Approach to assessment and diagnosis of chronic pain

Journal of Family Practice,  Oct, 2004  by Stephen Brunton

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TABLE 1

Goals of pain assessment

* Establish a diagnosis of pain

* Determine the type and severity of the
pain disorder

* Identify the pain mechanism(s)

* Assess the impact on functional status,
quality of life

* Identify contributing factors, including comorbid
conditions and psychosocial factors

* Establish treatment goals and an initial
management plan

* Refine the management plan as needed to
optimize patient outcomes

* Determine if consultation with specialist
or multidisciplinary team is needed

TABLE 2

Aspects of comprehensive pain assessment

* Physical examination, relevant laboratory
and diagnostic tests

* Effect of and understanding of current illness

* Meaning of pain and distress caused by the pain

* Coping responses to stress and pain

* Effects on activities of daily living (especially in
frail older persons and noncognizant persons)

* Psychosocial and spiritual effects

* Psychologic/social variables (anxiety, depression)

* Situational factors--culture, language, ethnic
factors, economic effects of pain and treatment

* Person's preferences and expectations/beliefs/myths
about pain management methods and person's
preferences and response to receiving information
related to his/her condition and pain

TABLE 3

Issues to be covered in the history

* What are location and character of pain?

* Is the pain continuous or intermittent?

* How and when did the pain start?

* Are there any relevant comorbidities?

* What are exacerbating and relieving factors?

* What is the effect of certain positions and activities
on pain?

* What is the effect of stress, alcohol, and other
substances on the pain?

* Is there an associated sleep or mood disturbance?

* What is the effect of pain and its treatment on
functioning at work or school?

* What is the effect of pain and its treatment on quality
of Life, including cognitive, social, sexual function?

* Does the patient have an ulterior motive (eg,
lawsuit, disability, desire for attention)?

* Does the patient blame anyone for the pain?

* Has the patient previously sought medical assistance
for the pain?

* What treatments have been or are being used?

TABLE 4

Pain assessment tools

Tools                  Strengths                 Weaknesses

UNIDIMENSIONAL

Numeric Rating Scale   Simple; reproducible;     Measures pain inten-
(NRS)                  can measure small         sity only; difficult
                       change in pain inten-     to use in cognitively
                       sity; can be verbally     impaired persons
                       administered; easily
                       understood by most,
                       including older persons
                       and different cultures;
                       used in prehospital
                       setting
Verbal Rating Scale    Simple; reproducible;     Measures pain inten-
(VRS)                  can measure small         sity only; not as
                       change in pain inten-     sensitive as the NRS
                       sity; can be verbally     or Visual Analog Scale
                       administered, easily
                       understood by most, in-
                       cluding older persons;
                       high completion rate in
                       cognitively impaired;
                       used in prehospital
                       setting
Visual Analogue        Simple; reproducible;     Measures pain inten-
Scale (VAS)            can measure small         sity only; requires
                       change in pain inten-     careful instruction;
                       sity; can be used in      difficult to use in
                       different cultures        cognitively impaired;
                                                 visual impairment may
                                                 affect accuracy
Faces Pain             Simple; useful in young   Measures pain inten-
Rating Scale           children, developmen-     sity only; requires
                       tally disabled, cog-      careful instruction;
                       nitively impaired, and    visual impairment may
                       in different cultures     affect accuracy
Knee Pain Scale        Useful in patients with   A bit cumbersome to
                       knee osteoarthritis;      use
                       assesses frequency and
                       intensity of knee pain

MULTIDIMENSIONAL

McGill Pain            Combines words and        Time-consuming; re-
Questionnaire          pictures to provide       quires careful ins-
(MPQ)                  a general analysis of     truction; not easily
                       overall pain expe-        used in cognitively
                       rience; shortened         impaired or in diffe-
                       version generally more    rent cultures
                       appropriate
Brief Pain             Combines ratings of       Time-consuming;
Inventory (BPI)        intensity and location;   requires careful
                       useful in different       instruction; not
                       cultures; BPI short       easily used in
                       form generally more       cognitively impaired;
                       appropriate in clinical   used mostly in
                       practice                  clinical research
Minnesota              Uses several scales to    Requires careful
Multiphasic            predict treatment         instruction; time-
Personality            outcome                   consuming; developed
Inventory (BPI)                                  for a general--not
                                                 pain--population;
                                                 ability to predict
                                                 treatment outcome is
                                                 variable
Checklist of Non-      Clinician evaluation      Low reliability and
verbal Indicators      of 6 pain-related         validity
                       behaviors at rest and
                       during movement;
                       developed for use in
                       cognitively impaired
Western Ontario and    Assesses disease          Time-consuming; user
McMaster University    progression in            fee required
Osteoarthritis Index   osteoarthritis; 5-point
(WOMAC)                Likert and VAS ver-
                       sions; recommended by
                       the World Health Orga-
                       nization; useful in
                       cognitively impaired,
                       different cultures
Arthritis Impact       Useful in all types of    Time-consuming; does
Measurement Scale      arthritic pain            not focus on specific
(AIMS)                                           features/locations of
                                                 pain

TABLE 5

Psychosocial risk factors
for the development
of chronic pain and disability

* Pain duration
* History of major psychopathology
* History of substance abuse or dependence
* Job dissatisfaction
* History of prolonged recovery from previous
  experiences of pain
* Pattern of reduced activity, coupled with excessive
  pain behaviors, supported by family and other
  social contacts who are either too solicitous or
  inconsistent or too harsh and punitive
* History of psychologic or physical trauma
* History of emotional, physical, or sexual abuse
* Negative or anxiety-provoking beliefs
  about the meaning of pain
* Explanatory model of pain

TABLE 6

Psychosocial risk factors
for a negative outcome of
chronic pain treatment

* Job dissatisfaction
* Reduced activity
* Negative beliefs
* Sustained attitude of hostility, anger, and alienation
* Reliance on maladaptive coping strategies