Dr Jenner discusses rehabilitation programmes for chronic pain in May’s edition of Your Expert Witness magazine
Rehabilitation programmes for chronic pain
By DR CHRISTOPHER JENNER MB BS FRCA FFPMRCA, consultant in pain medicine at Medicolegal Associates Ltd
Pain medicine consultants often recommend the services of a multi disciplinary rehabilitation programme to help manage chronic pain. The aetiology of chronic pain syndromes are not as well understood as acute pain problems where the symptoms are generally associated with a well-defined organic cause, can be identified by a physical examination or diagnostic imaging and then treated. Inadequate understanding of the complexities of chronic pain can result in either under or over-diagnosis of the condition.
Possible mechanisms of chronic pain range from persistent scar tissue around nerve roots, neuropathic pain, improper balance of serotonin or norepinephrine receptors, central spinal sensitisation and psychogenic causes. Social and psychological factors often play a strong role in the presentation of chronic pain for many patients or it can arise secondary to chronic musculoskeletal pain and neuropathic pain.
Unfortunately single modality treatment, such as physiotherapy or pain medication, is rarely effective and multiple medical and surgical treatments can be complicated to deliver, resulting in a fragmented treatment plan for the patient. Additionally, the cost to either the healthcare provider or patient can be extremely high. Therefore, a pain medicine consultant may recommend a rehabilitation programme to deliver unified multiple treatment and therapies to treat a patient with chronic pain. A good provider will provide a seamless and cost effective programme of treatment. The purpose of rehabilitation is to restore an injured or chronically ill person to as productive and independent a lifestyle as possible through the use of medical, functional and vocational intervention.
A pain rehabilitation programme will consist of a range of health care providers of different disciplines and usually includes a consultant in pain medicine, a specialist pain physiotherapist and a clinical pain psychologist at the core of the team. The programme is usually underpinned with cognitive behavioural therapy to help deal with the many areas of life chronic pain affects – physical, emotional and practical daily living.
Patients are assessed for their suitability for a programme by a consultant in pain medicine and a clinical pain psychologist, assessing the patient’s medical, psychosocial and other developmental circumstances. In complex cases where physical disability is significant a clinical specialist, occupational or physiotherapist or clinical nurse specialist may be involved. Following assessment, a multidisciplinary pain rehabilitation programme will be created specifically for the patient.
However, despite the proven benefits of effective early rehabilitation to chronic pain patients, specialist residential multi disciplinary programmes can be difficult to access on the NHS and prohibitively expensive privately. In addition, pre- and post-centre support may not be available to ensure continuity of progress. Poor access to services may cost more in the long term than the cost of the rehabilitation process and undoubtedly leads to much poorer outcomes in terms of the patient’s likelihood to return to work or play an active role in society and their family, potentially adding ongoing pressure to the NHS.
December 2015 saw the third version of the Rehabilitation Code being unveiled. The code provides a framework by which personal injury legal practitioners can start to make a difference for their injured clients and their families from the outset of the post-accident period. The guiding principles of the code are that ‘it should be the duty of every claimant’s solicitor to consider, from the earliest practical stage, and in consultation with the claimant and/or the family, whether it is likely or possible that early intervention, rehabilitation or medical treatment would improve their present and/or long term physical or mental wellbeing.’ This duty is ongoing through the early life of the case but is of most importance in the early stages. Given the potential benefit of rehabilitation, APIL members are now encouraged to consider whether rehabilitation is appropriate in every case. Also, the pre-action protocol for personal injury claims and the Rehabilitation Code place obligations on personal injury lawyers to achieve this.