Dr Jenner discusses Pain Medicine in the Medico Legal setting in the January 2016 issue of Your Expert Witness

The Effects of Pain Can Run Deeper Than Its Physical Presence

By DR CHRISTOPHER JENNER MB BS FRCA FFPMRCA, consultant in pain medicine at Medicolegal Associates Ltd

SOLICITORS AND BARRISTERS who are involved in personal injury and clinical negligence claims are increasingly finding that their clients need to be examined and assessed for on-going, long-term pain problems. That may require a consultant in pain medicine as an expert witness: someone who has had extensive training and experience in the treatment of patients with long-term pain conditions, including musculoskeletal and neuropathic (nerve) pain.

Pain is a complex area of medicine, with more than 90 different types of pain conditions identified, and is a very common problem. Chronic pain is associated with approximately one in seven of the population of the western world and accounts for a significant proportion of healthcare budgets.

When considering pain in the medicolegal arena, it can often be a barrier to rehabilitation; but with the early intervention of a pain clinician, providing the correct diagnosis and treatment, it is often possible to significantly improve the overall outcome for clients.

What is pain?

Pain is defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience, which is primarily associated with tissue damage or described in terms of tissue damage, or both. A more useful definition for solicitors to use with their clients is to acknowledge that ‘pain is whatever they say it is’.
Pain comes in two time courses – acute pain and chronic pain. By definition acute pain lasts for less than three months and chronic pain lasts for three months or more. Examples of acute pain include post-operative pain, pain following trauma such as road traffic accidents and a number of painful medical and surgical conditions including appendicitis, peritonitis and other acute inflammatory conditions.

Chronic pain includes more common long-term pain complaints such as neck pain, lower back pain and joint pain.

Types of pain

Pain is divided into two major types: nociceptive (normal) pain and neuropathic (nerve) pain. Nociceptive pain occurs where the pain signalling pathways are intact and functioning properly. This is found particularly in spinal pain and other musculoskeletal pains. Examples include lower back, neck, hip and other joint pain.
Neuropathic pain is a form of pain where there is damage and/or dysfunction to part of the sensory nervous system, causing hypersensitivity of the nervous system. Clients often use very florid language to describe this pain, including sharp, stabbing, burning or electrical shock-like pain. The client may also experience significant sensory dysfunction, with hypersensitivity of the skin, weakness and muscle wasting.

Examples of neuropathic pain in medicolegal practice include fibromyalgia, mysofacial pain, post-amputation pain and post-operative neuropathic pain.
In extreme cases, where limb movement has been adversely affected by pain, it can lead to disuse of the limb, causing muscle wasting and in some cases fibrosis and contractures.
Biopsychosocial approach to pain

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