Hmrc lecture final

Lecture to HMRC
Solicitors Office &
Personal Injury Group
London 13.04.2015

Dr Ilan Lieberman
FRCA FFPMRCA
Consultant in Pain Medicine
South Manchester University Hospitals
NHS Foundation Trust
ilanlieberman@mac.com
4 Consultants, 3 Nurse Specialists, 2 Clinical
Psychologists 2 Specialist Physiotherapist's
Pain Management Program 4 per year
Injection therapies
Specialist clinics in Refractory Angina, Breast Pain
& Urinogenital Pain

Chronic Pain
"Pain is a more terrible lord of mankind than even
death itself."
* Dr. Albert Schweitzer1931
“Pain is an unpleasant physical or emotional
experience associated with actual or potential tissue
damage, or described in terms of such damage”. *
A painful condition which lasts more than 3 months is
referred to as chronic.
IASP
International Association for the Study of Pain
British Pain Society www.painsociety.org
* Mersky H: Classification of Chronic Pain IASP Press 1994, p210.

The new thinking is that Chronic Pain Seen
should be viewed as a
Disease-Like State or “5th vital Sign”

Chronic Pain
• Incidence
• Chronic benign (non cancer) pain 2 - 40% of population dependant on
the study
• 1 in 7 prevalence in UK
• Netherlands chronic back pain costs 1.7% GDP
• Netherlands lost work as a result of back pain costs 1.5 million $ per
hour
• In the USA rate of disability claims associated with lower back pain has
increased over the rate of population growth by 1400%

Chronic Pain
• Incidence of significantly disabling pain
• Up to 80 primary care consults presenting with pain
• Neck 2 - 5%
• Fibromyalgia 2.5%
• Back 2 - 6%
• Angina 4%
• Migraine 10%
• Post shingles 1.5%

Qu 1.
What are the scientific explanations for patients who do not
appear to be suffering any recognisable organic symptoms, but
nonetheless complain of chronic pain?

First some theory……
dr@lieberman.co.k

Gate Theory Pain Control
 Pat Wall
 Ron Melzack
 Gate Theory Pain Control
1965

W. Brinjikji et al American J Neurology April 15 Mayo Clinic NIH Funded study

Wadell’s Signs
Waddell, et al. (1980) described five categories of signs:
• Tenderness tests: superficial and diffuse tenderness and/or nonanatomic
tenderness
• Simulation tests: these are based on movements which produce pain, without
actually causing that movement, such as axial loading and pain on simulated
rotation
• Distraction tests: positive tests are rechecked when the patient's attention is
distracted, such as a straight leg raise test.
• Regional disturbances: regional weakness or sensory changes which deviate from
accepted neuroanatomy
• Overreaction: subjective signs regarding the patient's demeanor and reaction to
testing
NOT A CHECKLIST FOR MALINGERING
Are an indicator that the underlying psychosocial issues need to be explored carefully

Psychology
Attitudes/Emotional
(distress)
• Symptom awareness and
concern
• Depressive reactions;
helplessness
• Anger & hostility
Beliefs/ Cognitive (beliefs
about pain and disability)
• Significance; controllability
• Fears and
misunderstanding about
pain
Behaviours/ Behavioural (pain
behaviour and coping
strategies)
• Guarded movements and
avoidance patterns
• Coping styles and strategies

Attitudes and Beliefs about Pain
Belief that pain is harmful or disabling resulting in fear-avoidance
behaviour, eg, the development of guarding and fear of movement
Belief that all pain must be abolished before attempting to return to
work or normal activity
Expectation of increased pain with activity or work, lack of ability to
predict capability
Catastrophising, thinking the worst, misinterpreting bodily symptoms
Belief that pain is uncontrollable
Passive attitude to rehabilitation

Behaviours
Use of extended rest, disproportionate ‘downtime’
Reduced activity level with significant withdrawal from activities of daily living
Irregular participation or poor compliance with physical exercise, tendency for
activities to be in a ‘boom-bust’ cycle
Avoidance of normal activity and progressive substitution of lifestyle away
from productive activity
Report of extremely high intensity of pain, eg, above 10, on a 0-10 Visual
Analogue Scale
Excessive reliance on use of aids or appliances
Sleep quality reduced since onset of back pain
High intake of alcohol or other substances (possibly as self-medication), with
an increase since onset of back pain
Smoking

Compensation Issues
Lack of financial incentive to return to work
Delay in accessing income support and treatment cost,
disputes over eligibility
History of claim/s due to other injuries or pain problems
History of extended time off work due to injury or other pain
problem (eg more than 12 weeks)
History of previous back pain, with a previous claim/s and
time off work
Previous experience of ineffective case management (eg,
absence of interest, perception of being treated punitively)

Emotions
Fear of increased pain with activity or work
Depression (especially long-term low mood), loss of sense
of enjoyment
More irritable than usual
Anxiety about and heightened awareness of body
sensations (includes sympathetic nervous system arousal)
Feeling under stress and unable to maintain sense of
control ll Presence of social anxiety or disinterest in social
activity
Feeling useless and not needed

Family
Over-protective partner/spouse, emphasising fear of
harm or encouraging catastrophising (usually well-
intentioned)
Solicitous behaviour from spouse (eg, taking over
tasks)
Socially punitive responses from spouse (eg, ignoring,
expressing frustration)
Extent to which family members support any attempt to
return to work
Lack of support person to talk to about problems

Work related issues
History of manual work, notably from the following occupational
groups:
Fishing, forestry and farming workers
Construction, including carpenters, builders and truck drivers,
Nurses
Disrupted Work history, including patterns of frequent job
changes, experiencing stress at work, job dissatisfaction, poor
relationships with peers or supervisors, lack of vocational
direction
Belief that work is harmful; that it will do damage or be
dangerous
Unsupportive or unhappy current work environment

Work related issues (continued)
Low educational background, low socioeconomic status
Job involves significant bio-mechanical demands, such as
lifting, manual handling heavy items, extended sitting, extended
standing, driving, vibration, maintenance of constrained or
sustained postures, inflexible work schedule preventing
appropriate break
Job involves shift work or working unsociable hours
Minimal availability of selected duties and graduated return to
work pathways, with unsatisfactory implementation of these
Negative experience of workplace management of back pain
(eg, absence of a reporting system, discouragement to report,
punitive response from supervisors and managers)
Absence of interest from employer

Qu 2
Are there any methods test to see if such pain is
genuine, or if it may be malingering in order to
support a financial claim for compensation
(which may be substantial)?

Client is assumed (by the experts) to be honest
Experts need to be focused on highlighting exaggeration which is far commoner
than complete deception
Psychological assessment of malingering
Close inspection of all records
Time with the client
Consideration by the expert of client reliability
Functional questions within the report
Attention to detail of daily tasks (shopping cycle, wheelie bins, driving and carrying)
Repeated questions and inter-question reliability
fMRI

Functional Questions
• Sports
• Cycling
• Pets, dog walking
• Gym membership
• Shopping cycle
• Hobbies
• Wheelie bins
• Ask the same question
several ways
• Cooking
• Food preparation
• Holidays (flights)
• Driving (time)
• Passenger (time)
• Work journey

Please can you provide any tips and pointers to help us when
reading a Claimant's medical report and the sort of questions we
should be putting to the Claimant's expert.
What are the pertinent, searching ,difficult to answer questions we
should be asking on behalf of our client?
• How long did the client spend with
the expert ?
• Did the expert examine the client ?
• Did they undress the client to do so?
• Was the expert chaperoned?
• If neuropathic pain is alleged was
formal sensory testing of the
modalities undertaken (cold hot pin
prick light touch) is there a map /
photo / sketch of the area of loss?
• Is variation in function covered?
• Time between interview and report?
• Detailing of medical records.
Discrepancy between applications for
benefit and contemporaneous
medical reports and HR records.

Please can you provide any tips and pointers to help us when
reading a Claimant's medical report and the sort of questions we
should be putting to the Claimant's expert.
What are the pertinent, searching ,difficult to answer questions we
should be asking on behalf of our client?
• How long did the client spend with
the expert ?
• Did the expert examine the client ?
• Did they undress the client to do so?
• Was the expert chaperoned?
• If neuropathic pain is alleged was
formal sensory testing of the
modalities undertaken (cold hot pin
prick light touch) is there a map /
photo / sketch of the area of loss?
• Is variation in function covered?
• Time between interview and report?
• Detailing of medical records.
Discrepancy between applications for
benefit and contemporaneous
medical reports and HR records.
• Previous claims history
• Specific section on report on pre-
existing vulnerability

What will a doctor know that a solicitor won't? If
he were the solicitor, what would he do?
Routinely talk to the expert pre instruction if necessary and
always post instruction
Much of the issues around pain require a thorough
biospychosocial assessment
Imaging may not be terribly helpful
Nerve conduction studies may not be terribly helpful
Clinical medical records only describe a partial truth as the
clinicians never have time or facility to access full records
and invariably accept patient statements at face value.

Definition of Neuropathic
Pain
Neuropathic pain arises as a direct
consequence of disease or injury affecting
the somato-sensory system
dr@lieberman.co.k

Negative and Positive Signs in Neuropathic Pain
Negative signs
(impaired or lost neural activity)
Numbness, lack of sensation
Weakness
Reduced function
Clumsiness
Loss of balance
Confined to the territory(ies) supplied by
the affected nerves or central sensory
and motor pathways
Positive signs
(excessive neural activity)
Increased sensitivity (touch becomes pain)
Disproportionate pain from painful stimuli
Pain continuing long after stimulus removed
Discolouration of affected skin
Trophic changes in affected area
Extend outside the territory(ies) supplied by
the affected nerves or central
somatosensory pathways
dr@lieberman.co.k

Terms in Neuropathic Pain
Hyperalgaesia
Lowering of pain threshold and increased response to noxious stimuli
Allodynia
Evocation of pain by non noxious stimuli
Hyperpathia
Variant of hyperalgaesia & allodynia, explosive pain from cutaneous areas
with increased sensory detection threshold
Paroxsysms
Shooting electrical pain occurring spontaneously or after stimualtion
Paraesthesia
Abnormal but non painful sensations (pins and needles)
Dysasthesias
Abnornormal and unpleasant sensations
dr@lieberman.co.k

Unexplainable "shooting pains" usually concentrating on a
particular limb, but also radiating out to other limbs to a lesser
extent (may be covered by Neuropathic Pain)
Question

Clinical Features of Neuropathic Pain – Herpes Zoster
and Post-herpetic Neuralgia
dr@lieberman.co.k

CRPS
Complex regional pain syndrome (CRPS) is a chronic pain condition.
The key symptom of CRPS is continuous, intense pain out of proportion to the severity of the
injury, which gets worse rather than better over time.
CRPS most often affects one of the arms, legs, hands, or feet. Often the pain spreads to
include the entire arm or leg.
Typical features include dramatic changes in the color and temperature of the skin over the
affected limb or body part, accompanied by intense burning pain, skin sensitivity, sweating,
and swelling.
We aren’t sure what causes CRPS. In some cases the sympathetic nervous system plays
an important role in sustaining the pain.
Another theory is that CRPS is caused by a triggering of the immune response, which leads
to the characteristic inflammatory symptoms of redness, warmth, and swelling in the affected
area.
Some CRPS may be caused by a mismatch between the S1 and M1 cortex
Lateral view of the brain

Complex Regional Pain Syndrome
dr@lieberman.co.k

Theory of why MVT should work
dr@lieberman.co.k
Lateral view of the brain
Coronal View of sensory and motor cortices
 Sensory cortex is a hard wired map of the body
 Lies adjacent to motor cortex
 Integrates with the motor cortex
 Disruption of stimulation to S1 felt as “loss” by S1
 Overgrowth of adjacent areas into areas of loss proposed as cause of phantom
pain and now ? CRPS, ?? Stroke pain ??? Neuropathic limb pain
 ??? Normalization of S1 activity leads to resolution of CRPS

Fibromyalgia - Introduction
• Widespread chronic
pain
• Multiple symptoms
• fatigue
• sleep disturbance
• cognitive
dysfunction
• depression
• Associated disorders
• IBS
• Chronic fatigue
• Irritable bladder
• Interstitial cystitis
• TMJ dysfunction

Fibromyalgia Epidemiology
• Common
• 4 women: 1 man
• 1-8% of women
• Age of onset 20-50
• 10-40% of new rheumatology referrals
• Often co-existing diseases e.g. OA, SLE

• What its not
• Somatisation
• Mad women
• Idiopathic
• Functional
• WHAT IT IS
• Prototypical “CENTRAL PAIN
SYNDROME”
Fibromyalgia - What is it?

Fibromyalgia - History
Remember Migraine
Condition described for centuries
1904 Fibrositis - Sir William Gowers
1904 to 1977 Fibrositis = common cause muscular pain =
Psychogenic Rheumatism
1977 Smythe & Moldofsky = Fibromyalgia
1981 Yunus reports other clinical manifestations
1990 ARC criteria (RESEARCH)
1992 onwards push towards central mechanism hypothesis driven by
functional imaging techniques and general advances in central pain
mechanisms

Fibromyalgia - Etiology
• Genetics
• Familial 8 fold increased risk in 1st degree relatives
• Family members more sensitive to pain and more likely to
have co-occurring pain disorders (IBS, TMD & headache)
• Twin studies half risk genetic half risk environmental
• Environmental Factors
• Trauma (trunk)
• Infection (parvovirus, EBV, Lymes Disease, Q fever)
• Psychological Stress
• Hormonal alterations
• Drugs & Vaccines

Fibromyalgia - Stress Stressors
Predisposition to adult pain syndromes following
childhood trauma - sexual - physical - injury - disease
Complex interplay between expectation, duration,
frequency, locus of control, psychological coping
capacity, social support, & expectation
Sleep & Exercise
2007 Arnson “Physical exercise protective in ex-
combatants with PTSD developing widespread pain
disorders”
Neuroendocrine HPA studies inconclusive to date

Randomly measured pain thresholds not influenced by
levels of distress * Petzke 99 01 & 03
Fibro patients more sensitive to pressure stimuli* Petzke 99
01 & 03
Fibro patients not hypervigilant
Fibro patient response to other modalities (heat, cold,
electrical stimulation) same as control EXEPT noxious
auditory
Diffuse noxious inhibitory control attenuated or absent
Fibromyalgia - Sensory Processing

Fibromyalgia - DNIC
Diffuse noxious inhibitory control DNIC
Mediated by descending opiodergic serotonergic-
noradrenergic pathways
In Fibro opiodergic activity normal or enhanced (thats
why opioids may not be that effective)
In Fibro patients serotonergic-noradrenergic activity
reduced (thats why compounds that enhance this activity
may work)
In Fibro Substance P levels enhanced (substance P
involved in windup)
In Fibro Glutamate (excitatory neurotransmitter)
increased

f-MRI
• f-MRI functional magnetic resonance imaging

Lateral view of the
brain
Fibromyalgia - Functional Imaging
• decreased rCBF caudate thalamus
• increased in somatosensory cortex
• longitudinal studies of amitriptyline shows
normalisation of rCBF
• Hypothesis that there is a left shift in the sensory
settings or volume gain in brain sensory
processing
• role of other psychological factors assessed

Fibromyalgia - Sleep
Juries out
Sleep disturbance commonly seen
Chicken or egg?
Clinically correction of sleep disorders may not lead
to improvements in core symptoms

Fibromyalgia - Behavioural & Psychological factors
Lots of noise on this topic
Incidence of Psychological disorders may be as high as 30 to
60%
Early studies now thought to be flawed as conducted in
tertiary centres which may have a biased patient group
3 patient groups
low level anxiety depression normal cognition mild tenderness
high depression more pain catastrophize and external locus of control (3ry
care)
low depression more pain no psychological or cognitive issues

Fibromyalgia - Diagnosis
ARC criteria were designed for
research
Pain main feature waxes wans
frequently migratory
Associated symptoms
fatigue, sleep difficulties,
weakness, memory issues, hot
/ cold intolerance, morning
stiffness, subjective swelling of
the extremities.
Functional disorders
associated include
chest pain, hear burn
palpitations, IBS,
dysmenorrhoea,
endometriosis, interstitial
cystitis, vulvodynia, prostatitis
Exclude any inflammatory
disorder

Fibromyalgia - Drug Treatments
• Strong evidence
• Tricycilics amitriptyiline
• Dual reuptake inhibitors
duloxetine venlaflaxine
milnacipran
• alpha 2 ligands gabapentin
pregablin
• Modest evidence
• Tramadol, SSRIs citalopram,
dopamine agonists
priamipexole, gamma-
hydroxybutyrate
• Weak evidence
• Growth hormone, 5-HT,
tropisetron, 5 adenosyl-l-
methionine
• Not effective
• Opioids, steroids,
benzodiazepines, melotonin,
guanifensin,
dehydroepiandosterone

Fibromyalgia -Non drug treatments
• Cognitive behavioural therapy
• CBT based pain management programs
• Graded exercise programmes
• have all been shown to be efficacious
• sustained improvements in fibromyalgia at > 1yr
shown for both CBT & exercise
• Mindfullness

Pain Medicine vs
Neurosurgeon
Finally, on a more general point, what
differentiates a Pain Expert from a
Neurosurgeon. There often seems a cross-
over between these two professions,
however, the former being brought in where
the latter can't make a conclusive
diagnosis.

Chronic Lower Back Pain
Psychology as important as Anatomy
What you say to a patient REALLY matters
Healthcare industry probably as harmful as it is helpful
Large number of perverse incentives
Reimbursement to treat not for the outcome

Back Pain
Back Pain is some of where our taxes go
Possibly 16.5 million suffers
3 to 7 million GP consults / yr
1.6 million OPD consults / yr
100,000 inpatients / yr
24,000 operations / yr
NHS cost £481 million
Non NHS health costs £197 million
DSS £1.4 billion
Lost production £3.8 billion
Work Loss in UK from Back Pain
1955
1965
1975
1985
1992
0
10
20
30
40
50
60
70
80
90
Years
Working days lost
(millions)

Back Pain
• History
• Exam
• Exclude red flags
• Note yellow flags
• Note signs of non organic pathology
• Investigate
• Rehabilitate

• Biomedical:
• review diagnostic
• triage nerve root problem
• serious spinal pathology
• ESR and plain X-ray
• Psychological:
• attitudes and beliefs about back pain
• fear avoidance beliefs about activity and work
• personal responsibility for pain and rehabilitation
• psychological distress and depressive symptoms
• illness behaviour
• Social:
• family attitudes and beliefs about the problem
• reinforcement of disability behaviour
• Work physical demands of jobjob satisfaction
• other health problems causing time off or job loss
• non-health problems causing time off or job loss

Risk factors for chronicity
• Previous history of low back pain
• Total work loss (due to low back
pain) in past twelve months
• Radiating leg pain
• Reduced straight leg raising
• Signs of nerve root involvement
• Reduced trunk muscle strength
and endurance
• Poor physical fitness
• Self-rated health poor
• Heavy smoking
• Psychological distress and
depressive symptoms
• Disproportionate illness
behaviour
• Low job satisfaction
• Personal problems - alcohol,
marital, financial
• Adversarial medico-legal
proceedings

Back or Leg Pain
• Simple backache
• Presentation between ages 20-55
• Lumbosacral region, buttocks and
thighs
• Pain "mechanical" in nature varies
with physical activity varies with time
• Patient well
• Prognosis good
• Nerve root pain
• Unilateral leg pain worse than low
back pain
• Pain generally radiates to foot or toes
• Numbness and paraesthesia in the
same distribution
• Nerve irritation signs reduced
• SLR which reproduces leg pain
• Motor, sensory or reflex change
• limited to one nerve root
• Prognosis reasonable
• 50% recover from acute attack
within six weeks

Thank you
ilanlieberman@mac.com
07958388881
0161 883 2728
@ilanlieb
www.chronicpaincare.co.uk

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