The longer I have worked across the medicolegal setting offering rehabilitation to individuals with trauma and persistent pain, the more I realise what a thorny issue the concept of pain is in this context.
A recent experience….
Recently I was working with a client following a really tricky injury. Chatting to others involved in their care, their interpretation was the client might be exaggerating their symptoms as their claim was due to settle and they were experiencing increased pain. They were also due to return to work after a long period of absence.
‘Are they making it up?’
Particularly when litigation is involved, it is sometimes suggested that there is ‘secondary gain’ to somebody’s pain (this may or may not be a conscious process but the undertone is ‘they are going to benefit from this injury’). Whilst we can never say with utter certainty, I would argue this happens in a small minority of cases rather than this being the norm. Pain is such a personal experience, there is no scientific way to measure someone’s experience of pain, and description of pain is always going to be subjective.
Pain is really strange
Remember that time you got a paper cut, tiny and insignificant, that caused you to swear it was so painful? Have you ever briefly stood on a small piece of lego? These are great examples of how injury does not always correlate with pain. Add in to that our understanding that our previous experiences, belief systems and other stresses and environmental factors will also alter our perception of pain, and we start to see how legitimately someone might experience increased pain towards the end of a claim, or when they are returning to work and filled with apprehension. At Retraining Pain, we approach pain firmly from the stance that all pain is real, and it always has both physical and psychological factors.
How can a multidisciplinary team help with this thorny issue?
This is where it is helpful to have frank multidisciplinary discussions around what different team members are experiencing with that individual in pain, and think about how we can get alongside the client to help them understand this and address these complex needs.
Modern pain neuroscience is educating us all the time about how increased perception of danger in our environment, whether that is from who we see, the messages we receive from our care team, the things we see, hear, taste and touch, the places we go, will all affect our perception of pain.
Our team conceptualises an individual’s pain using a biopsychosocial approach – and by understanding how their physical injury process, their beliefs and experiences and social environment all interplay, we can empower individuals to improve each of these areas to aid their rehabilitation. Always mindful of the Rehabilitation Code, the collaborative nature of rehabilitation and our overriding duty to the claimant, the multidisciplinary team can conceptualise the key features of pain and present this information to everyone involved; ideally placed to skilfully communicate these complex pain presentations.
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