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katieelizabeth · 4 years

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What would you call your body type? Definitely curvy

Are you a morning person? Yes and no. I’m taking sleep meds for nausea so right now waking up is kinda hard.

Have you ever been to Target? Loveeeeee Target

Do you like iced tea? Iced tea is always my jam

When is the next time you’ll be at work? Hmm it’s kinda up in the air right now. I’m itching to get back tho.

Do you have a savings account? Yes. one for myself, one with my boyfriend

Has anyone ever hacked your accounts before? Only once.

What color bedsheets are currently on your bed? Currently grey

Have you ever been to Disney World? If so, how many times have you been? Yes, I wanna say total like 6 times.

Does grammar and capitalization mean anything to you? It absolutely does.

Are you good at wrapping gifts for others? My boyfriend thinks I'm a terrible wrapper hahah

Do you have a dirty clothes hamper in your room? Yes.

What would you say is your favorite television show? If I had to narrow it down, probably Skins.

Do you enjoy big holiday dinners? Yes and no. I don’t care for holiday dinners with my family but I love holiday dinners with my boyfriends family.

Is there any piece of jewelry you’re constantly wearing? I’m not married or engaged but I do wear a small silver band on my ring finger.

What is one thing you desire as of now? To be able to just go and sit down in a restaurant. This virus has everyone living in fear and I'm tired of it and want to live normally and enjoy my pregnancy

What kind of phone do you have? An iPhone XR.

If you could move anywhere, where would you choose? Canada or London

Do you blog a lot, if at all? No not really. I used to when Xanga was big.

Is your present hair color, natural? Nope.

What makes you the most angry when it comes to people? My boyfriend thinks that anytime my opinion is different than his, then I'm trying to argue with him. It’s so fucking frustrating.

Describe your current outfit? Anaheim Ducks shirt and matching pj pants hahah

What was the last thing you ordered online? Some toothbrushes lol

Have you ever felt as though you were drifting apart from a best friend? Ive had two best friends in my life completely shut me out before. It sucks.

What color are your eyes? Poop brown

Have you ever worn color contacts? I have but I could never wear them because of the astigmatisms in both my eyes. Lasik was the best decision of my life

What’s the best thing about a hug? Right now I miss everything about hugs

Biggest fear? Losing my loved ones, death, never getting better/getting worse, never doing anything with my life....

If you have a significant other, how long have you been together? Just celebrated three years

Do you know any genuinely friendly people? Yes.

Do you buy your friends gifts? I try to when I can

What was the last thing you plugged in? My phone to the charger.

How old are you? 29

What color headphones do you own? They’re black.

Have you ever shopped on Urban Outfitters? No, just a reminder than I'm fat

Where do you buy the majority of your clothing? Amazon, Goodwill

Would you rather wear necklaces or earrings? Necklaces

Do you consider yourself fortunate? Very

Do you enjoy watching fights? Nooo.

Have you ever been in a physical fight? No way

Do you tend to talk badly about people? I try not to but everyone is guilty of that

Where are your parents as of now? Watching tv in the tv room

Does your computer cooperate most of the time? I literally just bought it so yes haha

Does your family have any cheesy traditions? Kind of

When did you last go to a book store? Gosh it’s been a while!

What’s the closest book store where you live? Barnes & Noble.

How much money do you have on you right now? On hand, $20.

Favorite personal feature? my hair and my lips

Are you wearing make up at the moment? Nope.

Favorite television channel? Bravo, E!, ID, HBO

Describe any piercings or tattoos you might have? 6 tattoos no piercings

Have you ever been fired from a job? INope

Are you currently losing a best friend? No.

Describe the worst day of your life: I’m good.

Do you play any video games? Not at the moment

Would you say you hate anyone? I feel hatred towards racists, homophobics, ect.

Do you think freckles are cute? Very cute!

Last time you went to the mall? Gosh its been a really long time

Name something that’s your favorite color: anything teal

Have you been to Red Lobster before? Yesssss. I want seafood

Do you judge by appearances? Anyone who tells you they don't to some degree is a fucking liar.

Do you follow a certain religion? No thank you

Who is your role model, if you had to choose? Im not really sure

Would you rather have nice hair or lips? Hair.

What are you most self conscious about? Pretty much my whole body

Do you have any family members who live out of town? Yeah.

Do you consider yourself short? Nope, I'm average height for a girl

What room are you in? Mine.

Hoodies or jackets? Hoodies.

Are you outside a lot? No not really. The sun doesn’t like my skin haha

Have you ever been dumped via text message? Nope

Do you like dreamcatchers? Not really

What is your favorite letter of the alphabet? I don’t have one.

Do you hate repetitive people and things? Depends on the situation

Do you think autocorrect is a blessing or curse? BOTH

Do you believe in any particular curses? No.

Ever play a Ouija board? Nope, my mom wouldn't let me growing up

What movie scares you the most? The Exorcist. I can watch the movie now no problem but it FUCKED up my childhood.

What was your bedtime as a child? 9. I remember watching Happy Days from 8-9

Reason why your favorite holiday is your favorite: Who doesn't love Christmastime?

Do you work with any close friends? I work with my baby daddy

Do you consider yourself spoiled? I would say in some way I'm probably spoiled

Do you listen to any country music? yes

Favorite high school teacher: I don’t specifically remember any high school teachers I liked. Probably my French teacher. He was super cool!

Do you ever get drunk? Of course. Can’t drink yet tho until after baby

Have you ever had highlights before? Nope

Favorite number: 7,10

Do you still sleep with any stuffed animals? Not anymore. I used to for a a long time

What is your biggest regret in life? Eh I've got a few

Would you say you think you have a mental disorder of some kind? Depression/anxiety. Ive taken meds for it

Are you normally an independent person? I like to think myself as independent but my boyfriend sure takes care of me. I dunno what id do without him

Do you have any paintings? a few

What is one clothing fad you wish never existed? anything from the early 2000s haha

Do you like to be organized? Do I like it? Yes. Am I organized? NO

Have you ever failed a class before? oh yes

Ever been judged because of your weight? All the time. Not so much as an adult tho

What is your favorite breakfast cereal? The sugary bad ones, ha.

Ever had a wish come true? Nope

Do you regret meeting any of your exes? No way

Do you own any coloring books? Yes haha those adult ones

What’s the meanest thing someone’s called you? I can’t think of anything specific. Probably fat

Have you ever bullied someone? I likely have, unfortunately :(

Do you ever watch Lifetime? Only for the reality shows

Ever tried to intentionally sabotage someone’s grade? God no

Do you own any brown clothing? Hmmm I don’t think so

What color are your walls painted? White.

Last thing you drank: I’m drinking decaf coffee

Have you ever seen a tornado in person? Noooo.

Do you have an inground pool at your house? Nope

What is the first digit of your phone number? 9

What’s the prettiest town you’ve been to? Anywhere in England

Do you tend to sleep a lot? yes and no. I’m taking sleeping meds but it’s hard for me to fall asleep

Silver or gold jewelry? Silver

Do you sometimes celebrate holidays early? Not usually. My boyfriends family Is out of state tho

Have you ever been in love? Yes.

What’s the best gift you’ve ever received? My unborn child

When was the last time you showered? Last night

Would you consider yourself attractive? Sometimes yes

Has anyone made you mad today? Nope

Favorite smell: Vanilla

Are you afraid of insects? I wouldn't say afraid

Do you have any children? I’ve got one cookin in the oven haha

If so, what are their names? I’ll tell you when I know the gender

Would ever consider having children in the future? MORE children? Lets see how traumatized this first one is haha

Have you ever lived on a farm? No.

Ever played any sports? Oh yes, played soccer till I was 18

Do both of your parents have jobs? They're both retired from jobs they were at for 40+ years

Where is the best place you’ve been on vacation to? Its a tie between South Africa, London and Colorado

Are you afraid people won’t accept you? Not anymore. Being an adult means getting over that haha

Are you, for the most part, an honest person? I try to be

Did you make prank phone calls as a child? oh yes!

Do you like to make donations? Yeah.

What is your current ringtone? Just the standard apple ringtone

Meet anyone from your past lately? No.

Have you ever called a teen suicide line? No.

Have you ever caught something on fire? Not that I can think of

Ever been obsessed with a show? Ive been obsessed with many shows

What type of perfume or cologne do you use? English Laundry Signature

What’s the last book you read? The book that Ted Bundys girlfriend wrote

Dream career: Zooologist

Have you ever climbed a mountain before? Yes, in Colorado

At what age do you plan to get married? Not sure, we aren't in a rush to marry

Ever been in a car accident? Yes, three

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narkinafive · 5 years

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this one’s a doozy

(i feel like i should have done sth like this for the prequels/the clone wars but oh well. i'll get around to it eventually! maybe! gotta do something while waiting for ix right lol)

oh, rebels. rebels rebels rebels. i know it's probably unbelievable, but i was so gutted by the clone wars cancellation that i really Did Not Like rebels at. it took... idk about two years for me to give it a real chance (and i was still deep in a previous fandom hole, so i didn't really get into it until like. the start of s4) (if you can guess what fandom it was you get a cookie) i am so glad i tried it again.

of course, ezra bridger is, was, will always be my favorite boy. i really did not expect him to waltz away with my heart! anakin has always been my favorite (and he still is, tbh), bc that kind of character and that kind of arc is so on brand for me, like. i LOVE my dark tragic messiah demigods, i really really do!!! but then this doofy dumbass kid with big blue eyes and a big blue heart and his many cat friends just punched me in the gut!

it's been a year and i've had time to digest the whole package. let me preface by saying that rebels is absolutely 100% perfect and my favorite piece of expanded sw media by a LONG mile. NOW. that doesn't mean that there weren't things i didn't like (going under a cut!)

many times, it tried too hard to tie into the greater saga - bringing in palpatine, the wbw, all the saga cameo characters, like... some of them worked better than others. the r2d2 and c3po cameos were the worst, w obi wan coming in at a close second. the best saga character cameo was definitely mon mothma (and bail). i really liked leia's episode, but. idk. it still felt a little shoehorn-y

i wish ezra's descent into the dark side had been more ... present? he gets some great, great moments. but it's kind of sudden (i've touched on this before so i won't keep going)

someone else has brought this up (and i ................. do not remember who sdfkjlsdfjlk) but pushing aside the Great Rivalry of thrawn and hera for the force stuff is... idk. that's a whole other thing

now i love the force shit. like i LOVE it. but i think rebels might have been stronger if it focused less on force shit and more on the early war effort, in the same vein as rogue one. i know it'd be more difficult to fill out four seasons rather than one movie, but as it got into s4 and closer and closer to episode iv... idk, put the force shit at the beginning of the season? idk. i really love how they did it, but... idk! it's complicated

oh, and speaking of complicated - maul. i love what they did with him, i love this sad garbage pile and watching him recreate his trauma onto others as a way of dealing with it... but i think it was a weird choice. maul is so... idk, grimdark? for such a lovely sweet show

kallus going to lira san better be bc he's being tried for war crimes lmao

sabine staying on lothal is... a choice. not one i hate. but i still don't quite understand it

and my biggest gripe, ironically one of my favorite parts of the show: ahsoka lives.

dont' get me wrong; i was so happy that ahsoka lived, i nearly threw my computer across the room when ezra yoinked her into the spacetime continuum. i am a diehard ahsoka fan and i will fight somebody to defend her honor. THAT SAID. the narrative of ahsoka going down at the hands of her former master? as he desperately tries to erase every part of his former identity? the great commander tano, clone wars veteran, an early casualty of the rebel alliance? it's so good. it's SO good. having her story end there would have been just some phenomenal shit. just superbly poetic. i'm glad she's alive! and the emotional impact is still the same, even with her coming back, but my god.

now. the things i love.

the character arcs. all of them. ezra bridger, war orphan, street thief, cast out by his people, finding he is stronger than he ever thought could be possible, giving his life for his people because he forgives them, and because it's the right thing to do. kanan jarrus, jedi knight, reclaiming his heritage and his jedi legacy (and yes, watching him die still hurt just as much as the first time aroundd) (and also, thanks to @aspiringwarriorlibrarian and @greatlakesrebel for pointing out many many many things, but first and foremost tonight, that dume the wolf was of course voiced by fpj) (i’m slow ok shut up). hera syndulla, who unfortunately had to learn the hard way how to balance love and war so she didn't become her father, pushing away everyone she loved for the greater cause. zeb orrelios, finding his people, learning he's not the last of his kind, leading the refugees to their ancestral home. sabine wren, forgiving herself and freeing her planet from oppression. and not just the hero arcs - the villain arcs, too!!!! darth maul's single minded obsession that kept him alive for 30 years ending in a 3-hit fight on a backwater planet because he just couldn't sustain that hate for so long. all of thrawn's cleverness couldn't predict the force. i don't have an issue with a single one of these!

THE FORCE (TM)!!!! there is so much delicious crunchy force nonsense, i could DROWN in it

among my many, many issues w the old EU, one of them was demystifying the force, quantifying and trying to label it too much. some things were quantified bc they needed to be (the holocrons, the sith code, etc) but most of it was kept as vague and nebulous as possible, which is GOOD. when it comes to mystical magic, less explanation is mostly always more

i love that we don't have clear cut answers for the loth wolves and the lothal temple, i could ponder that shit for WEEKS and never get bored

it does feel like a mostly self contained story. "been there made history" can get overused very easily (see: hbo rome) but rebels used it just enough to fit it into the larger saga

having rex survive both the clone wars AND the galactic civil war??? fuck yeah

kanan and ezra. kanan and ezra. there is so much i could say about kanan and ezra. it's everything to me. war vet finds plucky young orphan and adopts him? sign me tf up!! their relationship as it grows from mentor/mentee to peers is really really well done

and speaking of growth, ezra and sabine going from obvious romantic interest to battle forged siblings is not something that i was expecting but is definitely one of the best parts of the show

kevin has some really incredible tracks in this show: top of the list is 100% kanan's end credits, followed closely by it's over now. wow

and speaking of, the entirety of the last ten minutes of twilight of the apprentice deserves its own bullet. that shit is right up there with vader v luke round 2

the planet designs, mostly malachor and lothal, but when hera and sabine launch the dome, and the lothal sky suddenly turns to blue as the pollution is leeched out and destroyed... that shit is breathtaking

and so much more. like so much

this show holds such a special place in my heart :") now if only dave could bring back my son... like. PLEASE

see you all in rogue one!

#the pre ix rewatch

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viralhottopics · 7 years

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Sickening, gruelling or frightful: how doctors measure pain | John Walsh

The Long Read: Suffering is difficult to describe and impossible to see. So how can doctors tell how much it hurts?

One night in May, my wife sat up in bed and said, Ive got this awful pain just here. She prodded her abdomen and made a face. It feels like somethings really wrong. Woozily noting that it was 2am, I asked what kind of pain it was. Like somethings biting into me and wont stop, she said.

Hold on, I said blearily, help is at hand. I brought her a couple of ibuprofen with some water, which she downed, clutching my hand and waiting for the ache to subside.

An hour later, she was sitting up in bed again, in real distress. Its worse now, she said, really nasty. Can you phone the doctor? Miraculously, the family doctor answered the phone at 3am, listened to her recital of symptoms and concluded, It might be your appendix. Have you had yours taken out? No, she hadnt. It could be appendicitis, he surmised, but if it was dangerous youd be in much worse pain than youre in. Go to the hospital in the morning, but for now, take some paracetamol and try to sleep.

Barely half an hour later, the balloon went up. She was awakened for the third time, but now with a pain so savage and uncontainable it made her howl. The time for murmured assurances and spousal procrastination was over. I rang a local minicab, struggled into my clothes, bundled her into a dressing gown, and we sped to St Marys Paddington at just before 4am.

The flurry of action made the pain subside, if only through distraction, and we sat for hours while doctors brought forms to be filled, took her blood pressure and ran tests. A registrar poked a needle into my wifes wrist and said, Does that hurt? Does that? How about that? before concluding: Impressive. You have a very high pain threshold.

The pain was from pancreatitis, brought on by rogue gallstones that had escaped from her gall bladder and made their way, like fleeing convicts, to a refuge in her pancreas, causing agony. She was given a course of antibiotics and, a month later, had an operation to remove her gall bladder.

Its keyhole surgery, said the surgeon breezily, so youll be back to normal very soon. Some people feel well enough to take the bus home after the operation. His optimism was misplaced. My wife came home the following day filled with painkillers. When they wore off, she writhed with suffering. After three days she rang the specialist, only to be told: Its not the operation thats causing discomfort its the air that was pumped inside you to separate the organs before surgery. Once the operation had proved a success, the surgeons had apparently lost interest in the fallout.

During that period of convalescence, as I watched her grimace and clench her teeth and let slip little cries of anguish until a long regimen of combined ibuprofen and codeine finally conquered the pain, several questions came into my head. Chief among them was: Can anyone in the medical profession talk about pain with any authority? From the family doctor to the surgeon, their remarks and suggestions seemed tentative, generalised, unknowing and potentially dangerous: Was it right for the doctor to tell my wife that her level of pain didnt sound like appendicitis when the doctor didnt know whether she had a high or low pain threshold? Should he have advised her to stay in bed and risk her appendix exploding into peritonitis? How could surgeons predict that patients would feel only discomfort after such an operation when she felt agony an agony that was aggravated by fear that the operation had been a failure?

I also wondered if there were any agreed words that would help a doctor understand the pain felt by a patient. I thought of my father, a GP in the 1960s with an NHS practice in south London, who used to marvel at the colourful pain symptoms he heard: Its like Ive been attacked with a stapler; Like having rabbits running up and down my spine; Its like someones opened a cocktail umbrella in my penis Few of them, he told me, corresponded to the symptoms listed in a medical textbook. So how should he proceed? By guesswork and aspirin?

There seemed to be a chasm of understanding in human discussions of pain. I wanted to find out how the medical profession apprehends pain the language it uses for something thats invisible to the naked eye, that cant be measured except by asking for the sufferers subjective description, and that can be treated only by the use of opium derivatives that go back to the middle ages.

When investigating pain, the basic procedure for clinics everywhere is to give a patient the McGill pain questionnaire. Developed in the 1970s by two scientists, Dr Ronald Melzack and Dr Warren Torgerson, both of McGill University in Montreal, it is still the main tool for measuring pain in clinics worldwide.

Melzack and his colleague Dr Patrick Wall of St Thomas Hospital in London had already galvanised the field of pain research in 1965 with their seminal gate control theory, a ground-breaking explanation of how psychology can affect the bodys perception of pain. In 1984, the pair went on to write Wall and Melzacks Textbook of Pain, the most comprehensive reference work in pain medicine. It has gone through five editions and is currently more than 1,000 pages long.

In the early 1970s, Melzack began to list the words patients used to describe their pain and classified them into three categories: sensory (which included heat, pressure, throbbing or pounding sensations), affective (which related to emotional effects, such as tiring, sickening, gruelling or frightful) and lastly evaluative (evocative of an experience from annoying and troublesome to horrible, unbearable and excruciating).

You dont have to be a linguistic genius to see there are shortcomings in this range of terms. For one thing, some words in the affective and evaluative categories seem interchangeable theres no difference between frightful in the former and horrible in the latter, or between tiring and annoying and all the words share an unfortunate quality of sounding like a duchess complaining about a ball that didnt meet her standards.

But Melzacks grid of suffering formed the basis of what became the McGill pain questionnaire. The patient listens as a list of pain descriptors is read out and has to say whether each word describes their pain and, if so, to rate the intensity of the feeling. The clinicians then look at the questionnaire and put check marks in the appropriate places. This gives the clinician a number, or a percentage figure, to work with in assessing, later, whether a treatment has brought the patients pain down (or up).

A more recent variant is the National Initiative on Pain Controls pain quality assessment scale (PQAS), in which patients are asked to indicate, on a scale of 1 to 10, how intense or sharp, hot, dull, cold, sensitive, tender, itchy, etc their pain has been over the past week.

The trouble with this approach is the imprecision of that scale of 1 to 10, where a 10 would be the most intense pain sensation imaginable. How does a patient imagine the worst pain ever and give their own pain a number? Some men may find it hard to imagine anything more agonising than toothache or a tennis injury. Women who have experienced childbirth may, after that experience, rate everything else as a 3 or 4.

I asked some friends what they thought the worst physical pain might be. Inevitably, they just described nasty things that had happened to them. One man nominated gout. He recalled lying on a sofa, with his gouty foot resting on a pillow, when a visiting aunt passed by; the chiffon scarf she was wearing slipped from her neck and lightly touched his foot. It was unbearable agony.

A brother-in-law nominated post-root-canal toothache unlike muscular or back pain, he said, it couldnt be alleviated by shifting your posture. It was relentless. A male friend confided that a haemorrhoidectomy had left him with irritable bowel syndrome, in which a daily spasm made him feel as if somebody had shoved a stirrup pump up my arse and was pumping furiously. The pain was, he said, boundless, as if it wouldnt stop until I exploded. A woman friend recalled the moment the hem of her husbands trouser leg snagged on her big toe, ripping the nail clean off. She used a musical analogy to explain the effect: Id been through childbirth, Id broken my leg and I recalled them both as low moaning noises, like cellos; the ripped-off nail was excruciating, a great, high, deafening shriek of psychopathic violins, like nothing Id heard or felt before.

It seems a shame that these eloquent descriptions are reduced by the McGill questionnaire to words like throbbing or sharp, but its function is simply to give pain a number a number that will, with luck, be decreased after treatment, when the patient is reassessed.

This procedure doesnt impress Professor Stephen McMahon of the London Pain Consortium, an organisation formed in 2002 to promote internationally competitive research into pain. There are lots of problems that come with trying to measure pain, he says. I think the obsession with numbers is an oversimplification. Pain is not unidimensional. It doesnt just come with scale a lot or a little it comes with other baggage: how threatening it is, how emotionally disturbing, how it affects your ability to concentrate. The measuring obsession probably comes from the regulators who think that, to understand drugs, you have to show efficacy. And the American Food and Drug Administration dont like quality-of-life assessments; they like hard numbers. So were thrown back on giving it a number and scoring it. Its a bit of a wasted exercise because its only one dimension of pain that were capturing.

Illustration: Matthew Richardson

Pain can be either acute or chronic, and the words do not (as some people think) mean bad and very bad. Acute pain means a temporary or one-off feeling of discomfort, which is usually treated with drugs; chronic pain persists over time and has to be lived with as a malevolent everyday companion. But because patients build up a resistance to drugs, other forms of treatment must be found for it.

The Pain Management and Neuromodulation Centre at Guys and St Thomas Hospital in central London is the biggest pain centre in Europe. Heading the team there is Dr Adnan Al-Kaisy, who studied medicine at the University of Basrah, Iraq, and later worked in anaesthetics at specialist centres in England, the US and Canada.

Id say that 55 to 60% of our patients suffer from lower back pain, he says. The reason is, simply, that we dont pay attention to the demands life makes on us, the way we sit, stand, walk and so on. We sit for hours in front of a computer, with the body putting heavy pressure on small joints in the back. Al-Kaisy reckons that in the UK the incidence of chronic lower back pain has increased substantially in the last 15 to 20 years, and that the cost in lost working days is about 6 to 7 billion.

Elsewhere the clinic treats those suffering from severe chronic headaches and injuries from accidents that affect the nervous system.

Do they still use the McGill questionnaire? Unfortunately yes, says Al-Kaisy. Its a subjective measurement. But pain can be magnified by a domestic argument or trouble at work, so we try to find out about the patients life their sleeping patterns, their ability to walk and stand, their appetite. Its not just the patients condition, its also their environment.

The challenge is to transform this information into scientific data. Were working with Professor Raymond Lee, chair of Biomechanics at the South Bank University, to see if there can be objective measurement of a patients disability due to pain, he says. Theyre trying to develop a tool, rather like an accelerometer, which will give an accurate impression of how active or disabled they are, and tell us the cause of their pain from the way they sit or stand. Were really keen to get away from just asking the patient how bad their pain is.

Some patients arrive with pains that are far worse than backache and require special treatment. Al-Kaisy describes one patient let us call him Carter who suffered from a terrible condition called ilioinguinal neuralgia, a disorder that produces a severe burning and stabbing pain in the groin. Hed had an operation in the testicular area, and the inguinal nerve had been cut. The pain was excruciating: when he came to us, he was on four or five different medications, opiates with very high dosages, anticonvulsive medication, opioid patches, paracetamol and ibuprofen on top of that. His life was turned upside down, his job was on the line. The utterly stricken Carter was to become one of Al-Kaisys big successes.

Since 2010, Guys and St Thomas has offered a residential programme for adults whose chronic pain hasnt responded to treatment at other clinics. The patients come in for four weeks, away from their normal environment, and are seen by a motley crew of psychologists, physiotherapists, occupational health specialists and nursing physicians who between them devise a programme to teach them strategies for managing their pain.

Many of these strategies come under the heading of neuromodulation, a term you hear a lot in pain management circles. In simple terms, it means distracting the brain from constantly brooding on the pain signals it is getting from the bodys periphery. Sometimes the distraction is a cunningly deployed electric shock.

We were the first centre in the world to pioneer spinal cord stimulation, says Al-Kaisy. In pain occasions, overactive nerves send impulses from the periphery to the spinal cord and from there to the brain, which starts to register pain. We try to send small bolts of electricity to the spinal cord by inserting a wire in the epidural area. Its only one or two volts, so the patient feels just a tingling sensation over where the pain is, instead of feeling the actual pain. After two weeks, we give the patient an internal power battery with a remote control, so he can switch it on whenever he feels pain and carry on with his life. Its essentially a pacemaker that suppresses the hyperexcitability of nerves by delivering subthreshold stimulation. The patient feels nothing except his pain going down. Its not invasive we usually send patients home the same day.

When Carter, suffering from agonising pain in the groin, had failed to respond to any other treatments, Al-Kaisy tried his new combination of therapies. We gave him something called a dorsal root ganglion stimulation. Its like a small junction-box, placed just underneath one of the bones of the spine. It makes the spine hyperexcited, and sends impulses to the spinal cord and the brain. I pioneered a new technique to put a small wire into the ganglion, connected to an external power battery. Over 10 days the intensity of pain went down by 70% by the patients own assessment. He wrote me a very nice email saying I had changed his life, that the pain had just stopped completely, and that he was coming back to normality. He said his job was saved, as was his marriage, and he wanted to go back to playing sport. I told him, Take it easy. You mustnt start climbing the Himalayas just yet. Al-Kaisy beams. This is a remarkable outcome. You cannot get it from any other therapies.

The greatest recent breakthrough in assessing pain, according to Professor Irene Tracey, head of the University of Oxfords Nuffield Department of Clinical Neurosciences, has been the understanding that chronic pain is a thing in its own right. She explains: We always thought of it as acute pain that just goes on and on and if chronic pain is just a continuation of acute pain, lets fix the thing that caused the acute and the chronic should go away. That has spectacularly failed. Now we think of chronic pain as a shift to another place, with different mechanisms, such as changes in genetic expression, chemical release, neurophysiology and wiring. Weve got all these completely new ways of thinking about chronic pain. Thats the paradigm shift in the pain field.

Tracey has been called the Queen of Pain by some media commentators. She was, until recently, the Nuffield Professor of anaesthetic science and is an expert in neuroimaging techniques that explore the brains responses to pain. Despite her nickname, in person she is far from alarming: a bright-eyed, enthusiastic, welcoming and hectically fluent woman of 50, she talks about pain at a personal level. She has no problem defining the ultimate pain that scores 10 on the McGill questionnaire: Ive been through childbirth three times, and my 10 is a very different 10 from before I had kids. Ive got a whole new calibration on that scale. But how does she explain the ultimate pain to people who havent experienced childbirth? I say, Imagine youve slammed your hand in a car door thats 10.

She uses a personal example to explain the way perception and circumstance can alter the way we experience pain, as well as the phenomenon of hedonic flipping, which can convert pain from an unpleasant sensation into something you dont mind. I did the London Marathon this year. It needs a lot of training and running and your muscles ache, and next day youre really in pain, but its a nice pain. Im no masochist, but I associate the muscle pain with thoughts like, I did something healthy with my body, Im training, and Its all going well.

I ask her why there seems to be a gap between doctors and patients apprehension of pain. Its very hard to understand, because the system goes wrong from the point of injury, along the nerve thats taken the signal into the spinal cord, which sends signals to the brain, which sends signals back, and it all unravels with terrible consequential changes. So my patient may be saying, Ive got this excruciating pain here, and Im trying to see where its coming from, and theres a mismatch here because you cant see any damage or any oozing blood. So we say, Oh come now, youre obviously exaggerating, it cant be as bad as that. Thats wrong its a cultural bias we grew up with, without realising.

Recently, she says, there has been a breakthrough in understanding about how the brain is involved in pain. Neuroimaging, she explains, helps to connect the subjective pain with the objective perception of it. It fills that space between what you can see and whats being reported. We can plug that gap and explain why the patient is in pain even though you cant see it on your x-ray or whatever. Youre helping to bring truth and validity to these poor people who are in pain but not believed.

But you cant simply see pain glowing and throbbing on the screen in front of you. Brain imaging has taught us about the networks of the brain and how they work, she says. Its not a pain-measuring device. Its a tool that gives you fantastic insight into the anatomy, the physiology and the neurochemistry of your body and can tell us why you have pain, and where we should go in and try to fix it.

Some of the ways in, she says, are remarkably direct and mechanical like Al-Kaisys spinal cord stimulation wire. There are now devices you can attach to your head and allow you to manipulate bits of the brain. You can wear them like bathing caps. Theyre portable, ethically allowed brain-simulation devices. Theyre easy for patients to use and evidence is coming, in clinical trials, that they are good for strokes and rehabilitation. Theres a parallel with the games industry, where theyre making devices you can put on your head so kids can use thought to move balls around. The games industry is, for fun, driving this idea that when you use your brain, you generate electrical activities. Theyre developing the technology really fast, and we can use it in medical applications.

Illustration: Matthew Richardson

Pain has become a huge area of medical research in the US, for a simple reason. Chronic pain affects over 100 million Americans and costs the country more than half a trillion dollars a year in lost working hours, which is why it has become a magnet for funding by big business and government.

Researchers at the Human Pain Research Laboratory at Stanford University, California, are working to gain a better understanding of individual responses to pain so that treatments can be more targeted. The laboratory has several study initiatives on the go into migraine, fibromyalgia, facial pain and other conditions but its largest is into back pain. It has been endowed with a $10m grant from the National Institutes of Health to study non-drug alternative treatments for lower back pain. The specific treatments are mindfulness, acupuncture, cognitive behavioural therapy and real-time neural feedback.

They plan to inspect the pain tolerance of 400 people over five years of study, ranging from pain-free volunteers to the most wretched chronic sufferers who have been to other specialists but found no relief. The idea is to find peoples mid-range tolerance (theyre asked to rate their pain while they are experiencing it), to establish a usable baseline. They then are given the non-invasive treatments such as mindfulness and acupuncture and are subjected afterwards to the same pain stimuli, to see how their pain tolerance has changed from their baseline reading. MRI scanning is used on the patients in both laboratory sessions, so that clinicians can see and draw inferences from the visible differences in blood flow to different parts of the brain.

A remarkable feature of the assessment process is that patients are also given scores for psychological states: a scale measures their level of depression, anxiety, anger, physical functioning, pain behaviour and how much pain interferes with their lives. This should allow physicians to use the information to target specific treatments. All these findings are stored in an informatics platform called Choir, which stands for the Collaborative Health Outcomes Information Registry. It has files on 15,000 patients, 54,000 unique clinic visits and 40,000 follow-up meetings.

The big chief at the Human Pain Research Laboratory is Dr Sean Mackey, Redlich professor of anaesthesiology, perioperative and pain medicine, neurosciences and neurology at Stanford. His background is in bioengineering, and under his governance the Stanford Pain Management Center has twice been designated a centre of excellence by the American Pain Society. A tall, genial, easy-going man, he is sometimes approached by legal firms who want him to appear in court to state definitively whether their client is or is not in chronic pain (and therefore justified in claiming absentee benefit). His response is surprising.

In 2008, I was asked by a law firm to speak in an industrial injury case in Arizona. This poor guy got hot burning asphalt sprayed on his arm at work; he had a claim of burning neuropathic pain. The plaintiffs side brought in a cognitive scientist, who scanned his brain and said there was conclusive evidence that he had chronic pain. The defence asked me to comment, and I said, Thats hogwash, we cannot use this technology for that purpose.

Shortly afterwards, I gave a talk on pain, neuroimaging and the law, explaining why you cant do this because theres too much individual variability in pain, and the technology isnt sensor-specific enough. But I concluded by saying, If you were to do this, youd use modern machine-learning approaches, like those used for satellite reconnaissance to determine whether a satellite is seeing a tank or a civilian truck. Some of my students said, Can you give us some money to try this? I said, Yes, but it cant be done. But they designed the experiment and discovered that, using brain imagery, they could predict with 80% accuracy whether someone was feeling heat pain or not.

Mackey finally published a paper about the experiment. So did his findings influence any court decisions? No. I get asked by attorneys, and I always say, There is no place for this in the courtroom in 2016 and there wont be in 2020. People want to push us into saying this is an objective biomarker for detecting that someones in pain. But the research is in carefully controlled laboratory conditions. You cannot generalise about the population as a whole. I told the attorneys, This is too much of a leap. I dont think theres a lot of clinical utility in having a pain-o-meter in a court or in most clinical situations.

Mackey explains the latest thinking about what pain actually is. Now we understand that pain is a balance between ascending information coming from our bodies and descending inhibitory systems from our brains. We call the ascending information nociception from the Latin nocere, to harm or hurt meaning the response of the sensory nervous system to potentially harmful stimuli coming from our periphery, sending signals to the spinal cord and hitting the brain with the perception of pain. The descending systems are inhibitory, or filtering, neurons, which exist to filter out information thats not important, to turn down the ascending signals of hurt. The main purpose of pain is to be the great motivator, to tell you to pay attention, to focus. When the pain lab was started, we had no way of addressing these two dynamic systems, and now we can.

Mackey is immensely proud of his massive CHOIR database which records peoples pain tolerance levels and how they are affected by treatment and has made it freely available to other pain clinics as a community source platform, collaborating with academic medical centres nationwide so that a rising tide elevates all boats. But he is also humble enough to admit that science cannot tell us which are the sites of the bodys worst pains.

Back pain is the most reported pain at 28%, but I know theres a higher density of nerve fibres in the hands, face, genitals and feet than in other areas, Mackey says, and there are conditions where the sufferer has committed suicide to get away from the pain. Things like post-herpetic neuralgia, that burning nerve pain that occurs after an outbreak of shingles and is horrific; another is cluster headaches some patients have thought about taking a drill to their heads to make it stop.

Like Irene Tracey, Mackey is enthusiastic about the rise of transcranial magnetic stimulation (Imagine hooking a nine-volt battery across your scalp) but, when asked about his particular successes, he talks about simple solutions. Early on in my career, I used to be very focused on the peripheral, the apparent site of the pain. I was doing interventions, and some people would get better but a lot wouldnt. So I started listening to their fears and anxieties and working on those, and became very brain-focused. I noticed that if you have a nerve trapped in your knee, your whole leg could be on fire, but if you apply a local anaesthetic there, it could abolish it.

This young woman came to me with a terrible burning sensation in her hand. It was always swollen; she couldnt stand anyone touching it because it felt like a blowtorch. Mackey noticed that she had a post-operative scar from prior surgery for carpal-tunnel syndrome. Speculating that this was at the root of her problem, he injected botulinum toxin, a muscle relaxant, at the site of the scar. A week later, she came up and gave me this huge hug and said, I was able to pick up my child for the first time in two years. I havent been able to since she was born. All the swelling was gone. It taught me that its not all about the body part, and not all about the brain. Its about both.

Main illustration by Matthew Richardson

This is an edited version of an article that appears on Mosaic. It is republished here under a Creative Commons licence.

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