Chronic Pain...What is Chronic Pain Chronic pain is defined by the International Association of the...
54
Chronic Pain The perspective of the Physical Medicine and Pain Medicine Assessor
Transcript of Chronic Pain...What is Chronic Pain Chronic pain is defined by the International Association of the...
Chronic Pain
The perspective of the Physical Medicine and Pain Medicine Assessor
What is Chronic Pain
Chronic pain is defined by the International Association of
the Study of Pain
as an unpleasant sensory and emotional experience
persisting longer than the normal process of healing
usually longer than 3 months
Why is chronic pain such a relevant
topic to expert assessor
Can uarr severity of impairment
Can uarr physical disability greater than expected for the
physical condition
Highly subjectivehelliphellipreliability of reporting
No biomarker or objective test
Creates new questions on causation
Adds complexity in ascribing disability to an injury in
dispute
Objectivesoutline
Build basic understanding of types of chronic pain conditions
encountered
Improve understanding of contentious topics and range of opinions
in the field of chronic pain
Review basics of assessment and workup
Discuss issues and challenges in diagnosis and causation
Build a basic understanding on the principles of pain management
Chronic pain is common
20 population 1
Pain more common than (diabetes heart disease amp cancer
combined -AAPM 2011)
Mostly musculoskeletal in origin
uarr pain with uarr age
Acute pain rarr chronic pain
1Breivik Eur J Pain2006
Challenge in assessing chronic pain
Is there truly ldquopathologicalrdquo pain
Is there some painhellipbut x-ray findings used to ldquojustifyrdquo
pain complaint
What is the severity of pain
Is the pain report within the expected paradigm
What causes chronic pain
Genetic predisposition (in 13 of pts)
Individual has a ldquopain phenotyperdquo
Sensitive stress response system
A spreading of a localized problem
Previous adverse events
Previous pain experience
Current previous fragile psychological status
Alleged precipitating event in plusmn 13 of pts
Postulated pathophysiology
of chronic pain
Genetic factors amp stress response (HPA axis)
Plasma amp urine cortisol levels
Neuroimmune genetic inflammatory mechanisms
Microglia CNS inflammatory molecules (IL-6 IL-8 IL-10 TNF-α)
Polymorphism of genes coding serotonin transporters and catechol-o-
methyl transferase (COMT)Serotonin epinephrine norepinephrine
dopamine
Brain abnormalitieshellipfunctional connectivity brain volumes blood
flow
Proposed neurophysiologic mechanisms
for chronic pain
Peripheral sensitization
Central
sensitization
brain abnormality
Volume changes
Connectivity changes
Metabolic changes
Descending
darr inhibition
Central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system
to their normal or subthreshold afferent input
an upregulation in pain perception as a result of reorganization at the level of
the central nervous system
A maladaptive feature of nervous system plasticity in formation of synaptic
connections and changes in neurotransmitter release patterns
No biomarker to measure
painhellipany testing is
currently only for research
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
What is Chronic Pain
Chronic pain is defined by the International Association of
the Study of Pain
as an unpleasant sensory and emotional experience
persisting longer than the normal process of healing
usually longer than 3 months
Why is chronic pain such a relevant
topic to expert assessor
Can uarr severity of impairment
Can uarr physical disability greater than expected for the
physical condition
Highly subjectivehelliphellipreliability of reporting
No biomarker or objective test
Creates new questions on causation
Adds complexity in ascribing disability to an injury in
dispute
Objectivesoutline
Build basic understanding of types of chronic pain conditions
encountered
Improve understanding of contentious topics and range of opinions
in the field of chronic pain
Review basics of assessment and workup
Discuss issues and challenges in diagnosis and causation
Build a basic understanding on the principles of pain management
Chronic pain is common
20 population 1
Pain more common than (diabetes heart disease amp cancer
combined -AAPM 2011)
Mostly musculoskeletal in origin
uarr pain with uarr age
Acute pain rarr chronic pain
1Breivik Eur J Pain2006
Challenge in assessing chronic pain
Is there truly ldquopathologicalrdquo pain
Is there some painhellipbut x-ray findings used to ldquojustifyrdquo
pain complaint
What is the severity of pain
Is the pain report within the expected paradigm
What causes chronic pain
Genetic predisposition (in 13 of pts)
Individual has a ldquopain phenotyperdquo
Sensitive stress response system
A spreading of a localized problem
Previous adverse events
Previous pain experience
Current previous fragile psychological status
Alleged precipitating event in plusmn 13 of pts
Postulated pathophysiology
of chronic pain
Genetic factors amp stress response (HPA axis)
Plasma amp urine cortisol levels
Neuroimmune genetic inflammatory mechanisms
Microglia CNS inflammatory molecules (IL-6 IL-8 IL-10 TNF-α)
Polymorphism of genes coding serotonin transporters and catechol-o-
methyl transferase (COMT)Serotonin epinephrine norepinephrine
dopamine
Brain abnormalitieshellipfunctional connectivity brain volumes blood
flow
Proposed neurophysiologic mechanisms
for chronic pain
Peripheral sensitization
Central
sensitization
brain abnormality
Volume changes
Connectivity changes
Metabolic changes
Descending
darr inhibition
Central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system
to their normal or subthreshold afferent input
an upregulation in pain perception as a result of reorganization at the level of
the central nervous system
A maladaptive feature of nervous system plasticity in formation of synaptic
connections and changes in neurotransmitter release patterns
No biomarker to measure
painhellipany testing is
currently only for research
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Why is chronic pain such a relevant
topic to expert assessor
Can uarr severity of impairment
Can uarr physical disability greater than expected for the
physical condition
Highly subjectivehelliphellipreliability of reporting
No biomarker or objective test
Creates new questions on causation
Adds complexity in ascribing disability to an injury in
dispute
Objectivesoutline
Build basic understanding of types of chronic pain conditions
encountered
Improve understanding of contentious topics and range of opinions
in the field of chronic pain
Review basics of assessment and workup
Discuss issues and challenges in diagnosis and causation
Build a basic understanding on the principles of pain management
Chronic pain is common
20 population 1
Pain more common than (diabetes heart disease amp cancer
combined -AAPM 2011)
Mostly musculoskeletal in origin
uarr pain with uarr age
Acute pain rarr chronic pain
1Breivik Eur J Pain2006
Challenge in assessing chronic pain
Is there truly ldquopathologicalrdquo pain
Is there some painhellipbut x-ray findings used to ldquojustifyrdquo
pain complaint
What is the severity of pain
Is the pain report within the expected paradigm
What causes chronic pain
Genetic predisposition (in 13 of pts)
Individual has a ldquopain phenotyperdquo
Sensitive stress response system
A spreading of a localized problem
Previous adverse events
Previous pain experience
Current previous fragile psychological status
Alleged precipitating event in plusmn 13 of pts
Postulated pathophysiology
of chronic pain
Genetic factors amp stress response (HPA axis)
Plasma amp urine cortisol levels
Neuroimmune genetic inflammatory mechanisms
Microglia CNS inflammatory molecules (IL-6 IL-8 IL-10 TNF-α)
Polymorphism of genes coding serotonin transporters and catechol-o-
methyl transferase (COMT)Serotonin epinephrine norepinephrine
dopamine
Brain abnormalitieshellipfunctional connectivity brain volumes blood
flow
Proposed neurophysiologic mechanisms
for chronic pain
Peripheral sensitization
Central
sensitization
brain abnormality
Volume changes
Connectivity changes
Metabolic changes
Descending
darr inhibition
Central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system
to their normal or subthreshold afferent input
an upregulation in pain perception as a result of reorganization at the level of
the central nervous system
A maladaptive feature of nervous system plasticity in formation of synaptic
connections and changes in neurotransmitter release patterns
No biomarker to measure
painhellipany testing is
currently only for research
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Objectivesoutline
Build basic understanding of types of chronic pain conditions
encountered
Improve understanding of contentious topics and range of opinions
in the field of chronic pain
Review basics of assessment and workup
Discuss issues and challenges in diagnosis and causation
Build a basic understanding on the principles of pain management
Chronic pain is common
20 population 1
Pain more common than (diabetes heart disease amp cancer
combined -AAPM 2011)
Mostly musculoskeletal in origin
uarr pain with uarr age
Acute pain rarr chronic pain
1Breivik Eur J Pain2006
Challenge in assessing chronic pain
Is there truly ldquopathologicalrdquo pain
Is there some painhellipbut x-ray findings used to ldquojustifyrdquo
pain complaint
What is the severity of pain
Is the pain report within the expected paradigm
What causes chronic pain
Genetic predisposition (in 13 of pts)
Individual has a ldquopain phenotyperdquo
Sensitive stress response system
A spreading of a localized problem
Previous adverse events
Previous pain experience
Current previous fragile psychological status
Alleged precipitating event in plusmn 13 of pts
Postulated pathophysiology
of chronic pain
Genetic factors amp stress response (HPA axis)
Plasma amp urine cortisol levels
Neuroimmune genetic inflammatory mechanisms
Microglia CNS inflammatory molecules (IL-6 IL-8 IL-10 TNF-α)
Polymorphism of genes coding serotonin transporters and catechol-o-
methyl transferase (COMT)Serotonin epinephrine norepinephrine
dopamine
Brain abnormalitieshellipfunctional connectivity brain volumes blood
flow
Proposed neurophysiologic mechanisms
for chronic pain
Peripheral sensitization
Central
sensitization
brain abnormality
Volume changes
Connectivity changes
Metabolic changes
Descending
darr inhibition
Central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system
to their normal or subthreshold afferent input
an upregulation in pain perception as a result of reorganization at the level of
the central nervous system
A maladaptive feature of nervous system plasticity in formation of synaptic
connections and changes in neurotransmitter release patterns
No biomarker to measure
painhellipany testing is
currently only for research
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Chronic pain is common
20 population 1
Pain more common than (diabetes heart disease amp cancer
combined -AAPM 2011)
Mostly musculoskeletal in origin
uarr pain with uarr age
Acute pain rarr chronic pain
1Breivik Eur J Pain2006
Challenge in assessing chronic pain
Is there truly ldquopathologicalrdquo pain
Is there some painhellipbut x-ray findings used to ldquojustifyrdquo
pain complaint
What is the severity of pain
Is the pain report within the expected paradigm
What causes chronic pain
Genetic predisposition (in 13 of pts)
Individual has a ldquopain phenotyperdquo
Sensitive stress response system
A spreading of a localized problem
Previous adverse events
Previous pain experience
Current previous fragile psychological status
Alleged precipitating event in plusmn 13 of pts
Postulated pathophysiology
of chronic pain
Genetic factors amp stress response (HPA axis)
Plasma amp urine cortisol levels
Neuroimmune genetic inflammatory mechanisms
Microglia CNS inflammatory molecules (IL-6 IL-8 IL-10 TNF-α)
Polymorphism of genes coding serotonin transporters and catechol-o-
methyl transferase (COMT)Serotonin epinephrine norepinephrine
dopamine
Brain abnormalitieshellipfunctional connectivity brain volumes blood
flow
Proposed neurophysiologic mechanisms
for chronic pain
Peripheral sensitization
Central
sensitization
brain abnormality
Volume changes
Connectivity changes
Metabolic changes
Descending
darr inhibition
Central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system
to their normal or subthreshold afferent input
an upregulation in pain perception as a result of reorganization at the level of
the central nervous system
A maladaptive feature of nervous system plasticity in formation of synaptic
connections and changes in neurotransmitter release patterns
No biomarker to measure
painhellipany testing is
currently only for research
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Challenge in assessing chronic pain
Is there truly ldquopathologicalrdquo pain
Is there some painhellipbut x-ray findings used to ldquojustifyrdquo
pain complaint
What is the severity of pain
Is the pain report within the expected paradigm
What causes chronic pain
Genetic predisposition (in 13 of pts)
Individual has a ldquopain phenotyperdquo
Sensitive stress response system
A spreading of a localized problem
Previous adverse events
Previous pain experience
Current previous fragile psychological status
Alleged precipitating event in plusmn 13 of pts
Postulated pathophysiology
of chronic pain
Genetic factors amp stress response (HPA axis)
Plasma amp urine cortisol levels
Neuroimmune genetic inflammatory mechanisms
Microglia CNS inflammatory molecules (IL-6 IL-8 IL-10 TNF-α)
Polymorphism of genes coding serotonin transporters and catechol-o-
methyl transferase (COMT)Serotonin epinephrine norepinephrine
dopamine
Brain abnormalitieshellipfunctional connectivity brain volumes blood
flow
Proposed neurophysiologic mechanisms
for chronic pain
Peripheral sensitization
Central
sensitization
brain abnormality
Volume changes
Connectivity changes
Metabolic changes
Descending
darr inhibition
Central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system
to their normal or subthreshold afferent input
an upregulation in pain perception as a result of reorganization at the level of
the central nervous system
A maladaptive feature of nervous system plasticity in formation of synaptic
connections and changes in neurotransmitter release patterns
No biomarker to measure
painhellipany testing is
currently only for research
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
What causes chronic pain
Genetic predisposition (in 13 of pts)
Individual has a ldquopain phenotyperdquo
Sensitive stress response system
A spreading of a localized problem
Previous adverse events
Previous pain experience
Current previous fragile psychological status
Alleged precipitating event in plusmn 13 of pts
Postulated pathophysiology
of chronic pain
Genetic factors amp stress response (HPA axis)
Plasma amp urine cortisol levels
Neuroimmune genetic inflammatory mechanisms
Microglia CNS inflammatory molecules (IL-6 IL-8 IL-10 TNF-α)
Polymorphism of genes coding serotonin transporters and catechol-o-
methyl transferase (COMT)Serotonin epinephrine norepinephrine
dopamine
Brain abnormalitieshellipfunctional connectivity brain volumes blood
flow
Proposed neurophysiologic mechanisms
for chronic pain
Peripheral sensitization
Central
sensitization
brain abnormality
Volume changes
Connectivity changes
Metabolic changes
Descending
darr inhibition
Central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system
to their normal or subthreshold afferent input
an upregulation in pain perception as a result of reorganization at the level of
the central nervous system
A maladaptive feature of nervous system plasticity in formation of synaptic
connections and changes in neurotransmitter release patterns
No biomarker to measure
painhellipany testing is
currently only for research
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Postulated pathophysiology
of chronic pain
Genetic factors amp stress response (HPA axis)
Plasma amp urine cortisol levels
Neuroimmune genetic inflammatory mechanisms
Microglia CNS inflammatory molecules (IL-6 IL-8 IL-10 TNF-α)
Polymorphism of genes coding serotonin transporters and catechol-o-
methyl transferase (COMT)Serotonin epinephrine norepinephrine
dopamine
Brain abnormalitieshellipfunctional connectivity brain volumes blood
flow
Proposed neurophysiologic mechanisms
for chronic pain
Peripheral sensitization
Central
sensitization
brain abnormality
Volume changes
Connectivity changes
Metabolic changes
Descending
darr inhibition
Central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system
to their normal or subthreshold afferent input
an upregulation in pain perception as a result of reorganization at the level of
the central nervous system
A maladaptive feature of nervous system plasticity in formation of synaptic
connections and changes in neurotransmitter release patterns
No biomarker to measure
painhellipany testing is
currently only for research
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Proposed neurophysiologic mechanisms
for chronic pain
Peripheral sensitization
Central
sensitization
brain abnormality
Volume changes
Connectivity changes
Metabolic changes
Descending
darr inhibition
Central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system
to their normal or subthreshold afferent input
an upregulation in pain perception as a result of reorganization at the level of
the central nervous system
A maladaptive feature of nervous system plasticity in formation of synaptic
connections and changes in neurotransmitter release patterns
No biomarker to measure
painhellipany testing is
currently only for research
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Central sensitization
Increased responsiveness of nociceptive neurons in the central nervous system
to their normal or subthreshold afferent input
an upregulation in pain perception as a result of reorganization at the level of
the central nervous system
A maladaptive feature of nervous system plasticity in formation of synaptic
connections and changes in neurotransmitter release patterns
No biomarker to measure
painhellipany testing is
currently only for research
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
No biomarker to measure
painhellipany testing is
currently only for research
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Types of chronic pain
Chronic nociceptive pain
Chronic neuropathic pain
Central sensitization
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Chronic musculoskeletal pain
Chronic soft tissue pain
Soft tissue injury
Chronic musculoligamentous injury
Myofascial pain
Joint pain
Degenerativeinflammatoryposttraumatic arthritis
Mechanical pain
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Osteoarthritisthe most common cause of
chronic pain
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Systematic review 2014Amer Soc Neuroradiology 1
33 papershellipspine CT amp MRI
3110 asymptomatic persons
Disc degeneration 37 (20yr) 96 (80yrs)
Disc bulge 30 (20yr) 84 (80yrs)
Disc protrusion 29 (20yr) 43 (80yrs)
Radiographic changes do not correlate with
pain
ldquoNormal changesrdquo on CT amp MRI
1 Brinjikji Am J Neurorad 2014
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Chronic soft tissue paininjury
General term helliphelliphellipsprains strains and other tears
In spinal regions detectable clinically but normal x-
rays
Diagnosis
tenderness
decreased range of motion
and pain that matches anticipated pattern
in the setting of plausible mechanism
Mostly recover in 3 months but some become chronic
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Myofascial pain
Myofascial pain is a theory of pain
attributes pain to the formation of trigger points
Taut myofascial bands with palpable points that produce
characteristic referral patterns and characteristic responses when
pressed or injected
Points of contention
The term myofascial pain often used too liberally
Some use synonymously with chronic soft tissue injury
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Chronic neuropathic pain
Eg
Chronic nerve injury
Neuropathy
Phantom limb pain
Complex regional pain syndrome
ldquoSensitizationrdquo
Peripheral
Central
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Neuropathic pain
Mostly well understood with good understanding
- of nature of problem
- expectations to interfere in function
- management options
Buthelliphellip
- Central sensitization is outlier
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
A specific example of chronic neuropathic
pain complex regional pain syndrome
autonomically mediated pain
pathophysiology not fully clarified
Edema may play some role in pain generation
( possible non-neurogenic contributors)
Type 1 and type 2
Budapest consensus criteria for clinical diagnosis
Both clinical symptoms and
Examination findings
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Central Sensitivity Syndromes
a state of hypervigilance affecting various body systems
No definitive underlying physical pathology
Various overlapping chronic pain conditions
Fibromyalgia
Irritable bowel syndrome interstitial cystitis vulvodynia temporomandibular disorder
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
An example of ldquosensitizationrdquofibromyalgia
pain dysregulation sensitization hypervigilance
Prevalence2-5
middle aged women poorly recognized in men also children elderly
Across all continents amp social settings
5-7 yrs to diagnosis
35 disablement in North America
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Current concept of fibromyalgia
Chronic widespread pain (the cardinal symptom)
+
Fatigue andor unrefreshed sleep
+
other somatic symptoms mood disorder
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
19
12
2011 ACR Pain + other symptoms
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
The polysymptomatic distress scale
derived from 2011 ACR criteria for FM
Polysymptomatic distress =WPI+SSS (31)
The WPI - 0ndash19 count of painful body regions
SSS - 0ndash12 fatigue sleep and cognitive problems
Total=31
Can be applied to all pain conditions
High scores a marker of central sensitizationhigh somatic +
psychological symptom burden
Can predict poorer outcomes for many conditions
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Outcome for chronic pain is affected byhellip
Personal factors Genes previous amp present physical amp psychological status
Locus of control
Societal factors Social mileau SES education work environment
2nd gain
Health care professionals Excessive medicalization
Excessive polypharmacy
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
The medico legal challenges in assessing
chronic pain
Diagnosis
No confirmatory test
Causation
A claimed trigger
Severity amp disability
Nothing to measure severity
Reliability of subjective report
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Assessment of chronic pain
History
Physical
Investigations
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
EXPERT ASSESSMENT
The critical role of the expert is to assess
severity of the condition
impact on function
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
The expert must use all sources of information
Current complaints
Previous physical amp mental health
Objective impairment
Subjective disablement
Causation
Balance of probabilityhellip a material contribution for an effect
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
The expert musthellip
Confirm diagnosis
Are treatments appropriate
Assess symptom severity
report on inconsistencies (or lack thereof) during the examination
assist the trier of fact in understanding specific complex matters
Be empathetic but validate
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Assessment of Chronic Pain - History
Characterizing pain
Impact of pain on lifelifestyle
Management history
Pain scales
Yellow flags
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Characterizing pain
QualityIntensity
Time course
Aggravatorsrelievers
Distribution
Associated symptoms (sleep mood fatigue activity)
Premorbid pain history ndash what has changed
Many acronyms used ndash as long as fundamentals are
covered any are acceptable
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Impact of pain on lifelifestyle
Day to day function
ADLs iADLs
Mobility
Walking driving etchellip
Sleep
Recreationleisure
Occupational
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Pain
Sleep Disturbance
Reduced activity
Pain is not isolatedassociates with
Other somatic symptoms
Fatigue
Mood disturbance
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Pain scales
No scales or questionnaires validated for medico legal
setting
Validity in medico legal setting questionable
Numerous pain scales are available to quantify pain severity andor
impact upon life
Some are body region specific (for LE joints) some are problem
specific (for neuropathic pain) some are more function specific
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Pain scales problemshellip
Often seen in IMErsquoshellipbut validity
subjective +++++ can be completed to look bad
Mostly used as research outcome measure less as a
clinical measure
a comprehensive narrative history and observation
throughout the interview gives +++++ information
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Yellow flags
Always be humble when making a subjective assessment
Try to understand the important factors accounting for
presentation
Yellow flags provide an ldquoalertnessrdquo
History features which suggest higher risk of developing chronic
pain helliphellippsychosocial factors
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Yellow flags conthellip
Attitudes pain is indicative of severe damage
Beliefs there is something harmful that is disabling about the pain
Fear avoidance a fear of movement leading to a lack of movement
Ongoing litigationinsurance work
Depressionanxiety
Social financial or workplace issues
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Is this person honest in report
Inconsistencies in history Copious somatic symptoms
Exam begins in the waiting room should be normalhellipwith some body tenderness
Pain related behaviour
Report of severe pain on palpation
Inconsistencies for pain report on repeated examthe stethoscope examination
Dysaesthesia
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
How has the condition been treated to
datetoo little or too much
Physical interventions
active
passive
Mental healthbehavioural interventions
Medications
Type and pattern of usage
Procedures or surgeries
How well did treatments work
What is missing or what should be discontinued
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Physical examination for chronic pain
Neuro exam ndash will not be discussing specifics
MSK exam ndash will not be discussing specifics
Other relevant exam
Waddell Signs
Tests of Effort
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Waddell Signshellipcontroversial in an IME setting
What is true meaning of +ve signs
Often utilized in independent medical examinations but originally
designed for clinical use
Can be helpful in understanding relationship between pain
presentation and underlying physical pathology but cannot determine
the absence of physical impairment or the authenticity of a
presentation
This is not a test of central sensitization
This is also not a test of effort
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Tests of effort
May take a number of forms
Hooverrsquos Tests
Dynamometer grip tests
General appearance on performance and consistency
Physiological measures ndash heart rate
In FCE ndash cross validity measures on strength tests
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Diagnosiscausation
History and physical is crucially important ndash often more so than
imaging investigations
No specific imaginglaboratory investigations consistently
recommendedndash needs individualized approach to consider what needs
to be ruled out
Sometimes a specific physical pathology is cause of pain but often
unclear
The challenge in assigning causation to a particular event when
etiology of pain is unclear
Often critically important to obtain input from mental health assessor
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
The essence of chronic pain
management
Seldom is chronic pain completely resolved
2 principles in care
Improve the symptom (as best as possible)
Maintain function
Building adaptive and coping skills
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Remediationhellipimprove the symptom
Physical measures
Exercise healthy lifestyle practices (weight sleep mood)
Medical
Medicationsa modest effect only
treating co-morbid mood and sleep issues
Interventional
Trigger injections
Cortisone injections
Medial branch ablation
Surgical
Often in the chronic stages the goal becomes adaptation more than remediation
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
CopingAdaptive strategies
To be discussed in greater depth in talk on interdisciplinary pain program
Physical
Adaptive devices to accommodate limitations that cannot be remediated
Lifestyle
Pacing and prioritizing
Exercise to build tolerance and endurance despite pain
Educational
Hurt vs harm principles
Psychological
Relaxation techniques CBT ecthellip
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
General principles in management
Whenever physically possible
Engage in normal activities amp activity level
Active over passive forms of treatment
Encourage independence and self
sufficiency
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
hellipsome problems of chronic pain
Many are over treated
Too many drugs too much physio too many
investigations
Medicalization
Perpetuates sickness role
Some cannot afford to get better
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
A medical responsibility to society
Chronic pain is purely subjective
Diagnosis is not necessarily what patient says or what has
been repeated in the record
In the medico legal arena
Remain empathetic
But justify and validate report
Higher level of vigilance re feigning
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Summary for the adjudication of
chronic pain
In a patient with chronic pain in a legal setting pay attention to
Previous health amp psychological status
Look for consistency
Mitigating factors
Temporality
a diagnosisne disability
Fraudulent behaviour is prevalent
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
Closing remarks
Chronic pain is challenging for both claimants and assessors
To appropriately assess chronic pain a detailed and thorough
assessment is required and determination on diagnosis and causation
is only as reliable as the quality of the assessment
There are a broad spectrum of opinions on chronic pain but it is
important to separate fact from hypothesis and to draw conclusions
from assessment findings (such as Waddell signs) within their intended
meaning
Not all causes of chronic pain have a discernable physical etiology but
physical assessors do have the means to make determinations as to
when the presentation fits an identifiable physical pathology and when
non-physical factors appear to be playing a predominant role in the pain
presentation
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
References Staud R Is it all central sensitization Role of peripheral tissue nociception in chronic
musculoskeletal pain Curr Rheumatol Rep 2010 Dec12(6)448-54
httpwwwiasp-painorgTaxonomynavItemNumber=576
Yunus MB Editorial review an update on central sensitivity syndromes and the issues of nosology and psychobiology Curr Rheumatol Rev 201511(2)70-85
Salaffi F Sarzi-Puttini P Atzeni F How to measure chronic pain New concepts Best Pract Res Clin Rheumatol 2015 Feb29(1)164-86
Fitzcharles M et al 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome executive summary Pain Res Manag 2013 May-Jun18(3)119-26
Hague M Shenker N How to investigate Chronic pain Best Pract Res Clin Rheumatol 2014 Dec28(6)860-74
Clifford J Woolf Central sensitization Implications for the diagnosis and treatment of pain Pain 2011 152 S2ndashS15
AMA guides to the evaluation of Permanent Impairment ndash 4th edition
Waddell G et al Nonorganic physical signs in low back pain Spine 1980 5(2) 117-25
Tischler M et al Neck Injury and Fibromyalgia ndash Are they Really Associated Journal of Rheumatology 2006 33(6)1183-5
James H et al Central Poststroke Pain An Abtrusive Outcome Pain Res Manag 2008 13(1)41-49
Karl A et al Reorganization of motor and somatosensory cortex in upper extremity amputees with phantom limb pain J Neurosci 2001 1521(10)3609-18
