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What is pain? According to the generally held definition, which was produced by the International Association for the Study of Pain, it is the subjective and emotional response to actual or potential tissue damage or described in terms of such damage.
These are fine words, but what does this mean in reality, and how does it have an impact upon the way in which I produce my reports? The essence of this definition is that pain is subjective, and in the end it comes down to the fact that pain is what the patient says that they have. Also, the definition allows for the fact that there does not actually have to be any tissue damage for pain to be produced. Therefore there does not have to be any overt damage to the patient for the pain to exist.
As a consultant in pain management I see patients on a regular basis who have a chronic pain problem, which, by the time I get to see them in my clinic, has been going on for many years, for which they have seen multiple consultants, and has had a destructive effect upon their lives, frequently causing them to lose their jobs, their marriage and their self esteem. These are not patients who are currently in on-going litigation, and the biggest problem is that they have not been provided with a diagnosis for their pain, and may feel that because there is no diagnosis, the healthcare professionals that they come in contact with will not believe that they have a problem.
One of the things that helps these patients more than anything in coming to a pain management centre is that, possibly for the first time, they are talking to someone who believes that they have a problem and accepts their story as being true. This may therefore make a pain management expert look like an easy touch to get support for the claimant’s case.
It also has the effect that medical experts in different specialities can be pitted against each other, particularly orthopaedics versus pain management. This is particularly true in cases of whiplash injury, where the orthopaedic expert will examine the patient and state that, as there is no evidence of damage on the scans, the problem will resolve very quickly, and that failure to do so will be considered as malingering on the part of the claimant. Meanwhile, the pain management expert will tend to be more realistic (not necessarily sympathetic) in their assessment of the problem, particularly with the knowledge of the underlying molecular pathology of the situation.
There has been, and continues to be, a vast amount of research into the development of chronicity of pain, trying to find the answer to the question of why pain from an acute injury will persist beyond the normally expected duration, a major problem for healthcare in general as many procedures performed surgically have been shown to have chronic pain post-operatively in up to 30% of patients (something that the majority of them are not warned about when consent is being sought).
Because of the knowledge of the molecular changes it is possible to put forward an argument to explain why a patient may have developed chronic pain after what may appear to be a relatively minor injury. The problem is that, as the changes are at the cellular and sub-cellular level, to demonstrate them is impossible, and we have to rely upon the evidence gleaned from animal experiments. There are new methods being developed of imaging the brain, and these are being extensively researched, but as yet they are not able to say whether or not a patient has pain.
Pain experts should not be considered as naïve. Although there may be a greater tendency to accept that what the claimant is saying is the truth, there still has to be corroborative evidence, which is not normally found in X-rays, but in the General Practitioner’s records. A thin set of records with few attendances prior to the index event tends to suggest that the claimant is not used to assessing the healthcare system, but if the number of attendances goes up subsequently, it suggests that there has been a radical change in their life.
Secondary gain is normally minimal in many of these people and tends not to be a driving force to maintain a state of pain. Most claimants want to get back to where they were before the index event which threw them into the world of litigation, and they are not well served if we turn our backs upon them.
George Harrison 5/5/06
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