Neck pain following a low velocity road traffic accident occurs frequently in personal injury claims.
Recovery is variable but most will recover within 6-10 weeks, once the acutely injured soft tissues are healed. However, in some people, the pain persists beyond this period and despite healing of the acute injury, chronic pain ensues.
Chronic pain is recognised as a condition in its own right by Scottish Government, the National Institute for Clinical Excellence (NICE) and in Judicial College Guidelines. Pain and injury are separate entities and chronic pain can present in the absence of injury.
Chronic pain is derived and maintained by completely different mechanisms to those of acute pain. Instead of a manifestation of injury, inflammation and a chemical messenger cascade, chronic pain is a disorder of nerve function. The nerves supplying skin, muscle and ligaments need not be injured, chronic pain is a functional problem in that these nerves have remained in an overly sensitive, hyper vigilant state, and continue to bombard the brain with messages as though the threat of injury or danger remained.
The management of such nerve derived, neuropathic pain is different too. Usual over the counter painkillers are not effective. Instead, drugs which modify nerve function and transmission are considered.
But there remains an elephant in the room; is it all in their head, so-called psychological pain? Why does it happen in some countries and not others? In some cultures and not others? In low as well as high velocity accidents?
Are such clients malingering? Or exaggerating their symptoms?
The short answer is no.
The pain is very real pain, but being made inappropriately, it’s production is no longer helpful to our survival. Chronic pain has few or no signs, and no blood test or scan that can prove or disprove its existence. The diagnosis is made from the clients’ history, paying particular attention to the impact of their symptoms on day to day life.
The pain is not ‘all in their head’ but pain is made by the brain and psychological factors do modify the pain experience a great deal, as do social factors including work, friends, family.
Medication is not the answer in the long term. Instead a biopsychosocial approach is recommended. This addresses these significant inputs, harnessing them to modify the pain experience in a positive way.
Psychological factors include thought patterns, beliefs, emotions and memory. Social factors and cultural norms determine the response to injury and whether or not chronic pain will develop.
In the UK, there is very much an expectation this type of injury is significant and requires medical attention. The spinal board and neck collar en route to hospital; promoting fear and worry leads to hypervigilence, and of previous trivial symptoms being amplified and attributed to the accident. The high level of attention we pay to pain (pain scores, talking about it) increases it, whereas distraction reduces it. Alongwith our adversarial blame culture, a spiral develops of low mood, isolation, illness behaviour, a belief the pain will persist, a lack of belief in self efficacy, catastrophising and so on.
This creates an internal environment enabling pain. Throw in absence from work, financial concerns, worry over prognosis, earning ability and you have the perfect storm for maintaining these dysfunctional pain pathways.
Adopting a biopsychosocial approach requires client education, sensitive explanation, reassurance they are believed and acknowledgement that this is a viable, better alternative to more or stronger painkillers. This is a difficult transition for clients to make, occurring over months or years, and many will dismiss it without question.
My take home message is to remember that very few of these clients are malingering. Give them the benefit of the doubt, and don’t settle the claim too early.
References
- Pain Barrier. Emma Potter, Partner, Barlow Robbins. PI focus Jun 2019, vol 29, issue 5, pp 20-23
- Factors predicting outcome in whiplash injury. Journal of orthopaedics and Trauma. March 2017, Vol18, Issue 1, pp9-16.
- The late whiplash syndrome: a biopsychosocial approach. Ferrari, Schrader, BMJ journals (neurology neurosurgery and psychiatry) Vol 70, issue 6
