Shai Katz), in Kfar Saba (by Simon Hoffman and Robert Judeikin) and in Rehovot (by David Soroker). In 1990 Niv set up a Pain Clinic to serve the Israel Defense Forces. In parallel, physicians in the fields of orthopedics, neurosurgery, oncology, palliative care and general practice started to become sensitized to the problem of pain and active in management and research. Special mention should be made of Zvi Harry Rappaport and Pesach Schvartzman.
In addition to providing clinical services, many of these centers also supported clinically oriented research activities, including the development of clinical devices. The latter include, for example, a TENS apparatus developed by F. Magora, together with Joseph Tannenbaum of the engineering Department at Hadassah, and later marketed by Agar Ltd. of Kibbutz Ginossar, and an apparatus for quantitative sensory testing developed by David Yarnitzky (Rambam) and Medoc Inc., under Udi Gafni. Perhaps the most influential contribution in the area of clinical research was the development of epidural morphine therapy by Murat Bahar, David Olshvang, F. Magora and Terry Davidson (Lancet, 1979).
A strong impetus to both clinical activities and basic research on pain in Israel was Patrick D. Wall’s close association with the Hebrew University, as visiting professor beginning in the early 1970s. In 1973 Wall and Beller co-hosted a landmark Batsheva de Rothschild Foundation seminar in Zichron Yaacov and Jerusalem that was attended by Bonica, Ronald Melzack, John Liebeskind, Harold Merskey, William Nordenbos and other international pain luminaries. It was at the Bastheva seminar that the idea of forming an International Association for the Study of Pain (IASP) was first discussed in earnest. Beller, A. Magora and Wall were among the founding members of IASP. Additional impetus was provided by other frequent guests who lectured, taught, and otherwise contributed. Notable among these are Mark Swerdlow (UK), Basel Finer (Uppsala), Ben Crue (USA), Mark Metha (UK) and Matthew Lee (USA), and later Joachim and Sigrun Chrubasik (Germany). Swerdlow arranged for Birkhan to be invited by the World Health Organization (WHO) to participate as a consultant in cancer pain relief in a WHO pilot study that included Israel, India, Brazil, Japan and Sri Lanka.
In 1977 Wall, together with Beller, Sharav, Marshall Devor, Bob Werman, Peter Hillman and Alex Keynan, and with the help of Raphael Mechoulan, then rector of the University, established the Center for Research on Pain at the Hebrew University. Beller served as founding director. The Center had considerable impact on the development in Israel of world-class scientific research on pain. Wall’s laboratory, established in the Institute of Life Sciences (Russian Compound) at the Hebrew University in 1973, was home at various times to a number of well-known investigators including Michael Gutnick, Peter Carlen, Marshall Devor, and Ze’ev Seltzer. Other foci of pain related research in the Center were at the Faculty of Dental Medicine (Yair Sharav, Michael Tal, Eli Eliav and Rafi Benouliel), the School of Pharmacy (Felix Bergmann, Martha Weinstock-Rozin and Mechoulam), and the Department of Psychology (Udi Shavit and Raz Yirmiya). Basic science research on pain also flourished elsewhere in Israel. At the Technion in Haifa, with Amiram Carmon (who later moved to Jerusalem) and later at the Technion’s Rambam Hospital with Eisenberg and David Yarnitzky), at Tel Aviv University, with Yossi Sarne, Gideon Urca and Hannan Frenk, at Bar Ilan University in Ramat Gan, with Matisyahu Weisenberg, and at the Weizmann Institute in Rehovot with Rabi Simantov. Special mention is due to John Liebeskind (UCLA) who was research mentor to Urca, Frenk, Shavit and Yirmiya, and to Ron Dubner and Gary Bennett (NIH), who hosted Seltzer, Tal, Sharav, Benouliel and Eliav for postdoctoral training and sabbatical leaves.
In 1982 the Israel Society of Anesthesiologists formed a special interest group on pain which was opened to anesthesiologists and other physicians. F. Magora served as president 1982-1995. A second pain interest group called “Ilchush” (analgesia), organized by Mark Chayen, was active in the early 1980s in the Tel Aviv area. The Hebrew University Center and the two pain interest groups cooperated to found the Israel Pain Association (IPA) which was recognized as the Israeli chapter of IASP at the 4th IASP World Congress on Pain, held in Seattle, Washington 1984. The mission of the IPA is to serve all Israeli professionals interested in pain, including both physicians and non-physicians such as psychologists, nurses, physiotherapists and investigators in the basic sciences. Chayen was the first president of the IPA, followed in 1988 by Niv, in 1992 by Birkhan, in 1995 by Weisenberg, in 1998 by Birkhan, in 2001 by Tal, and in 2004 by Eisenberg.
The IPA has held annual national conferences yearly since its inception, including joint meetings with other regional pain societies, and several international meetings. Notable among these are: the joint Italian-Israeli Congress on Pain held in Rimini, 9/1988, “Pain 1989”, held in Herzliya, the 5th International Congress "The Pain Clinic" Jerusalem, 9/1992, the International Congress: Paradigm of Pain, Tel Aviv, 9/1994, which also hosted a meeting of the IASP Council, the Turkey/ Israel/ Egypt (TIE) meeting on Cancer Pain, Tel Aviv, 11/1995, “Pain Management Towards 2000”, the first major congress of the World Institute of Pain, Eilat 11/1998, which was also occasioned the inaugural meeting of PUGO, the IASP special interest group on Pain of Urogenital Origin, and “Pain in a Mediterranean Corner” (with the Hellenic and Turkish IASP chapters) Heraklion, Crete, 3/1999. Niv, representing the IPA, was instrumental in the organization of all of these conferences.
Since the early days, Pain Research and Medicine has become increasingly well established in the academic scene in Israel. Likewise, Israelis have had considerable impact on developments related to pain in the international arena. At present, consultations for in-hospital patients with pain problems are provided at all major Israeli hospitals. This includes an Acute Pain Service for the control of postoperative pain in most instances. Some centers have a permanent full time staff assigned to this task, while others rotate physicians on a part-time basis to provide pain services. In addition, all but two major hospitals run outpatient pain management clinics. Three hospitals have full-service multi-disciplinary pain units that include, among other facilities, surgical rooms for carrying out invasive procedures such as the implantation of spinal stimulators and pumps. Pain Clinics are part of the services offered to the members of two of the principal national healthcare providers (“Kupat Holim”) in Israel. Finally, pain services are offered by numerous physicians and allied healthcare professionals on a private basis throughout the country. In 1996, the Israel Society of Anesthesiologists and the Scientific Board of the Israel Medical Organization accepted a proposal to include six months of training in the field of pain medicine as an integral part of the specialty program in Anesthesiology. The IPA is currently lobbying actively to obtain official status for Pain Medicine as a recognized medical sub-specialty in Israel.
Compiled by: M. Devor with the help of J. Birkhan, F. Magora, D. Niv, M. Tal, and Y. Sharav. Aug. 3, 2005