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21

www.solicitorsjournal.com

FEATURE

MEDICO-LEGAL

Claimants who

catastrophise

will be at much

greater risk of

poor response to

treatment

>>

thus leading to greater disability.

One interesting study has highlighted the

important role of stress-related genes in recovery

from soft tissue injury. Researchers followed up

90 individuals in an A&E department, hours after

experiencing a whiplash injury. Those with a‘pain

susceptible’stress-related gene were more than

twice as likely to complain of moderate to severe

pain, headache, and dizziness in A&E, and this

group also estimated a longer time for physical

and emotional recovery.

There are now calls for larger clinical studies

looking at the role of genetic factors and their

influence on stress response pathways.

Contemporary approaches to chronic pain

management – pioneered by Jon Kabat-Zinn’s

meditation/mindfulness approach to pain –

often include stress reduction strategies such

as meditation or clinical hypnosis. By virtue of this

emergent evidence base, physiotherapists are now

using stress reduction techniques in the early days

following soft tissue injury to expedite recovery.

Central sensitisation

Soft tissue injuries may also produce chronic

ongoing pain in those claimants whose nerves and

spinal cord are vulnerable to what has been termed

‘sensitisation’. The term‘central sensitisation’refers

to hypersensitivity of the spinal cord, and once

again both stress-related responses and genetic

factors have been implicated as a cause.

Interestingly, this is usually measured in the

laboratory by inflicting pain on a person and

measuring how intense the pain stimulus has to

be to produce a reflex movement away from the

pain: the less painful the stimulus required to

produce a reflex movement, the greater the

central sensitisation.

A number of non-traumatic conditions have

been associatedwith central sensitisation,

including fibromyalgia and tension-type headache.

Management of sensitisation often includes

medication that targets the nervous systemand

stress-reduction techniques, asmentioned above,

such asmeditation, clinical hypnosis, or relaxation

training.

Catastrophisation

As we have seen, there is increasing evidence that

psychological factors have a critical role to play in

themagnification of pain following soft tissue injury,

and pain catastrophising is perhaps one of themost

important measures. Heightened vigilance,

rumination on pain, and pessimistic beliefs

regarding the long-termoutcome of a soft tissue

injury – so-called‘catastrophisation’– can all increase

the intensity of pain, most probably by inhibiting

the body’s natural pain-relieving endorphin system.

So, thosewho catastrophisewill feel more pain and

distress and displaymore overt pain behaviours

such as grimacing andmoaning. We also know

that claimants who catastrophise will be at much

greater risk of poor response to treatment.

Closely related to catastrophisation is fear of

re-injury or harm. Claimants who catastrophise

may believe that physical activity will harmor

injure them, and this can lead to reduced activity

levels, deconditioning, and an increased vigilance

with regard to performing the simplest of day-to-

day tasks. Movements become what has been

termed‘maladaptive’, with some claimants

displaying a phobia tomovement (‘kinesio-

phobia’), which is defined as an excessive,

irrational, and debilitating fear of movement

(for example, the low back pain patient who uses

a wheelchair).

Risk of poor recovery

There are now robust and valid questionnaires

that can be used to screen for stress responses,

catastrophisation, and fear of movement, and

these are being increasingly utilised by

physiotherapists working with soft tissue injuries

in the NHS and private sector to identify and guide

management in those at risk of chronic pain.

Indeed, more recently physiotherapy researchers

at the University of Keele have pioneered a simple

generic screening tool that can identify these

factors early following soft tissue injury, with a view

to stratifying care (the STarT Back screening tool,

published in

The Lancet

, 29 October 2011).

This may have utility in the medico-legal context:

factors such as fear of injury, worry, lack of

enjoyment, poor expectations for recovery,

catastrophic thoughts, and‘bothersomeness’all

indicate heightened risk of poor or non-recovery

following soft tissue injury. Those individuals

scoring highly on this screening tool are treated

with‘psychologically informed’physiotherapy

integrating both physical and psychological

approaches.

As it has become clearer that recovery following

soft tissue injury bears little or no relationship

to the degree of physical soft tissue injury itself,

the limitations of the traditional medical model’s

capacity to explain and predict chronic pain in an

individual claimant is being exposed.Thus clinical

objectivemeasures such as range of motion, x-rays,

andMRI scans are found to beweak predictors

of ongoing pain. However, a claimant’s stress

response, the presence of central sensitisation,

catastrophising, and fear of movement and re-injury

have been found to be strong predictors of poor

outcome, and are proving to be critical factors to

measure and address through psychologically

informed physiotherapymanagement of soft tissue

injuries, regardless of the severity of the pain or

disability experienced by the claimant.

SJ

SJ 160/6

Expert Witness Supplement Spring 2016