Patterns of disharmony; Can the traditional Tibetan system of the medical humors (nyes'pa) offer a systems approach to the delivery of non-pharmacological management of paediatric chronic pain?

Abstract

The ontological understanding of disease and suffering fundamentally rooted in Tibetan medicine systems approach of nyes’pa imbalance is a framework for seeing interrelationships rather than things. The complexity of paediatric chronic pain and its multifactorial components of disease demands a multi-disciplinary non-pharmacological approach. This can lead to variable healthcare outcomes and health costs. Utilizing a systems approach developed from cross-cultural learnings from Tibetan medicine may offer an opportunity to improve clinical effectiveness and economic efficiencies by directing resources and interventions appropriately, based on the observations and interrelationships of individual disease presentation.

Full text

1
Riemer, J (2024) Paerns of disharmony: Can the tradional Tibetan system of the medical humors (nyes’pa) oer a systems approach to the delivery
of non-pharmacological management of paediatric chronic pain?
Paerns of disharmony; Can the tradional Tibetan system of the medical humors (nyes’pa) oer a
systems approach to the delivery of non-pharmacological management of paediatric chronic pain?
Jonathan Riemer
Introducon
Medicine is increasingly complex, involving a highly connected system of people, resources, processes, and
instuons [1]. A systems approach, a framework for seeing interrelaonships rather than things, for seeing
paerns rather than stac snapshots,[2] oers more dynamic delivery of healthcare. This also confers an
opportunity for clinical ecacy and ecient use of healthcare resources.
Tradional healthcare approaches such as in Tibetan medicine that ulise a systems approach to ill health,
may oer some deeper understanding in improving delivery of non-pharmacological management of
paediatric chronic pain. This is because the subjecve experience of pain is constructed and modulated by
complex mul-dimensional interacons of sensory, aecve and cognive funcons [3], requiring an equally
complex and dynamic treatment approach, making a systems approach more responsive and adapve to
individual needs.
Within the Tibetan Medical tradions and framework of pracce, pain is an ontological reality. A list of top
ten common invesgated diseases complied by Luo et al (2015) suggested that Tibetan Medicine probably
has potenal advantages of treang pain [4]. Within The Secret Essence of Ambrosia, a 12th century medical
text, pain is listed as a primary component in the observaonal diagnosis of disease.
Tibetan medical understanding of disease, through paerns of disharmony, that are not bound within
convenonal categories of domains of health but extend across all domains of health, may oer a broader
understanding of approaches to pain management to that currently being delivered from evidence-based
medicine. This aligns to what we currently know about chronic pain in that it is associated with sleep
disturbance, obesity and weight gain, chronic fague, limited physical funconality, and decreased quality
of life [5]. Pain is not merely a sensaon but realised and inuenced to varying degrees by biological,
psychological, and social factors [6].
The current epidemiology of paediatric chronic pain is unclear; esmaons range between 11% to 38%,
around 3% to 5% reporng signicant disability [7]. This uncertainty may limit the appropriate allocaon of
clinical services,[8] as well as lead to a widening economic burden on health and social providers. In treang
chronic pain, a major gap also exists not only in treang the physiological condion, but also in addressing
the interplay with psychological aeologies [9]. A need to develop a systems approach for direcng non-
pharmacological intervenon to paediatric chronic pain, both protecng resources and establishing clinical
ecacy is therefore needed. Ulising the Tibetan system of nyes’pa, or medical humors, may lead to cross
cultural understandings that helps to develop such an approach to achieve this. Current limits of the
modern medical armamentarium in treang and manging pain, reected by the extent of chronic pain in
populaons [10] only highlights the need for “casng the net wider” to help improve both understanding
and intervenons. Whilst, with technological advances and applicaons in paediatric chronic pain, such as
arcial intelligence, ulising a systems model may addionally contribute to future developing algorithms
or machine learning for both diagnosc instruments and outcome measures in an emerging eld of
healthcare [11].

2
Riemer, J (2024) Paerns of disharmony: Can the tradional Tibetan system of the medical humors (nyes’pa) oer a systems approach to the delivery
of non-pharmacological management of paediatric chronic pain?
Tibetan medicine
Tibetan Medicine, also known as Sowa Rigpa, is a tradional medical system that has been pracced for
centuries in the Himalayan region, parcularly in Tibet, Bhutan, Nepal, and parts of India. It is a holisc
approach to healthcare that integrates various elements of medicine, astrology, philosophy, and spirituality.
Tibetan medicine demonstrates interdependent causal relaons and systemac organizaon of the body
and mind through funconal modes [12] and has such an accumulated wealth of experience in the
treatment of chronic disease [13] where mul-modal rather than monotherapy is oen indicated and more
eecve.
The ontological understanding of disease is fundamentally rooted in Buddhist and Bönpo philosophical
tradions and concepts of suering. The concept of suering and its mental aicons [14], also known as
the three poisons (dug gsum) are thought to disturb the balance of the three fundamental energies in the
body or nyes’pa; namely gLung, mKhris-pa, Bad-kan, (gure 1), that if otherwise balanced confer health
and homeostasis.
The convenonal and subjecve experience of life and the individual self is known as ma-rigpa and exposes
individuals to the constant risk of imbalance and therefore disease. Imbalance between the three nyes’pa,
realised through the body leads to disharmony and the development of disease and its symptoms.
Fundamentally, therefore, health in Tibetan Medicine is achieved through the balance of the three nyes’pa,
[15] and Sowa Rigpa i.e. betan medical intervenon, aims at nurturing a prisne state not subject to
suering and disease or nyes’pa disharmony, known as rigpa, that is essenally the anthesis of ma-rigpa.
Figure 1 – A Simplied diagrammac representaon of a Tibetan ontology of disease, suering and
healing
Symptoms of disharmony, manifest as an outcome of such imbalance such that parcular diseases or
symptoms can be recognised both through their paern of imbalance and their appearance in associated
body systems [16].
Homeostasis, and as such health, is both the dynamic balancing of nyes’pa in response to allostac load and
associated internalised changes. Pawo Tsuklak Trengwa, a prominent Tibetan sixteenth-century Kagyu

3
Riemer, J (2024) Paerns of disharmony: Can the tradional Tibetan system of the medical humors (nyes’pa) oer a systems approach to the delivery
of non-pharmacological management of paediatric chronic pain?
scholar, whose best-known composion was the Chojung Khepai Gaton (chos 'byung khas pa'i dga' ston), or
“Scholars Feast” states:
Because the management of pain is special
and consequenal, one should be neither too
lax nor too ambious [17]
This perhaps infers the need to achieve a state of balance in pain management both in its treatment and in
restoring the state of homeostasis in the paent, indicang the concept of pain being both an indicator and
outcome of imbalance or disharmony in a system of health.
As previously menoned, pain is a mul-dimensional phenomenon that directly impacts upon homeostasis
[18] and therefore not surprisingly mulple domains of health. In acute circumstances pain disturbs
homeostasis that ulmately drives a systems response to re-establish homeostasis, enacng healing
through behavioural and physiological change mechanisms. In chronic pain the homeostac disturbance,
imbalance or disharmony is pervasive and therefore can be mapped out with a cluster of symptoms and
behaviours in both a Tibetan medical model of humors as well as in current evidence based medical
domains of health and medical elds e.g. psychology, rheumatology, neuroscience.
It is this concept of being able to map the cluster of symptoms and dysfuncon onto both a model of
Tibetan medicine and evidence-based medicine that allows for the opportunity for comparave insight into
current management of paediatric chronic pain.
Pain in Tibetan Medicine
As with all sociees pain reects social condions and health related beliefs and occurs within sociopolical
contexts, [10] impacng upon and realised in all domains of health and closely connected with all
dimensions of physical and mental health.
As detailed above, the Tibetan cultural context of Tibetan Medicine, Sowa Rigpa, understands pain and
disease within a Buddhist and Bönpo belief system and philosophical framework that has emerged over the
thousands of years of history of spiritual dialogue and pracce between Tibet, India and other Himalayan
neighbours.
Homage to you, O liberated one,
Who delivers from all pain!
Homage to you, the tranquil one
Who perfectly tames all the untamed ones! [19]
Pain has its roots within the foundaonal teachings on the nature of suering (sdug bsngal) in Buddhist and
Bönpo tradions, such that pain as a phenomenon is not only approached from a physical perspecve but is
also understood within the broader context of Tibetan cultural understanding of existence.
Within this system, the concept of pain is replete in Buddhist and Bönpo teachings and pracces as a
symptom of an individualised convenonal experience of existence (ma-rigpa). Such teachings and
intervenons aim to transform mulple domains of health within the individualised experience, both
embedded in a religious and socio-cultural framework. Whereas ma-rigpa can be understood as the

4
Riemer, J (2024) Paerns of disharmony: Can the tradional Tibetan system of the medical humors (nyes’pa) oer a systems approach to the delivery
of non-pharmacological management of paediatric chronic pain?
subjecve individualised personal experience of life that is exposed to pain and suering. Through suering,
disease and the imbalance of the nyes’pa, it becomes necessary to nurture balance, having examined both
the causes and interacons of components of a system of health in aempng to support the achievement
of a disease-free state (rigpa), free from such suering. This essenally is framework of medicine
encapsulated within Sowa Rigpa.
In this way, the concept of pain in Tibetan Medicine can be seen to align with the Internaonal Associaon
of Study of Pain denion, this being that pain is always a personal experience that is inuenced to varying
degrees by dierent factors and domains of health, modied by life experience [20] and modulated by
complex mul-dimensional interacons of sensory, aecve and cognive funcons [3].
However, considering the physiology of pain in Tibetan Medicine, specic and focal explanaons of pain
exist in the Tibetan medical texts:
“Regarding sunken, obscured, and unclean channels, that is, if the [pulsaons in the] channels are sluggish
and obscure, such channels [portend] that pain will occur [15]”
There is a suggeson that pain is a symptom of a disharmony in the nyes’pa that leads to an obstrucon,
restricon or stasis in ow of normal physiological funcon in the body. This is not unlike “bi” syndrome as
described in classical Chinese medical texts, the word 'Bi'(痹) in Chinese means an obstrucon, whereby the
obstrucon of Qi and or Blood will give rise to pain as a symptom [21]. In both tradions this is perhaps the
outcome of hundreds of years of empirical observaon of both rheumatological condions replete with
pain where inammaon and obstrucon of movement is co-existent. This is something that we also see in
trauma where an inammatory response is principle in healing. Both obstrucon or reduced movement,
(i.e. stas) and pain are universally recognised in all pain condions.
In Tibetan Medicine, the channels (rtsa) referred to are not necessarily limited to vascular circulaon, as
understood convenonally, but have complex usage and can refer to transportaon of blood, nutrients,
waste products, glung and substances that together maintain the body, health and longevity[22]. As one of
the nyes’pa, glung is intrinsically associated with movement and transportaon in a health system and
physical body. It is therefore no surprise that symptoms of disharmony of the glung nyes’pa tend to
bedominant in disease diagnosis where chronic pain is present. Where obstrucon of normal funcon is
pervasive, not just within the domain of the body but, as Gustchow (2021) has exposed [23], within the
psychosocial and cultural domains health, including obstrucon to social mobility, cultural identy and
social equality. Tibetan medicine emphasises glung disharmony in both physical and psychological
symptoms [24]. gLung is understood to be inmately related to consciousness and movement; the concept
of glung obstrucon or disturbance not only prevails in chronic illness, but points to aspects of disharmony
or disconnecon between the individual microcosm and macrocosm, as well as a body and mind disconnect
that we nd in chronic paediatric pain.
However, we also need to remind ourselves, that within a systems model of health, and with chronicity,
disharmony or imbalance in one component of the system can both cause or result in disharmony,
imbalance and dysfuncon in another component of the system. This is something that is both
acknowledged in Sowa Rigpa as well as the World Health Organisaon’s internaonal classicaon of
funcon, disability and health [25].

5
Riemer, J (2024) Paerns of disharmony: Can the tradional Tibetan system of the medical humors (nyes’pa) oer a systems approach to the delivery
of non-pharmacological management of paediatric chronic pain?
Models of pain
Early incorporaon of the integrave non-pharmacological therapies ulising a muldisciplinary pain
management approach such as physiotherapy, psychology and lifestyle rounes support from occupaonal
therapy, is acknowledged and evidenced in treang paediatric chronic pain [26,27]. These therapies include
targeted intervenon on sleep hygiene, pacing, pain de-sensisaon, breathwork, mindfulness, acceptance
and commitment therapy and movement-based therapy (e.g. exercise and hydrotherapy). Each of which
have their own body of evidence-based pracce and ongoing research.
Together, non-pharmacological intervenons address a biopsychosocial model of paediatric chronic pain
that represents the role of changes in structure and funconal neural connecvity and neuroplascity in
maintaining the pervasiveness of symptoms as well as co-morbidies such as sleep disturbance and fague
that consolidates chronicity (gure 2).
Figure 2 – Biopsychosocial model of paediatric chronic pain- adapted from Rabbis, J.A., Palermo, T.M.
and Lang, E.A., 2020. [28]
As a model of pain in paediatric health, it suggests that there is a complex interplay of biological,
psychological, social and cultural factors that inuence the presentaon of chronic pain. These factors that
essenally account for an imbalance in a biopsychosocial model of health, that leads to dysfuncon, is
comparable to imbalances in the nyes’pa within the Tibetan model of health. In this way idencaon of
the interrelaonships between chronic pain symptoms ulising a comparave framework of the Tibetan
medical humors might highlight where resources and approaches to non-pharmacological treatments can

6
Riemer, J (2024) Paerns of disharmony: Can the tradional Tibetan system of the medical humors (nyes’pa) oer a systems approach to the delivery
of non-pharmacological management of paediatric chronic pain?
be directed and opmised. Both models are aligned in recognising established opinion that biological,
psychological, social, and environmental factors directly or indirectly aect chronic pain [29].
This model also confers the view that pivotal transion processes from acute to chronic pain as being
sensive to social and psychological factors [10] and further supports the need of a systems approach that
acknowledges both internal and external imbalances and disconnecons such as expounded in Tibetan
medicine.
Based on the known and accepted paerns of imbalance within the Tibetan medical humoral model (gure
3) we can map this system onto a biopsychological model of health within paediatric chronic pain that
allows us to target non-pharmacological intervenons more eecvely.
Figure 3 - Tibetan medical humoral model of chronicity
Tradional Tibetan medical clinical examinaon would typically idenfy these paerns following an
established protocol of subjecve and objecve examinaon, including pulse reading, urinalysis, physical
examinaon and consideraon of environmental, lifestyle and constuonal factors. Through such
subjecve and objecve examinaon, the underlying derangement of harmony between the nyes’pa is
exposed.
Therefore, there is potenal to develop a simplied assessment (Table 1) and idenfy the prominent
imbalance in the nyes’pa that corresponds to individual paents’ pain and dysfuncon. Clinical paerns
represent the highly subjecve and individualised burden of pain symptoms, such that a model based on
nyes’pa imbalance allows the systemac categorizaon of symptoms into paerns to facilitate eecve
treatment. This has further potenal in developing pathways of care in non-pharmacological treatments by
direcng resources appropriately, individualising care and opmising resource provision guided by the
paent dominant presentaon.

7
Riemer, J (2024) Paerns of disharmony: Can the tradional Tibetan system of the medical humors (nyes’pa) oer a systems approach to the delivery
of non-pharmacological management of paediatric chronic pain?
Table 1 -
This also has potenal to develop an assessment framework that could have clinical ulity in establishing an
individualised paent care plan of non-pharmacological intervenons, opmising resource provision and
providing a beer understanding of the armamentarium required for paediatric chronic pain management
and services.
Conclusion
The ontological understanding of disease and suering fundamentally rooted in Tibetan medicine systems
approach of nyes’pa imbalance is a framework for seeing interrelaonships rather than things. The
complexity of paediatric chronic pain and its mulfactorial components of disease demands a mul-
disciplinary non-pharmacological approach. This can lead to variable healthcare outcomes and health costs.
Ulizing a systems approach developed from cross-cultural learnings from Tibetan medicine may oer an
opportunity to improve clinical eecveness and economic eciencies by direcng resources and
intervenons appropriately, based on the observaons and interrelaonships of individual disease
presentaon. Both current evidence-based pracce in chronic pain management and Tibetan medicine
relies on empirical observaons of a paent’s dysfuncon in all domains of health. In Tibetan medical terms
this is consolidated as an imbalance. Understanding the nature of this imbalance may guide a more
dynamic and responsive treatment with non-pharmacological modalies that oers health ecacy, protects
health resources and increases condence in the selecon of dierent treatments. Further, with
technological advances and applicaons in paediatric chronic pain such as arcial intelligence [11] and
virtual reality, cross-cultural learnings ulising a systems model may further enhance developments in this
eld where the reliance on algorithms, paerns and machine learning demands a systems approach.

8
Riemer, J (2024) Paerns of disharmony: Can the tradional Tibetan system of the medical humors (nyes’pa) oer a systems approach to the delivery
of non-pharmacological management of paediatric chronic pain?
Recommendaons
Cross-cultural knowledge exchanges and learnings from dierent sources remain the mainstay of medical
anthropology with ethnographies of health systems becoming a rapidly growing area of study [30]. Despite
this, there appears to be paucity in collaboraon between medical anthropology and clinical pracce in
research areas, especially around paediatric chronic pain.
Chronic paediatric pain, with its mulfactorial, mul-domain aeologies oers perhaps an ideal opportunity
to develop collaborave mul-disciplinary research that will both favour paent outcomes and
understanding of this condion.
It is therefore recommended that further research is undertaken to assess whether a systems approach to
non-pharmacological management of paediatric chronic pain can deliver both opmisaon of resources
and benet paent outcomes in real life populaons.
References
1. Clarkson J, Dean J, Ward J, Komashie A, Bashford T. (2018) A systems approach to healthcare: from
thinking to -pracce. Future Healthc J. Oct;5(3):151-155. doi: 10.7861/futurehosp.5-3-151. PMID:
31098557; PMCID: PMC6502599.
2. INCOSEUK (2009) What is systems engineering? Creang successful -systems. Z Guides, Issue 3.0
March; Available at hp://incoseonline.org.uk/Documents/zGuides/Z1_What_is_SE.pdf [Accessed
13 September 2018]
3. Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHae JG, Coghill RC. (2015) Mindfulness
Meditaon-Based Pain Relief Employs Dierent Neural Mechanisms Than Placebo and Sham
Mindfulness Meditaon-Induced Analgesia. J Neurosci. Nov 18;35(46):15307-25.
4. Luo H, Zhong G, Yue L, Wang Q, Ma L, Luobu Z. (2015) Tradional Tibetan medicine in China: A
systemac overview of randomized clinical trials. European Journal of Integrave Medicine. Oct
1;7(5):450-9.
5. Smith SL, Langen WH. (2020) A systemac review of mindfulness pracces for improving the
outcomes in chronic low back pain. Int J Yoga;13:177-82.
6. Internaonal Associaon for the Study of Pain (2020), Revised Denions of Pain Translaons
available from hps://www.iasp-pain.org/resources/terminology/ last accessed 7:28am, 9th May
2024
7. Murray CB, de la Vega R, Murphy LK, Kashikar-Zuck S, Palermo TM. (2022) The prevalence of chronic
pain in young adults: a systemac review and meta-analysis. Pain. Sep 1;163(9):e972-84.
8. Tutelman PR, Langley CL, Chambers CT, Parker JA, Finley GA, Chapman D, Jones GT, Macfarlane GJ,
Marianayagam J. (2021) Epidemiology of chronic pain in children and adolescents: a protocol for a
systemac review update. BMJ open. Feb 1;11(2):e043675.

9
Riemer, J (2024) Paerns of disharmony: Can the tradional Tibetan system of the medical humors (nyes’pa) oer a systems approach to the delivery
of non-pharmacological management of paediatric chronic pain?
9. Polaski, A.M., Phelps, A.L., Smith, T.J., Helm, E.R., Morone, N.E., Szucs, K.A., Kostek, M.C. and Kolber,
B.J., (2021). Integrated meditaon and exercise therapy: a randomized controlled pilot of a
combined nonpharmacological intervenon focused on reducing disability and pain in paents with
chronic low back pain. Pain Medicine, 22(2), pp.444-458.
10. Zajacova A, Grol-Prokopczyk H, Zimmer Z. (2021) Sociology of chronic pain. Journal of health and
social behavior. Sep;62(3):302-17.
11. Wen, Z. and Huang, H., (2022). The potenal for arcial intelligence in healthcare. Journal of
Commercial Biotechnology, 27(4).
12. Donden Y. (2003) Health through balance: An introducon to Tibetan medicine. Molal
Banarsidass Publ.; Oct 15.
13. Yu, L., Li, S., Pu, L., Yang, C., Shi, Q., Zhao, Q., Meniga, S., Liu, Y., Zhang, Y. and Lai, X., (2022).
Tradional Tibetan medicine: therapeuc potenal in rheumatoid arthris. Froners In
Pharmacology, 13, p.938915.
14. Deane S. (2019) rLung, mind, and mental health: the noon of “Wind” in Tibetan concepons of
mind and mental Illness. Journal of religion and health. Jun 15;58(3):708-24.
15. McGrath, W.A., (2017). Buddhism and Medicine in Tibet: Origins, Ethics, and Tradion (Doctoral
dissertaon, Department of Religious Studies, University of Virginia).
16. Bauer-Wu, S., Lhundup, T., Tidwell, T., Lhadon, T., Ozawa-de Silva, C., Dolma, J., Dorjée, P., Neshar,
D.R., Sangmo, R. and Yeshi, T., (2014). Tibetan medicine for cancer: an overview and review of case
studies. Integrave Cancer Therapies, 13(6), pp.502-512
17. dPa’ bo gtsug lag phreng ba. (2002). Chos ʼbyung mkhas pa’i dga’ ston. Sarnath and Varanasi: Wa
nga badzra bidya dpe mdzod khang. Mkhas pahi dgah ston by Dpah-bo-gtsug-lag ʼphreng-ba. 1965.
Lokesh Chandra (ed.) New Delhi: Internaonal Academy of Indian Culture. (Śatapiṭaka Series no. 9
(4))
18. Salcido, C.A., Geltmeier, M.K. and Fuchs, P.N., (2018). Pain and decision-making: interrelated
through homeostasis. The Open Pain Journal, 11(1).
19. Mañjuśrīmūlakalpa ;The Root Manual of the Rites of Mañjuśrī, (2023) Translated into Tibetan by
Kumārakalaśa , Śākya Lodrö First published 2020, Current version v 1.21.28 available from 84000:
translang the words of the Buddha hps://read.84000.co/translaon/toh543.html [Accessed
14th February 2024]
20. Raja, Srinivasa N.a; Carr, Daniel B.b; Cohen, Miltonc; Finnerup, Nanna B.d,e; Flor, Hertaf; Gibson,
Stepheng; Keefe, Francis J.h; Mogil, Jerey S.i; Ringkamp, Mahiasj; Sluka, Kathleen A.k; Song, Xue-
Junl; Stevens, Bonniem; Sullivan, Mark D.n; Tutelman, Perri R.o; Ushida, Takahirop; Vader, Kyleq.
(2020) The revised Internaonal Associaon for the Study of Pain denion of pain: concepts,
challenges, and compromises. PAIN 161(9):p 1976-1982

10
Riemer, J (2024) Paerns of disharmony: Can the tradional Tibetan system of the medical humors (nyes’pa) oer a systems approach to the delivery
of non-pharmacological management of paediatric chronic pain?
21. Zhang EQ. (2010) Bi syndrome (arthralgia syndrome). Journal of Tradional Chinese Medicine. Jun
1;30(2):145-52.
22. Gerke B. (2013) On the ‘subtle body’and ‘circulaon’in Tibetan medicine. Religion and the subtle
body in Asia and the West: between mind and body. New York: Routledge. Apr 12:83-99.
23. Gutschow, K (2021) The Interplay of Amchi Medicine and Ritual Treatments in Zangskar: A Case of
Wind Disorder in Pordié, L. and Kloos, S. eds., (2021). Healing at the Periphery: Ethnographies of
Tibetan Medicine in India. Duke University Press
24. Gerke B. (2014) The art of Tibetan medical pracce. Bodies in balance: The art of Tibetan
Medicine.:16-31.
25. World Health Organizaon (2002) ,Towards a Common Language for Funconing, Disability and
Health, The Internaonal Classicaon of Funconing, Disability and Health, available from
www.who.int/publicaons/m/item/icf-beginner-s-guide-towards-a-common-language-for-
funconing-disability-and-health [Accessed 14th August 2024]
26. Wren, A.A., Ross, A.C., D’Souza, G., Almgren, C., Feinstein, A., Marshall, A. and Golianu, B., (2019).
Muldisciplinary pain management for pediatric paents with acute and chronic pain: a
foundaonal treatment approach when prescribing opioids. Children, 6(2), p.33.
27. Dezfouli SMM, Khosravi S. (2020) Pain in child paents: A review on managements. Eur J Transl
Myol. Jan 9;30(2):8712.
28. Rabbis, J.A., Palermo, T.M. and Lang, E.A., (2020). A conceptual model of biopsychosocial
mechanisms of transion from acute to chronic postsurgical pain in children and adolescents.
Journal of Pain Research, pp.3071-3080.
29. Sant'Anna, M.B., Kimura, L.F., Vieira, W.F., Zambelli, V.O., Novaes, L.S., Hösch, N.G. and Picolo, G.,
(2024). Environmental factors and their impact on chronic pain development and maintenance.
Physics of Life Reviews.
30. Closser, S., Mendenhall, E., Brown, P., Neill, R. and Jusce, J., (2022). The anthropology of health
systems: a history and review. Social science & medicine, 300, p.114314.