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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
Because pain is a subjective experience and individual pain thresholds and analgesic responsiveness differ, a patient self-report is the most reliable indicator of the existence and intensity of pain. In addition to the patient's self-report, specific questions should be asked to assess the physical and psychosocial aspects of pain (TABLE 3). (11,12) The initial evaluation should include a thorough analgesic history, including current and previously used prescription medications, over-the-counter medications, complementary or alternative remedies, and alcohol use or abuse. The effectiveness and any side effects of current and previously used medications should be recorded. The patient's satisfaction with current pain treatment or health should be determined, and concerns should be identified. [Evidence level IIIB: Evidence from respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Moderate evidence to support the use of a recommendation; clinicians "should do this most of the time." Available at: http://www.guideline.gov/summary/ summary.aspx?ss=15&doc_id=3365&nbr=2591& string=persistent%20AND%20pain.]
The differentiation of chronic nociceptive pain from chronic NP based upon symptoms may be challenging as there may be considerable overlap in the patient's descriptions. (13) Symptoms that are more suggestive of NP include numbness, tingling, continuous burning pain, electrical or other abnormal sensations (as can be seen with chronic dysesthesias, which are unpleasant abnormal sensations) or sharp, stabbing, shooting, knifelike pains, often following a sudden paroxysmal pattern. (14) Even among the NP syndromes, there is variability in the pain descriptors, which supports the belief that different mechanisms are involved. (15) For example, patients with postherpetic neuralgia often identify their pain as being more sharp, less cold, more sensitive, and itchier than pain identified by patients with diabetic neuropathy, peripheral nerve injury, or reflex sympathetic dystrophy. (16) Patients with lung cancer identify their pain as throbbing, aching, numb, tender, punishing, pulling, tugging, pricking, penetrating, miserable, and nagging. (13)
Neuropathic pain may manifest itself as negative symptoms (sensory loss) or positive symptoms such as paresthesias (abnormal sensations) or hyperalgesia (increased response to painful stimuli). Negative symptoms might result from impaired conduction of afferent sensory nerve activity that results in an area of sensory deficit, which is perceived as numbness. A negative symptom also can be caused by impaired conduction of efferent motor nerve activity, which can lead to muscle deficits, experienced by patients as weakness. Enhanced sensations or positive symptoms also may be observed ranging from paresthesias, such as tingling and prickling, to hyperesthesias (heightened but not painful sensations), to dysesthesias. This explains why a cold stimulus such as ice may reduce nociceptive pain due to inflammation but produce excruciating pain in NP. (7) A diagnosis of NP may be missed if the signs and symptoms of neural dysfunction are not recognized. Conversely, a patient with nerve damage and coincidental pain from another source may be misdiagnosed as having only NP. (17)
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