Why Do You Need a Pain Expert?
By Dr Christopher Jenner MB BS FRCA FFPMRCA Pain Expert at Medicolegal Associates Ltd
What is a Pain Expert?
A pain medicine specialist or pain expert is a doctor with specialised training and expertise in all aspects of the diagnosis and the management of painful conditions. The field encompasses a wide spectrum, including acute, chronic and cancer pain.
In the UK, pain medicine is a sub-specialism under the auspices of the Royal College of Anaesthetists. The vast majority of British pain specialists are therefore Consultant Anaesthetists who have undergone a significant additional period of specialised training in pain medicine. This typically takes the form of an accredited full-time pain fellowship within a recognised pain management centre as part of a (RCoA) pain training programme.
Why Instruct an Expert in Pain Medicine?
Pain experts are often required for medico legal cases where there is a relative lack of robust diagnosis, causation and prognosis. An expert report from a consultant in pain medicine can make a significant difference in this respect.
Solicitors and counsel often find it useful to seek the opinion of a consultant in pain medicine where the claimant’s symptoms do not fit with the reported pathology. For complex cases associated with significant or ongoing pain or hypersensitivity, our opinion can be very useful in determining a prognosis.
It can be considered remiss if the opinion of a pain medicine specialist is not sought for patients with complex chronic pain disorders and it can have a significant and negative bearing on a case and any award made.
Medical evidence from a credible pain expert also makes an allegation of malingering or ‘putting it on’ very difficult to be pursued with confidence.
How can a Pain Expert assist in a Medico Legal Claim?
Pain experts can offer a comprehensive multi-dimensional assessment and report incorporating well recognised, internationally validated scores for pain, function and psychological disorder. Their expertise is helpful both when acting for the claimant or when defending a claim.
In the NHS, pain medicine specialists, including myself, usually work within the setting of a multi-disciplinary clinic which may employ other health professionals with specialist expertise such as physiotherapists and psychologists. As such, our practice needs to combine appropriate pathophysiological knowledge relevant to the nervous system as well as the musculoskeletal system.
Essentially, the remit of a pain medicine specialist spans a broad spectrum of pain disorders and conditions.
We use a broad range of techniques in order to diagnose, identify causation and treat patients and manage pain symptoms. Most importantly, specialists in pain medicine need to have the correct diagnosis which entails the following:
- History taking
- Clinical examination
- Review of medical notes
- Relevant investigations
- MRI scans
- Ultrasound scans
- Other imaging
- Blood tests
- Other tests, e.g. EMG
Pain specialists also advise on a range of multidisciplinary pain treatments including the following:
- Analgesic medication
- Physiotherapy-based rehabilitation
- Clinical pain psychology
- Minimally invasive pain management procedures.
- Advanced pain management procedures, e.g. spinal cord stimulation
The area of practice for pain medicine specialists may overlap with other hospital specialisms, but no other single speciality combines the scope or range of expertise of a pain expert.
Rheumatologists diagnose and manage arthritis and other disorders for the joints, while neurologists diagnose and manage diseases of the nervous system. Orthopaedic surgeons diagnose and operate on diseases of the musculoskeletal system, while spinal surgeons diagnose and operate on disorders and injuries to the spine. Consultants in Pain Medicine routinely work alongside all of these specialities.
Therefore, it is usually recommended, and is of great benefit to a personal injury or clinical negligence claim, for a pain expert to be instructed in addition to these other specialists in the diagnosis, treatment options and prognosis to remove subjectivity and explain the complexity which is often associated with chronic pain conditions.
How do I know if I need an Expert in Pain Medicine?
In cases where the patient has sustained a physical injury for example, it is important to get the opinion of an expert witness in orthopaedic surgery to diagnose any underlying orthopaedic issues – for example, a disc prolapse, fracture, tear or other definable problem.
However, in a large number of cases that continue through the medico legal process, the patient may suffer with ongoing pain in the face of minimal clinical evidence of an ongoing orthopaedic issue. The orthopaedic expert may find that any orthopaedic injuries or issues have subsequently resolved. Despite this, the patient continues to suffer with pain and this is where the expertise of an Expert in Pain Medicine should be sought.
As a Consultant in Pain Medicine working in a UK pain clinic at Imperial Healthcare NHS Trust, I am used to taking approximately 50% of referrals from General Practitioners and approximately 50% of referrals from consultant colleagues within the NHS Trust. A significant proportion of these referrals come from my consultant orthopaedic colleagues, with whom I work with closely, including the joint care of a number of patients, in particular patients with spinal pain.
The cause of ongoing pain in the face of minimal or healed orthopaedic injury for example is within the domain of Pain Medicine. There are well recognised pathophysiological effects which occur including the following:
- Acute pain – pain that lasts for less than three months
- Development of chronic pain – pain that lasts for greater than three months
- Acute or chronic pain
- Central sensitisation – a process of hypersensitivity of the peripheral and central nervous system
Contemporary Pain Medicine takes a bio-psychosocial approach to the diagnosis and management of painful conditions. This firmly includes the causation of painful conditions.
I have been involved in the preparation of medico legal reports for over 15 years and generally work in collaboration with orthopaedic, rheumatologists and other medical experts to present a claimant’s case as robustly as possible or to defend a client’s alleged liability. This has included giving evidence in court including criminal court, county court and the high court.