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Brain imaging tests for chronic pain: medical, legal and ethical issues and recommendations

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  • CT Brain imaging tests for chronic pain: medical, legal and ethical issues and recommendations

    https://www.nature.com/nrneurol/jour....2017.122.html

    Abstract
    Chronic pain is the greatest source of disability globally and claims related to chronic pain feature in many insurance and medico-legal cases. Brain imaging (for example, functional MRI, PET, EEG and magnetoencephalography) is widely considered to have potential for diagnosis, prognostication, and prediction of treatment outcome in patients with chronic pain. In this Consensus Statement, a presidential task force of the International Association for the Study of Pain examines the capabilities of brain imaging in the diagnosis of chronic pain, and the ethical and legal implications of its use in this way. The task force emphasizes that the use of brain imaging in this context is in a discovery phase, but has the potential to increase our understanding of the neural underpinnings of chronic pain, inform the development of therapeutic agents, and predict treatment outcomes for use in personalized pain management. The task force proposes standards of evidence that must be satisfied before any brain imaging measure can be considered suitable for clinical or legal purposes. The admissibility of such evidence in legal cases also strongly depends on laws that vary between jurisdictions. For these reasons, the task force concludes that the use of brain imaging findings to support or dispute a claim of chronic pain — effectively as a pain lie detector — is not warranted, but that imaging should be used to further our understanding of the mechanisms underlying pain.
    Subject terms:Introduction

    Great science brings great responsibility. In the field of pain research, developments in imaging technology are bringing closer the possibility of objective assessment of pain. In a clinical context, these developments could help physicians to understand and treat chronic pain. However, developments in imaging technology raise legal and ethical issues about the appropriateness of using such technology to assess chronic pain. The scientists who develop these technologies must take responsibility for their use beyond the scientific and clinical contexts.

    Chronic pain is defined as pain that is present every day for >3 months (or is present on ≥50% of days for 6 months) or beyond the expected period of healing and does not have the warning function that acute pain does1, 2, 3, 4. Chronic pain is associated with enormous personal and societal costs; individuals with chronic pain often have a reduced quality of life and unmet therapeutic needs, and society is struggling to cope with the large numbers of people with this condition. Chronic pain affects up to 35% of the population, and costs of medical care and loss of wages and productivity are escalating5, 6, 7. Efforts to improve prevention, treatment and rehabilitation for patients with chronic pain are ongoing. Chronic pain is also the subject of many legal disputes between patients, health care systems and disability benefit providers, in which proof or disproof that a patient is or is not experiencing pain might affect payments. Consequently, research to address whether chronic pain can be identified objectively is needed for a variety of reasons, particularly to provide evidence for insurance and legal purposes.

    Given that the International Association on the Study of Pain (IASP) definition of pain is an “unpleasant sensory and emotional experience8, 9”, self-report, although subjective, is currently the gold standard for the assessment of pain. In drug development and clinical treatment, researchers and clinicians rely on self-reporting of pain (alongside other indicators of quality of life) to evaluate a patient's condition and the success of treatment. Nevertheless, diverse groups — including patients, researchers, clinicians, pharmaceutical and medical device companies, insurers and the legal community — seek methods for evaluating chronic pain besides self- reporting. Patients seek objective testing to demonstrate the reality of an invisible condition that is sometimes subject to doubt, researchers seek brain imaging markers that provide scientific, diagnostic and prognostic information that cannot be provided by patient self-reporting, and legal representatives and officials seek techniques to supplement self-reporting and objectively support or challenge claims related to chronic pain.

    Brain imaging technologies, including functional MRI (fMRI), PET, EEG and magnetoencephalography (MEG), have the potential to provide objective measurements of patterns of brain activity that underlie perceptual experiences (Box 1). Consequently, some people are looking to brain imaging to provide a window into the experience of chronic pain, particularly because testimony based on fMRI was deemed to be admissible as evidence of pain in a 2015 state trial court in the USA10, 11. This case was highly publicized, although the judgement was not published so no legal precedent was set, and the grounds on which the fMRI evidence was admitted were criticized by established experts in brain imaging studies of pain10, 11.
    Last edited by Jo Bowyer; 12-09-2017, 08:19 PM.
    Jo Bowyer
    Chartered Physiotherapist Registered Osteopath.
    "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

  • #2
    I find this quite an interesting one, working with a lot of people with work injuries. It's a system that endeavours to quantify everything with objective measures. As it says "self-report, although subjective, is currently the gold standard for the assessment of pain", but from a medico-legal point of view, that often isn't enough. One more than one occasion I have been asked directly by third parties "do you believe this person is in as much pain as they say?", or basically do I think they are lying about their pain. Anecdotally, I find there are few people who see me who are consciously making up their pain, though I'm sure it happens. Some may exaggerate their pain, but once again, is this a conscious decision?

    My job isn't to decide if the person in front of me is in pain, it is to understand why they are reporting the pain they are, and to the best of my ability help them through it.

    This case was highly publicized, although the judgement was not published so no legal precedent was set, and the grounds on which the fMRI evidence was admitted were criticized by established experts in brain imaging studies of pain
    IF one day a precedent is set, it could be very interesting. Not necessarily in a good way.
    Ben

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