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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
Most general pain assessment tools, including the Arthritis Impact Measurement Scale, do not assess pain during movement, especially movement that places stress on the hip or knee. They are, therefore, inadequate to assess pain due to osteoarthritis of the hip or knee. In this setting, the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) is the most widely used and is recommended by the World Health Organization. The WOMAC is a multidimensional tool that groups symptoms into 3 categories: pain, stiffness, and physical function. The WOMAC has been used successfully in patients with cognitive impairment. (22)
* PSYCHOSOCIAL ASSESSMENT
A critical part of the evaluation of a patient with chronic pain is the assessment of psychosocial risk factors. Ten largely independent psychosocial risk factors have been shown to serve as obstacles to the recovery from acute pain, thereby serving as risk factors for the development of chronic pain (TABLE 5). (12) A history of substance abuse or dependence is an important consideration in developing the management plan. Pain duration also is of particular importance as it is directly related to the likelihood that chronic pain and disability will develop. Patients who are unemployed for 6 months have a 50% chance of returning to their old job; after a year, there is only a 10% chance of a successful return to work. (12) This serves to reinforce the importance of correctly identifying the pain syndrome and implementing a comprehensive management plan.
Other issues of critical importance to primary care clinicians are the 5 psychosocial risk factors that are predictive of a negative outcome in the treatment of chronic pain (TABLE 6). (12) Negative beliefs predispose the patient to think that a return to work is not possible unless the pain is completely eliminated. When coupled with job dissatisfaction or an attitude of anger or hostility, resolution of chronic pain symptoms is particularly difficult. Multidisciplinary treatment and psychotherapeutic intervention may prove necessary.
Anxiety and depression are particularly important factors that may contribute to chronic pain. (27-29) Preliminary evidence suggests that these psychopathologies are preexisting, semidormant characteristics of the individual that are activated by a stressful event such as chronic pain. (30) Anxiety, for example, has been found to decrease the pain threshold and tolerance, (31) whereas depression is associated with less successful treatment outcomes. (32) Anxiety and depression have been associated with magnification of medical symptoms. (33)
Various assessment tools have been employed to assess the psychosocial contribution to chronic pain. Some of those most commonly used include the Beck Depression Inventory (BDI), the Spielberger State-Trait Anxiety Inventory (STAI), and the Minnesota Multiphasic Personality Inventory (MMPI). The BDI is a 21-item questionnaire that is easy to use and score. It reliably distinguishes between depressed and nondepressed patients with chronic pain. The STAI is a 40-item questionnaire that asks patients how they feel at present (state anxiety) and how they feel generally (trait anxiety). The MMPI is widely used by pain specialists. It takes 1 to 2 hours to complete, has a strong orientation to psychopathology, and is sometimes perceived by patients as implying that their pain is imaginary. (12,34)
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