Pain is real, but must still be assessed

by Dr NICHOLAS PADFIELD consultant in anaesthesia and pain management at Guy’s & St Thomas’s NHS Trust

“Pain is an unpleasant sensory and emotional experience.”

There you have it: that is the core definition by the International Association for the Study of Pain.

It thus has a physical component; it affects our emotions, feelings and mood and it occurs over time. That time may be short and finite, or prolonged with no end in sight.

In assessing a claimant complaining of pain following an incident, the expert will need to determine the mechanism and genesis of the pain for causation, which will take into account the nature and circumstances of the index event, the relevant antecedent medical history and the treatment following the incident to the time of the consultation for the preparation of the medicolegal report.

Experience teaches the expert that whatever is written in the final report must be justifiable under robust crossexamination.

It is no help to anyone to bend with the prevalent wind; the expert must be independent and impartial.

Claimants vary in their accuracy and recall of events for numerous reasons. In the pain clinic context physicians take what is asserted at face value; to do so in a medicolegal context would be naïve.

To support assertions made by a claimant the expert relies on consistency and compatibility of the symptoms with the physical signs at clinical examination, which must include the claimant’s demeanour and affect.

Contemporaneous records are crucial in establishing the veracity and extent of a claimant’s assertions; thus, full sets of GP and hospital records must be available for scrutiny before the report can be finalised.

When surveillance has been undertaken it is helpful if it is disclosed as early as possible. It is often noncontributory, for example consisting of long periods of viewing a claimant through the rain seated at a bus stop, or being driven in a car with short periods of activity that neither support nor deny the claimant’s assertions.

However, the author has seen some hilarious ‘reverses’, with a wheelchairbound claimant, too disabled to travel for a consultation, stripped to the waist laying bricks on a garden wall, and another wheelchair-bound claimant pushing his own wheelchair up-hill with his wife walking alongside: to cite just two examples.

Reports from other experts are often helpful in the final opinion on a claimant, especially those from occupational therapists, physiotherapists and psychologists. In certain cases other medical specialities such as neurophysiology, psychiatry, rheumatology and orthopaedics can be very contributory.

It is a case of Venn diagrams with overlap between different specialities.

The caveat for the solicitor running the case is that the different medical perspectives may give the appearance of significantly different views, and while these can usually be reconciled at joint conferences, some reports will be at best irrelevant or at worst misleading.

For example, soft tissue injuries may not be best assessed by an orthopaedic opinion if there are no bones broken or joints damaged, or a neurological opinion if there is no nerve damage.

As pain affects us physically and emotionally, all the different components of the impact of the pain should be addressed so that, in addition to causation, future rehabilitation and treatment can be recommended.

Therefore, pain medicine supported by psychology and psychiatry, physiotherapy and occupational therapy may prove to be the most appropriate opinion to seek in cases of personal injury complicated by pain.