Dr Stephen Humble MBChB MSc PhD FCARCSI, a consultant in anaesthesia and pain medicine at Medicolegal Associates Ltd outlines below exactly what a pain medicine specialist is and role they take as expert witnesses.
A pain medicine specialist is a doctor with specialised training and expertise in all aspects of the diagnosis and management of painful conditions. The field encompasses a wide spectrum, including acute, chronic and cancer pain. In the UK, pain medicine is a subspecialism 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. 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.
Pain medicine specialists are often required for medico-legal cases where there is a relative lack of robust diagnosis, causation and prognosis. As the courts now recognise chronic pain as a compensatable condition in its own right, having an expert report from a consultant in pain medicine can make a significant difference to the overall amount awarded to a claimant.
Solicitors 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 their opinion is 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 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.
Pain medicine specialists can offer a comprehensive multi-dimensional assessment and report incorporating internationally validated scores for pain, function and psychological disorder which are well recognised.
GPs and other hospital specialists typically refer patients with the most complex chronic pain disorders to pain medicine specialists. They undertake a biopsychosocial approach to diagnosing and managing patients with conditions that can have a disabling impact on their quality of life – such as neck and back pain, joint pains, neuropathic pain, complex regional pain syndrome, phantom limb pain, failed back surgery syndrome, fibromyalgia/chronic widespread pain syndrome and chronic postsurgical pain.
Most pain medicine specialists work in the NHS but some also work in private practice. A relatively small number also undertake work in the medico-legal field after undergoing appropriate expert witness training. In the NHS, pain medicine specialists 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, their practice needs to combine appropriate pathophysiological knowledge relevant to the nervous system as well as the musculoskeletal system.
They need to be acutely aware of the need to recognise and manage psychological issues such as personality disorder, anxiety and depression from which a high number of patients suffer in addition to their pain. Essentially, the remit of a pain medicine specialist spans a broad spectrum of complex disorders.
Pain medicine specialists use a broad range of techniques in order to treat patients and manage symptoms that cannot necessarily be cured. In addition to medications, they may use X-Ray or ultrasound-guided injection based therapy for patients with conditions such as spinal pain and also for patients where surgery is not safe or not indicated. In the most challenging cases, patients may be enrolled in pain management programmes that utilise psychological techniques such as mindfulness or acceptance and commitment therapy combined with education and physical rehabilitation.
The area of practice for pain medicine specialists may overlap with other hospital specialisms, but no other single specialty 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.
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.