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Industry: Email Alert RSS FeedApproach to assessment and diagnosis of chronic pain
Journal of Family Practice, Oct, 2004 by Stephen Brunton
The clinical assessment of a patient with chronic pain is a dynamic process with several specific goals (TABLE 1) that ultimately lead to the implementation and ongoing refinement of a comprehensive, yet targeted management plan. A critical first step, however, is to acknowledge to the patient that you believe the pain is real, and that although elimination of the chronic pain is likely not realistic, you will work with him/her to reduce the pain and improve his/her quality of life.
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Clinicians should be cautioned not to rush through the assessment in an effort to bring immediate relief to the patient's suffering. Establishing a diagnosis, at least tentatively, is important so that a treatment plan can be implemented that will result in short- and long-term pain relief, while minimizing side effects. The "PQRST" mnemonic (Palliative or precipitating factors, Quality of pain, Region of radiation of pain, Subjective description of pain, Temporal nature of pain) may provide a useful guide to assessment. The history and physical examination are particularly important in establishing the diagnosis. In fact, physicians who focus on this and their patient's health behaviors are much more likely to diagnose pain. (1) Of course, there are several aspects to a comprehensive pain assessment (TABLE 2). (2) [Evidence level: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality. Available at: http://www.guideline.gov/ summary/summary.aspx?ss=15&doc=id=3720&nbr:2946&string=.]
* CHARACTERIZING THE PAIN
Pain may be categorized according to its duration and onset, ie, acute, chronic, or breakthrough. Acute pain may have a sudden or recent onset but is transient in nature. Chronic pain is defined as pain that persists beyond the time normally associated with healing for a specific illness or injury. Chronic pain can be either associated with an unrelenting abnormality or recurrent. Breakthrough or incident pain can occur with numerous pain syndromes and be severe enough to significantly compromise function and quality of life.
Pain also is categorized according to its etiology as nociceptive, neuropathic, or mixed-type (FIGURE 1). Nociceptive pain can be considered a physiologically appropriate response to the inflammation caused by activity in neural pathways in response to noxious stimuli that damage tissue. Consequently, nociceptive pain serves a protective function by alerting a person that tissue damage is imminent or has already occurred; it prompts a response to avoid further noxious stimuli. Nociceptive pain usually is finite, localized, and resolves with normal healing or removal of the tissue-damaging stimuli. (3) Visceral and somatic pain are subsets of nociceptive pain. Examples of nociceptive pain commonly seen in clinical practice include arthropathies, mechanical low back pain, sickle cell crisis, sports injuries, ischemic disorders, postoperative pain, and skin and mucosal disorders. Most nociceptive pain syndromes involve acute pain, although the arthropathies, and sometimes, low back pain, are notable exceptions.
[FIGURE 1 OMITTED]
In contrast, neuropathic pain (NP) is initiated or caused by a primary lesion or dysfunction in the peripheral or central nervous system. (4) These abnormalities within the nervous system likely lead to a reorganization of sensory transmission pathways that continues after healing has taken place. Many types of NP are considered a chronic pain disorder. Unlike nociceptive pain, NP is pathophysiologic and serves no useful purpose.
Numerous mechanisms have been postulated as substrates for NP; in any given patient, multiple mechanisms may coexist, including excitotoxicity, abnormal expression of sodium channels, ectopic discharge, deafferentation, or central sensitization, (5-8) These underlying mechanisms are increasingly important considerations when selecting therapy, as will be discussed in the Dr McCarberg's article.
Neuropathic pain can be divided into 3 broad categories based upon presentation and distribution of symptoms. The first category is peripheral mononeuropathy (eg, carpal tunnel syndrome, trigeminal neuralgia, postherpetic neuralgia, and complex regional pain syndrome). The second is peripheral polyneuropathy (eg, diabetic and human immunodeficiency virus [HIV] neuropathy) and the third category is central neuropathy (eg, poststroke syndrome, spinal cord injury and HIV myelopathy). (3,9)
While some types of chronic pain may be classified clearly as nociceptive or of neuropathic origin, other chronic pain disorders are of the mixed type and involve both nociceptive and neuropathic elements. An example of a mixed-type pain syndrome is chronic, recurrent headache.
* HISTORY
A detailed history establishes a solid foundation to guide further diagnostic workup and to implement a comprehensive management plan. The initial and, perhaps, most critical step in taking the history is to let the patient tell his/her own story. Unless the patient is cognitively impaired, this is the best source of information regarding the pain. Listening to the patient helps to identify specific issues that warrant further investigation. It also serves to validate the patient's pain and forges a trusting relationship with the patient. The use of the Personal Pain Tracker has been shown to improve patient perception of the quality of the primary care physician-patient communication and contribute to greater overall satisfaction with medical visits. (10) The Personal Pain Tracker is a self-administered clinical diagnostic aid that assesses 9 aspects of pain in a questionnaire and pictorial format and includes 20 pain descriptors shown to be familiar to patients.
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