1. Pain Management a Consultant Perspective
Karen H Simpson
Pain Physician Leeds

2. Overview Pathophysiology of chronic pain?
What is a ‘chronic pain syndrome’ (CPS)?
Assessment of pain
Psychological vs physical pain – does this dichotomy exist?
Pain management
Practical advice for lawyers and experts

3. Chronic Pain Can be caused by minor or major injury
Adults and children
Defined as pain lasting for 6 months or more
No evidence for ‘pain prone personality’
Evidence for organic basis for chronic pain
Basic science research - animal and human
Functional imaging
Systematic reviews

4. Functional imaging
PET scans of patients with LBP showing glial cell activation in thalamus (Brain 2015)

5. Chronic Pain Activation of nerves called “Nociceptors”
Continued nociceptor activation changes in
Central Nervous System (CNS)
spinal cord
peripheral nerves
Emotional effects
Functional effects
Social effects
family
occupation
litigation
Financial effects

6. Chronic Pain Syndrome (CPS)?
Persistent pain
Usually no identifiable source
Normal investigations
Associated with
abnormal illness behaviours
hypervigilance
catastrophization
fear avoidance
mood disorders
effects on function
withdrawal from occupation

7. Chronic Pain Syndrome (CPS)?
Does this differ from chronic pain?
Does it exist clinically?
Is CPS useful terminology?
Somatic symptom disorder
CPS and CRPS confusion?

8. Psychological Component?
Dualistic view
pain is either physical or psychogenic
Are these mutually exclusive?
Current view
pain is affected by multiple biopsychosocial factors
it is physical and psychological
DSM 5 (SSD)
Exaggeration
unconscious
conscious

9. Vulnerability to chronicity?
Consulted GP/HCPs more than average in past
Past complaints but no cause found for symptoms
More prevalent in females
History of problem drug use
History of abuse
physical
emotional
sexual
Social deprivation
Family history of chronic pain – learned behaviours

10. Early indications of chronicity
Pain or functional impairment out of proportion to
original injury and examination findings
Objective measures e.g. ODI, NDI,
Behaviours and beliefs
Patient and carer distress
Usual therapies not effective or give transient relief
Multiple consultations with different HCPs in different settings
Social and work issues
Litigation issues

11. Continuum

12. Factors that maintain chronicity
Sleep disorders
Problem drug use
Social isolation and loss of status
Loss of sense of self
Lack of acceptance of situation
Pre-accident vulnerability
Anger about the accident
Financial anxiety
An adversarial legal system!

13. Neuropathic Pain
Pain as a direct consequence of a lesion/disease affecting the somatosensory system
Pain generated by damage and abnormal function in the nervous system
shingles
post-amputation
CRPS

14. Features of Neuropathic Pain (NeP)
Prickling, tingling, pins and needles (dysaesthesia)
Electric shocks or shooting pain
Hotness or burning sensations
Ice cold sensations
Numbness
Pain evoked by light touch
Altered appearance
Altered perception about limb

15. Neuropathic Pain
NeP poorer physical and mental health than nociceptive pain
NeP commoner in elderly
NeP resists normal analgesic drugs
NeP associated with poor function
NeP causes abnormal body perception
cortical processing
brain re-mapping
NeP carries a poor prognosis
NeP present >2 years is incurable

16. Treatment and Rehabilitation
Medication / topicals
opioid and anti-NeP drug abuse
Physical therapies
acupuncture/TENS
Nerve blocks/Botox
Surgery
Neuromodulation
new technology
Psychological therapies
PMP/rehabilitation
group
individual

17. Practical advice for lawyers
Be aware of and identify potential chronic pain early
Do not allow the person to exaggerate
Obtain complete GP, hospital, OH and DWP records
Discuss surveillance
Deal with Claimant confusion about care/legal process
Facilitate investigation/treatments where appropriate

18. Practical advice for experts
Make sure the case within you area and no COI
Examine complete GP, hospital, OH and DWP records
Read the records before you see the Claimant
Do not allow the person to exaggerate
Discuss surveillance –need to record function carefully
Deal with Claimant confusion about care/legal process
Reply to queries in a timely manner
Tell the instructing solicitor if you view changes