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A Real Pain
- Dec 1, 2022
- Latest Journal
How can we as Experts evaluate the intensity, effect and long term consequences of chronic pain on individuals after injury?
Pain is immune to empathy...like love.’ - Barbara Lazear Ascher
Pain empathy is a mental ability that allows one person to understand another person’s pain and how to respond to that person effectively.
(From; Pain Management – Practices, Novel Therapies and Bioactives 2021)
Mr West sits on his sofa whilst we talk. He is a young man, healthy looking, well groomed and neatly turned out. A closer look however reveals he looks drawn, tired, agitated and as his two year old daughter asks to sit on his lap he cautiously invites her to climb up gently on his right side and avoid his flexed, contorted, pale left arm. He apologetically refuses a cuddle.
During my time spent in his home as we discuss his injury, he wriggles, squirms, gasps and winces, he tries to provide comprehensive answers to my questions and attempts to smile through his clear agony. The arm remains fully flexed and pronated against his torso but when he moves to change position the limb sharply spasms in a a flexor withdrawal I clearly recognise from my years as a therapist on acute neurological wards and intensive care.
He yawns almost continuously, a sign of the poor quality sleep he describes, forced to spend the nights on a sofa away from his young wife and children for fear of disturbing them. Mr West stands often in an apparent attempt to find relief from another pain he reports since the index accident, this time in his back and left leg. He walks, toe weight bearing only on his left, leaning heavily on a stick.
Mr West is a young father, construction worker and Army reservist who also ran for pleasure several times a week before a fall from height at work. Before me now is a man who has a spinal cord stimulator fitted in his neck, an intrathecal Baclofen pump in his abdomen, is reliant on opiod and neuropathic pain medication and walks with a stick. The pain and spasticity in his left arm is such that he can no longer open his fingers to maintain the hygiene of his hand and has had to undergo surgical procedures to cut his fingernails and treat skin infections of his hand.
I am in no doubt that his pain is genuine and am also certain that no one else will ever experience his pain how he experiences it. Pain is subjective. We might both stub our toe (as I frequently do!), and despite the mechanism of injury being the same, my pain will feel different to yours. I will deal with it differently to you. I will find it hard to describe in both nature and intensity, all I will know is that it hurts and I would rather it went away.
Over 28 years in clinical practice I have seen a great many people in pain, both physical and psychological. I have also witnessed how each individual manages their pain differently. Some might say, and I might tend to agree, that the older generations often complain less, report pain less and consider pain as a natural and expected consequence of aging joints and muscles. Their pain might be evident less by their vocalisations and more in the way they slow down, stiffen, refrain from certain activities or become less mobile. The younger generations have been more encouraged to report pain and seek treatment, rightly so, but it still remains subjective and as a clinician and an Expert my job is to evaluate a Claimant’s pain as best I can by what I observe.
Over the years, I have noticed an increase in the number of Claimant’s who have developed chronic pain or Complex Regional Pain Syndrome (CRPS) post injury. The index accident has sometimes seemed minor and in most instances has been appropriately treated and managed medically. Nonetheless for reasons often unexplained, some individuals have gone on to develop crippling chronic pain conditions which then dominate their lives leading to loss of role, income and hope for the future.
However, I am also confronted sometimes as an Expert with a Claimant’s who I find it hard to make an assessment of, where the pain they describe seems out of alignment with what I see before me.
Let’s compare Mr West with Mr Adams. Mr Adams left hand is also deformed, his wrist fixed in neutral and digits 3, 4 and 5 fully flexed to his palm. He cannot passively extend them and although he can form a pinch grip with his thumb and forefinger, he describes poor function with his hand and intense pain in the hand which radiates into the arm and neck at times.
During my visit I observe no distinct pain behaviours as we speak. He is clearly functionally limited by his disability but my sense is that he is in a position where he could do more for himself and even consider a return to employment if he were approaching things in a different frame of mind. He tells me he cannot use the hand usefully, cannot drive and needs support with all domestic chores and some personal care. The appearance of his injured limb does not suggest a diagnosis of CRPS in colour, temperature or the presence of allodynia for example, but alas it may have been mentioned at some stage of the litigation or during his medical management and therefore seems to have stuck.
In this case, unlike Mr West’s circumstances, my report to the Court suggests that although injured and now disabled as a consequence, Mr Adams’ needs are much less and the intrusion of the injury into his life less profound with the suggestion that some proactive therapy, background practical support and minimal equipment could assist him in transitioning back into the world of work and independent living.
Some weeks after I saw Mr Adams I received video surveillance from the defendant. Over the years I have watched a great deal of surveillance, but the majority of the time my clinical assessment of the individual in question changes little by what I see. They are genuine, their condition might fluctuate but they are not observed undertaking any activities that they have suggested they cannot do and often I can see the subtleties of how they may have adapted tasks that maybe the surveillance operative may not. This time however is one of the few times in my career I am shocked by what I see.
Mr Adams has a genuine injury and who am I to say whether he feels pain or not and how intense that pain is one day to the next? However, his abilities to functionally use his injured hand throughout the surveillance is telling – from fine tasks like holding a cigarette to walking a pulling pet dog and driving a manual vehicle around town.
Is Mr Adams misrepresenting himself? This is not for me to decide. His pain is variable, sometimes he manages well and other times it might be intolerable. My duty to the Court however is to reflect his abilities, his disabilities and as a Care Expert to seek to recommend reasonable and appropriate provision of support for those tasks he can no longer manage. Where a Claimant has misrepresented themselves in this way however this can become most difficult.
So, how do we assess someone who is in pain?
What are the tried and tested methods from questionnaires to analog scales to thermal imaging and so on. As a non-medical Expert I can rely on others to undertake the formal clinical testing but my face to face assessment of the Claimant in their own environment is also key. So what am I looking for and how do I know their description of their symptoms is genuine?
The answer is there is no easy answer! But these things are key from the moment you are greeted at the door:
• How are they dressed? Is their clothing loose, easy to get on and off, are they well groomed, are they wearing splints, or any support?
• How they walk? Their gait, any walking aids, which hand are they in, do they favour one leg more than the other, their posture, speed and how they sit down.
• Where they choose to sit? The type of chair – is it soft or firm, pillows, cushions can they transfer on/off of it OK, what type of support does it offer, high back, recliner etc and where do they place their personal items in relation to where they sit.
• Their behaviour? Pain behaviours such as grimacing, gasping, sucking teeth, wriggling, shuffling, adjusting themselves frequently, self-massage. Refusal to move affected limbs, obvious tension in the body, slowness and carefulness of movement. Medicating whilst you are in the home.
• The consistency of the information? What did they tell other Experts whose reports you have read, can they describe the pain in useful terms, are the patterns of pain what you might expect such as changes between activity and rest, disturbed sleep, overuse of unaffected body parts, stiffness in adjacent joints. Does their functional limitation correlate to their described pain and the affected limb/limbs.
• Vulnerability to pain? Strictly a matter for the Medical Experts, but do they have a history of chronic pain pre-dating the index injury, have they sought treatment and taken time off work before for prolonged or recurrent periods for example. Where there are pre-existing long term conditions or joint problems which might be exacerbating the current condition?
• Mental health? Does their mood and demeanour suggest they are in debilitating pain, ie. Flat effect, poor motivation, tired, withdrawn, irritable, tearful, their interaction with their partner/family whilst you are there where possible.
• Their environment? The layout of the home, adjustments which might have been made, where they are sleeping – separate sleeping arrangements for example, where they eat meals and the layout of the kitchen, the bathroom(s) and the external space, access to vehicles etc.
Finally and of course very importantly
• The written evidence? What reports and records have been made available before the assessment, what treatment has been received to date, how the Claimant has engaged in treatment - have they been attending appointments, willing to try anything suggested for example, how have they presented to other Experts, do the Experts agree?
Visual analog rating scales or VAS (where the patient rates their pain levels in intensity), first used as early as 1921, might be of some use in identifying the varying levels of pain and the influence of movement and activity, but again these are entirely subjective and not able to be objectively measured. I sometimes might use a simple version but not often, opting rather to use the emotive words the Claimant uses to describe their pain and my observation of their presentation.
Sometimes, of course we might not get it right in terms of our judgement and formulating our opinion. Over the years, however, I have found it becomes easier with experience to see the Claimant’s for whom pain is all encompassing and those who may be suffering but are able to functionally manage the pain and enjoy a reasonable quality of life. Alarm bells will usually ring when it is clear the Claimant is exaggerating the effects of their pain, influenced by the litigation.
So how do we as Care Experts seek to compensate someone in pain?
In returning to the idea of pain empathy, we cannot feel the pain of others but we can, where we sense the pain is genuine and debilitating, seek to provide those suffering appropriate care, therapy and equipment to attempt to fulfil our duty of putting them back into the position had they not been injured. As a Care Expert our duty is to value and cost this rehabilitation and care and our biggest challenge is building a package that assists the Claimant to best manage their pain whilst promoting their independence. Especially as pain will vary day to day for many.
Support may be in the form of proactive therapies, alongside practical care via support work or domestic agencies and in some cases vocational rehabilitation. There might be a place for an intensive multi-disciplinary pain management programme where this has yet to be tried but as there is often a debate, especially with those who have maybe adopted a ‘sick role’ or iatrogenic symptoms, as to whether this is of benefit.
I am a believer in a functional restoration programme approach as a proactive alternative in most cases.
A functional restoration programme (FRP) is defined as a customized program of pain management, designed to help patients suffering from chronic pain. (London Pain Clinic)
This type of programme is multi-disciplinary and usually community based. It comprises education, proactive exercise, reconditioning and functional retraining on a background of a cognitive behavioural therapy approach. Techniques for managing flare-ups in symptoms are taught and the emphasis is on encouraging the patient to take charge of their pain and how they respond to it.
Sadly, in some cases, much like Mr West maybe, the influence of the pain on the body and the resulting disabilities may mean this type of approach will have limited benefit and other adjunctive methods have to be tried with invasive procedures such as spinal cord stimulation, intrathecal medication or even amputation. Thankfully these instances are rare but they have to be take into account in the Care Expert’s report supported by the medical views. Recommendations in these cases might centre more around supporting the Claimant and family to accept the disability and rely more on practical care, equipment provision and housing adaptations to minimise the disruption to their lives.
In summary, as a care and therapy Expert involved in assessing claimants with chronic pain, there is a lot to consider. Pain is subjective, presents differently in every individual and is hard to accurately assess. The impact of chronic pain is sometimes very dramatic and entirely life changing however, and claimants need to be compensated appropriately for this. The assessment process needs to be careful and consideration of the evidence both written, visual and oral meticulous prior to formulating our opinion to assist the Court. Recommendations have to be reasonable, proportionate and of course achievable.
References
Barbara Lazear Ascher, Author ‘On Pain’ New York Times
Pain Management – Practices, Novel Therapies and Bioactives 2021, edited by Viduranga Y. Waisundara
Hayes, M.H.S. and Patterson, D.G. (1921) Experimental development of the graphic rating method. Psychological Bulletin, 18, 98-99.
Author
Jean Phillips is a state registered occupational therapist, qualified adult education teacher and accredited expert witness. She qualified in 1994 and has been an expert witness since 2004. Between 2004 and 2017 she worked as a care and occupational therapy expert for two leading UK agencies including at assistant director level, whilst maintaining her clinical work either within the NHS, private sector or for charitable organisations. She became an independent practitioner in 2017 and takes referrals from both claimant and defendant. Since 2021 she has also been working within the NHS mass vaccination programme.
Jean can be contacted via email on: consultjp@outlook.com or via Linkedin: www.linkedin.com/in/jean-phillips-91357498