CHRONIC PAIN 1998

Chronic benign pain is very common in all industrialised nations studied. By the time litigators are actively involved, the original physical injury is fully healed and the pain - suffering - behaviour elements have a life of their own.

Typically, orthopedic surgeons and rheumatologists no longer have a diagnostic, therapeutic or medicolegal role. Treatment is multidisciplinary and is directed not at reducing pain but at increasing functioning despite pain.

The International Association for the Study of Pain defines ¹ pain as "an unpleasant sensory and emotional experience associated with actual and potential tissue damage, or described in terms of such damage", chronic pain as "pain, that persists beyond the normal time of healing..."

The current psychological terminology is Chronic Pain Disorder Associated with Psychological Factors (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, DSM-IV).

Chronic benign pain is very common in all industrialised nations studied. At any time, according to reports in the world research literature, between two and forty percent of various populations suffer from Chronic Pain ²: 25-30% is a realistic estimate in industrialised countries ³. The annual cost to the US economy was 16 years ago estimated ⁴ at a crippling 40 billion dollars.

A useful model ⁵ for personal injury litigators identifies 4 components of chronic pain, nociception - pain - suffering - behaviour.

Nociception is the appreciation of injury that triggers the experience of pain. In Acute Pain there is a direct and readily understood linkage with suffering and Pain Behaviour.

By the time litigators are actively involved, the original physical injury is fully healed and the pain - suffering - behaviour elements have a life of their own. In Chronic Benign Pain, the causal linkage between the appreciation of injury and the experience of pain is a temporary occurrence that can be established only by examination of contemporaneous documentation. Expert opinion about such causal connection can be meaningful only if pre-injury clinical records are included in the analysis.

Thus the tissue damage that gave birth to the pain is gone, the umbilical cord of medical causation cut. The experience of pain, suffering and pain behaviour now have a life of their own, and this autonomous phenomenon is determined ⁵ by "toughness", cultural values and Secondary Gain. In medicolegal terminology, a significant segment of society have the psychological thin skull that translates temporary injury into long-term disability.

Typically, orthopedic surgeons and rheumatologists no longer have a diagnostic, therapeutic or medicolegal role. Once physical healing is complete, typically within 3 months of a soft tissue injury, physical medicine subspecialists have completed their contributions. The principal physician is the physiatrist or anesthetist head of a multidisciplinary team of educators, physiotherapists, occupational therapists, psychologists and psychiatrists.

Treatment is multidisciplinary and is directed not at reducing pain but at increasing functioning despite pain. Note that abolition or even reduction of pain experience is not a therapeutic goal ⁶. Thus, therapists are continually challenging the client's faulty belief that Chronic Pain is protective against further injury.

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