chronic pain

Chronic Pain: when the injury doesn’t fit

by Barry Bittman, MD

If you’ve you ever known anyone who, after a seemingly minor accident or injury developed ongoing pain that eventually led to disability, read on.

This poorly understood phenomenon is certainly one of the ongoing dilemmas in the practice of modern pain management. While some cases are clearly associated with malingering, or simply an attempt to beat the system for financial gain, a significant number, however, appear to be real.

The bona fide cases typically involve minor fender benders or low impact whiplash injuries. Some include falls, or routine industrial accidents that most of us would not think twice about. Frequently, the individual is in good physical condition, initially, and often there are no clear-cut signs of injury, such as cuts, wounds, or local swelling. Often, the principle complaint is neck pain, low back pain or headaches. Less frequently, almost any area of the body can be severely affected.

Classic diagnostic tests such as x-rays and scans are almost invariably unremarkable. As a result, the suggestion of malingering is often entertained by an insurer or healthcare provider.

When I reflect back on more than 16 years of practice in this field, the recollection of a number of patients immediately surfaces. Actually, their outcomes after settlement are what I remember the most. For it is the way they lived their lives after the settlement that eventually unraveled the mystery of whether or not their suffering was real.

It is an understated fact that despite a physician’s best efforts, an accurate diagnosis is not always possible. Some individuals who convinced me that they were disabled, immediately recovered after the insurance company check was written. For others, in whom their veracity I doubted, life progressively worsened despite their financial reward.

As a result, I’ve spent countless hours trying to better understand the nature of this issue, which troubles most physicians who care for such patients. What I’ve learned can be summarized as follows:

The incident or accident that becomes the central focus of the person’s distress is often no more than a triggering event. It is not uncommon for such injuries to occur in people who are under great stress. Some have been abused, beaten, ridiculed or assaulted mentally or physically. Many are unhappy with their lives and their jobs. A small number may have never been ill before, while the overwhelming majority have responded inappropriately to other incidents in the past.

Most are experiencing difficulty coping with a build-up of tension and stress that progressively sets the stage for almost any incident to trigger an overall cascade in the quality of their lives. Their past history is generally well concealed.

The healthcare provider often treats the patient as if the first day of the syndrome began with the accident or injury. It is unfortunate that the underlying volcano that was ready to erupt with almost any incident is typically overlooked. As a result, the devastating issues that promote the ongoing nature of the pain are not appropriately addressed.

The legal system fails miserably as well. Attorneys argue that their client never suffered migraines or back pain in the past, thereby concluding that the accident directly resulted in disability. To support such contentions, expert witnesses present biomechanical data documenting how a five mile per hour fender bender resulting in no measurable damage to a car can produce irreversible pain and disability. Juries are frequently swayed and insurers eventually cave in and settle out of court.

Yet, what happens to the sufferer? The answer is simple. They continue to live in agony, focussing all of the blame on an incident that was PROVEN by the system to be the source of their life-long distress. Eventually, one’s soul becomes enveloped by suffering. Quality of life fades, as anger continues to be directed at a source that, in reality, represented only one teaspoonful of water¾ the final teaspoon that sank the ship.

In the end, the system fails¾ for suffering continues at a costly price.

It is time to begin to explore what cannot be logically explained through a physical perspective alone by investing in rational counseling and psychological interventions that have the potential to restore quality to the rest of one’s life. When we do so, suffering will be transformed into success on many levels¾ Mind Over Matter!