Chronic pain is a frustrating and often heartbreaking reality for many patients. But when those patients are also involved in personal injury litigation, your role as a treatment provider becomes more than clinical—it becomes legal.

In the recent Nova Scotia Supreme Court case Anderson v. Gagne, 2025 NSSC 131, an injury victim’s entire claim for chronic pain damages was dismissed because of gaps and inconsistencies in her treatment history and documentation. The case offers a powerful reminder that your notes, reports, and observations can make or break your patient’s claim.

Here’s what happened—and what every physiotherapist, massage therapist, chiropractor, and rehab professional should know.

Case Recap: When Subjective Pain Meets Legal Scrutiny

Ashley Anderson was rear-ended in a motor vehicle accident in 2014. She reported chronic pain that persisted for more than a decade—impacting her career, daily life, and overall function.

She alleged a range of symptoms:

  • Chronic neck and shoulder pain
  • Migraines and dizziness
  • Right knee pain
  • Fatigue, cognitive fog, and sleep disturbance

A physiatrist, Dr. Ryan Williams, diagnosed her with chronic pain syndrome and confirmed lasting physical impairments. But the court was not convinced. Why?

Because, in the Court’s opinion, the physiatrist’s conclusions didn’t match the evidence provided by the injury victim.

What Went Wrong?

Despite having credible experts and a strong story, Ms. Anderson’s claim fell apart due to:

❌ Delayed reporting of key symptoms

Years after the accident, she began reporting that she had hit her head and had a bruise—yet these details weren’t documented early on. This appears to have raised a question with the court about the veracity of her other claims. 

❌ Lack of objective findings

Many symptoms (especially headaches and fatigue) were subjective and not tied to functional assessments.

❌ Sparse or inconsistent treatment records

There were long gaps between treatment sessions. Some providers didn’t document symptom progression clearly. Others didn’t record whether symptoms were improving or worsening.

❌ Report relying too heavily on patient self-report

The court placed little weight on opinions that were not backed by objective clinical data or consistent treatment records.

Why This Matters for You

As a treatment provider, you may not think of your progress notes as vital evidence —but in personal injury cases, they can be the different maker between winning and losing a key issue at trial.

Your records can:

  • Validate your patient’s pain complaints.
  • Establish timelines for symptoms.
  • Demonstrate consistency and credibility.
  • Support physiatric or medical expert opinions.
  • Help the court understand the connection between pain and functional limitation.

Tips for Treating Patients in Legal Claims

Here are 5 key best practices when working with chronic pain patients involved in personal injury litigation:

1. Document Early and Often

Start treatment documentation as soon as possible post-injury. Capture initial complaints, mechanism of injury, and pain behaviours.

2. Use Consistent Language

Clearly chart the patient’s complaints using validated pain scales and functional outcome measures (e.g. VAS, ROM, ADLs, sleep impact).

3. Track Progress (or Lack of It)

Whether your patient is improving or plateauing, record that fact. A treatment plan that shows effort—even without resolution—helps establish chronicity.

4. Note Activities and Limitations

Be specific about what the patient can’t do: lifting, sitting, driving, concentrating. These details help establish the real-life impact of pain.

5. Keep Objective Findings in Focus

Include things like reduced ROM, spasm on palpation, functional testing, gait abnormalities, and compensatory movement patterns.

Treatment Provider Legal Checklist

Use this as a quick-reference when treating patients involved in MVAs or injury litigation:

Item Description
📝 Initial Assessment Record mechanism of injury, areas of pain, ADL impact
📆 Timeline of Symptoms Note when symptoms began and how they’ve changed
📈 Pain Tracking Use consistent scales (e.g., 0–10), and update regularly
🧪 Objective Measures ROM, strength testing, postural findings, mobility
💬 Subjective Impact Sleep, mood, work capacity, energy levels
🗓️ Treatment Frequency Chart attendance, cancellations, and adherence
🧭 Functional Goals Set and monitor progress toward specific tasks
🔁 Response to Treatment Note if symptoms respond or flare to specific techniques
📷 Imaging/Referrals Include any known diagnostics or physician notes
🔐 Storage & Sharing Ensure records are secure and available if subpoenaed

Final Thoughts

In Anderson v. Gagne, the court didn’t deny that chronic pain exists—but it did demand better proof. As treatment providers, you are on the front lines of this proof. Your detailed records, clinical observations, and consistent care plans aren’t just good practice—they’re essential to helping your patient’s voice be heard and believed in court.

So, next time you’re documenting a visit with a chronic pain patient, remember: what you write may one day speak louder than their words ever could.

For more information about this subject, please see our previous post: From Collision to Courtroom: How Nova Scotia Courts Assess Concussion in a Car Accident Injury Case.

Do you have questions about how to be the best advocate for your patient? Contact Jeff Mitchell, Esq. of NOVA Injury Law today for more information.