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The Pain Puzzle

Part 1: The Challenge of Pain

September 2022

It is estimated that one in five people suffer from chronic pain. However, not all of these individuals will seek or, in fact, be able to afford, treatment. 

So what is pain?

Pain is defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage. 

However, it is not enough to just understand the definition of pain, we need to understand the lived experience of those who suffer from pain. How do we know if someone has pain? Can we see it in their face, in the way they move, in the way they hold themselves? Sometimes yes, but not always. The only way to know if someone has pain is to ask them, and in fact, self-report is considered the gold standard in the assessment of pain.

Pain is multidimensional. It consists of biological, psychological, social, and contextual components that work together to generate an experience. It is always subjective, always personal, and always real.

Pain is what the claimant says it is, but it is this very subjectivity that confounds us, as it confronts our bias, our tendency to assume that if we can’t find a direct causal and temporal relationship between the medical history and what the claimant reports, then that must mean the claimant is lying.

We are not the first people to wrestle with this. The father of the Biopsychosocial model of health identified this as a significant barrier to healthcare, back in 1960, in his article: ‘A Unified concept of Health and Disease’, when he wrote:

It is customary in medicine… to place the greatest emphasis on that which can be determined objectively, i.e., by the physician rather than the patient, often preferably by some impersonal instrument, such as a laboratory procedure. Regardless of the nature and the severity of a patient's complaint, the failure to discover an abnormality on physical or laboratory examination means to many physicians that there is "nothing wrong.”

George L. Engel

And yet we know that it is possible to have pain without tissue damage and tissue damage without pain. Working with claimants with pain, regardless of where their path crosses ours, therefore, requires the clinician to make a conscious decision to believe the claimant.

Acute vs Chronic Pain

Pain can be acute or chronic, or even a little bit of both! Determining whether pain is acute or chronic is key to understanding the clinical presentation of the claimant and determining the appropriate treatment options.

In the past, the only metric used to classify pain as acute or chronic was time. Pain that was present for less than 6 weeks was classed as acute, while anything from 12 weeks on was considered chronic.

A more helpful way of considering whether pain is acute or chronic is to think about whether it is still helpful and adaptive.

Pain has a job – its job is to protect us, to help us survive. In the acute setting, this might mean that we don’t use an injured limb so that it can heal, or that we rest in bed if we have body pain due to a fever, but what happens if the pain persists past the point of tissue healing? It becomes maladaptive, it is no longer doing its job, it is no longer useful.

Acute pain is described as pain of recent onset and probable limited duration. It usually has an identifiable temporal and causal relationship to injury or disease. It has predictable behavior and responds to treatment in the expected way. On the flip side, chronic pain is a disease in and of itself, where pain and pain-related disability becomes the problem, more than the underlying structural pathology (if any).  It is often unpredictable and does not respond to treatment in the expected way.

So how do we understand pain as a disease? The current preferred model is that of the body-self-neuromatrix, which describes pain as an output that has multiple dimensions across multiple body systems including the central nervous system, cognition affect, the limbic system, the endocrine system, the stress system, the immune system and the sensory system to name but a few.

The premise, therefore, is that the clinical presentation of someone with chronic pain is much more complex than merely what their diagnosis is on paper and that the focus of an assessment of pain should be to determine the underlying physiological mechanisms that are contributing to the unique experience of the output of pain.

It is essential for the clinician to consider the whole person, including their thoughts, fears, concerns, and ideas about their pain as well as their readiness to engage in treatment. A critical shift in emphasis in the treatment of chronic pain is that the goal is not necessarily to take the pain away, but rather to increase function, improve independence and improve quality of life despite pain, and so doing hopefully also reduce the intensity of the pain.

So, what is the bottom line?

Pain is complex, invisible, disempowering, and socially isolating. Claimants with pain are not difficult or high maintenance – they have pain and deserve compassion and respect for the part of the road that they have already traveled. Understanding the physiology (to the extent that we can) and the context is critical to identify the right treatment for the right claimant at the right time. Due to the multidimensional nature of pain, there is no one size fits all approach. Treatment should be multimodal and ideally delivered by an interdisciplinary team. The focus of treatment must be the restoration of ‘well-behaviors’ rather than symptom alleviation; and return to work forms a critical part of this. Early intervention that focuses on improving resilience and changing modifiable vulnerability factors can prevent secondary complications and decrease disability.

The second article in this series focuses on claims considerations in relation to pain and looks at some common challenges at claims stage and potential solutions.

Belinda Thorpe
Belinda Thorpe
Head of Claims Africa and 
Middle East
Linda Hiemstra

Occupational Therapist