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12 Articles in Volume 12, Issue #1
Ask the Expert: Escalating Opioids
Can Yoga and Stretching Exercises Relieve Chronic Low Back Pain?
Cortisol Screening in Chronic Pain Patients
Editor's Memo: FDA Removes Homeopathic HCG; Helps Legitimate Use In Pain Treatment
Formulation: The Four Perspectives of a Patient in Chronic Pain
Guide to Chronic Pain Assessment Tools
How to Select an In-Office Electromagnetic Field Device
Letters to the Editor: Hormone Therapies
Managing Pain in Active or Well-Controlled Systemic Lupus Erythematosus
PPM Editorial Board Examines Steps to Prevent Accidental Overdoses
Saliva Drug Screening in the Office Setting: Detection of Drug Use and Abuse
Understanding the Toxicology of Diazepam

Guide to Chronic Pain Assessment Tools

A comprehensive history, physical, and psychological examination performed during a chronic pain patient’s initial assessment is vitally important and will guide the proper diagnosis and treatment plan.

Many busy clinicians struggle with finding the time to conduct a thorough assessment of the pain patient, especially the patient with chronic pain. This is the case even though pain is among the most common reasons patients seek medical care.

This article reviews how to properly assess a patient with chronic pain. A patient-centered approach includes a comprehensive history and thorough physical examination with supplemental information from diagnostic studies and psychometric instruments. The assessment is finalized using the organizational framework of four perspectives to assist in developing an individualized case formulation and treatment plan.1

See article "Formulation:  The Four Perspectives Of a Patient in Chronic Pain" for description of formulations.

Treating the Whole Patient
Chronic pain assessments are often more involved and complex than assessment of the patient with acute pain. It is now widely recognized that there is more to the management of pain than just analgesia. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) has recommended a set of core outcome domains for clinical trials in pain. These domains include pain, physical functioning, emotional functioning, participant ratings of global improvement, symptoms and adverse events, and participant disposition.Although these domains are recommended for clinical trial outcome measures, they show the importance of viewing the patient comprehensively.

In chronic noncancer pain, pain is defined as lasting for 3 months or longer. It may be experienced by the patient as continuous or as intermittent and recurrent.3 Because chronic pain affects multiple areas of a patient’s life, the diagnosis and treatment should incorporate a multidisciplinary approach. To address the affective, cognitive, and behavioral aspects of pain management, a psychiatrist may be consulted. The psychiatrist should be involved early in the course of treatment, and comprehensive interdisciplinary care is recommended.4

The role of the psychiatrist should be to individualize the case formulation, diagnose co-occurring psychiatric disorders, and apply psychopharmacology to the treatment of chronic pain syndromes.5 The initial assessment is vitally important and will guide the proper diagnosis, treatment plan, and role of other clinicians and programs, as well as provide the patient’s baseline at the start of treatment.

Assessment
A common pitfall in the assessment of a patient with chronic pain is that all of the patient’s difficulties are assumed to be caused by the suffering associated with the experience of chronic pain. However, each case and the primary diagnosis, as well as comorbidities that may contribute to the overall condition, must be reviewed and examined. There is no single diagnostic test for chronic pain or each chronic pain disorder. There are numerous causes of chronic pain conditions to consider (Table 1).

A comprehensive history and physical and neurologic examination should be performed when evaluating and identifying the patient’s subjective description of pain.6 An initial functional and psychosocial assessment should be performed by the treating physician, with input from other team members. This information should verify the preliminary impression and guide the physician in the selection of laboratory, imaging, and further specialist consultations (Table 2).7During the full assessment, consultants may perform further evaluations and diagnostic tests. Specialized assessments, such as imaging, neurophysiologic, laboratory, and psychological tests, must be determined on a case-by-case basis.8

A 10-step approach to long-term chronic pain management is useful (Table 3).9 This structured approach provides a consistent and effective evaluation method. In assessing pain, the baseline descriptions and scores are important for diagnosis and for future assessment of treatment efficacy. The use of pain scales may be of benefit and is discussed in a separate section. A useful mnemonic to perform a comprehensive evaluation is L-DOC-SARA—location, duration, onset, characteristics, severity and pain goal, aggravating factors, relieving factors, and associate symptoms. Another mnemonic to assess treatment response is the four As (analgesia, adverse events, activities of daily living [ADLs], and aberrant behaviors). The four As should be followed and monitored throughout treatment.

Keep in mind during the assessment that multiple aspects of the patient’s well being are affected by a chronic pain disorder. Patients with chronic pain suffer dramatic reductions in physical, affective, psychological, and social well being, and they rate their health-related quality of life lower than those with almost all other medical conditions.11,12 It is useful to keep the IMMPACT domains recommended for clinical trials in mind (eg, pain intensity, physical functioning, emotional functioning, participant ratings of global improvement, symptoms, and adverse events). Not every patient requires multiple scales as recommended by IMMPACT, but they should be kept in mind when performing an evaluation, generating the case formulation, and following the patient’s care (Table 4). For example, compare a patient’s ADLs on a typical day from visit to visit via an outline. Evaluate mood changes and anxiety symptoms along with possible comorbid depression or anxiety disorders. Always assess for suicide, because this population has a suicide rate two to three times the rate of that in the general population.13 Sleep disturbances are a common complaint, and sleep patterns, nighttime rituals, and use of medications or substances should be addressed. Also evaluate changes in interpersonal interactions and, if possible, obtain collateral information.

 

Addressing each aspect of a patient’s case may require multiple team members. There is substantial evidence that interdisciplinary pain rehabilitation programs improve functioning in several areas for patients with a number of chronic pain syndromes.14-17 Early use of this interdisciplinary team approach should be employed and provides the best outcomes for this patient population. Collaborative care initiatives that provide pain specialists’ assistance to primary care practitioners significantly improve pain-related outcomes.18 However, for many primary care physicians, the resources necessary to assemble a multidisciplinary team may not be available. Creative solutions may be required to build a “virtual” team. For example, core components of a team may include psychology, psychiatry, exercise, and physical therapy. However, one survey in North Carolina found that only 7% of pain clinics met the criteria of having at least a physician, registered nurse, physical therapist, and mental health specialist.19 The case formulation also may direct treatment toward the use of specialists such as anesthesiologists, orthopedists, neurologists, physiatrists, and psychiatrists. Therefore, the primary care physician will likely design systems of care that place the patient in partnership—the patient is the center of care and the primary care physician is the chief coordinator of care. The primary care physician and his or her office staff will need to maintain communication with the patient as well as other practitioners who are caring for the patient. An iterative treatment plan will emerge for each patient with the primary care physician taking new information regardless of the source and incorporating it into a revised set of goals, strategies, and therapies.

Psychometric Testing
There are numerous types of psychometric testing, ranging from simple numeric scales to comprehensive questionnaires. A clinical evaluation with adjunctive psychometric testing should be part of the chronic pain assessment. By no means should all of the scales be used in each case, but a physician should become comfortable with one or two valid and reliable measurements. These tests can assist in the screening process as well as measure the efficacy of therapies. As mentioned above, core domains have been developed from the IMMPACT study group, with some validated and reliable measurements suggested. The scales outline the importance of viewing the chronic pain patient from multiple perspectives. They can serve as guidelines in everyday clinical practice. The use of these scales should not replace clinical evaluations, but should enhance assessments, improve efficiency, and, hopefully, facilitate better outcomes.

Pain Scales
The gold standard of pain intensity is the patient’s self-report using a pain scale. The most frequently used and studied scales include the single-item visual analog scale (VAS) and the numeric rating scale.20 These scales are widely used, simple, reliable, and valid. Some scales are preferable to others. For patients who have difficulty assigning a number to pain, the VAS is a good initial option. The FACES rating scale is another option for young children or those who cannot speak English fluently. However, no one scale has consistently demonstrated greater responsiveness in detecting improvement.21,22

A decrease in pain greater than 30% reflects at least moderate improvement, and a decrease greater than 50% reflects substantial improvement.23 Documenting the use of rescue or breakthrough medication assists in determining the effectiveness of the current treatment regimen.

The sensory and affective qualities of pain also can be measured. In addition to descriptors given by the patient during the interview, the McGill Pain Questionnaire (MPQ) may be used to reveal specific sensory attributes of pain. The MPQ has been validated as demonstrating that different pain syndromes can be consistently described with specific constellations of descriptors.24 The short-form MPQ is a more easily implemented version of the questionnaire.25,26

Disability Scales
Chronic pain interferes with ADLs. Interference or disability scales from the Multidimensional Pain Inventory (MPI) and Brief Pain Inventory (BPI) provide reliable and valid measures of the effect of chronic pain on physical and social function.27-29 These inventories provide generic measures available for all chronic pain conditions and are not disease specific like some scales. A change in the interference scales of the MPI of about 0.6 point and the BPI of about one point has been suggested as a benchmark for clinically meaningful change.23

Emotional Scales
Emotional functioning is an important aspect of chronic pain. Depression, anger, anxiety, and irritability all are accompaniments of chronic pain.12,30,31 The Beck Depression Inventory (BDI) and Profile of Mood States are widely used, reliable, and valid assessments.32,33 Given that various symptoms of depression overlap with chronic pain, determining whether there is an independent depressive disorder can be a challenge. A score of at least 21 on the BDI discriminates major depression from an understandable reaction to chronic pain.34

Global Scale
People with chronic pain report that most aspects of their daily lives are affected by chronic pain. Enjoyment of life in general, emotional well being, fatigue, weakness, and sleep are difficult to assess if separate questionnaires are required.35 A global measure of function can determine the overall benefit of a treatment plan. An aggregate of all aspects of the patient’s experience, including global improvement and satisfaction, can be measured by the Patients’ Global Impression of Change scale. This single-item measure encompasses aspects of the patient’s personal experience, with improvement in physical and emotional functioning, side effects, convenience, and a therapy such as pain relief.36

Types of Pain
There are numerous mechanisms of pain with potential overlapping presentations. Nociceptive, or inflammatory, pain results from activity in neural pathways caused by potentially tissue-damaging stimuli.37 Examples include postoperative pain, arthritis, mechanical low back pain, sickle cell crises, and injuries. Neuropathic pain is defined as pain initiated or caused by a primary lesion or dysfunction of the nervous system.38,39 Examples of peripheral neuropathic pain syndromes include HIV sensory neuropathy, postherpetic neuralgia, and diabetic neuropathy. Examples of central neuropathic pain include central post-stroke pain, spinal cord injury pain, trigeminal neuralgia, and multiple sclerosis pain. Patients with chronic pain may experience one or more types of pain syndromes simultaneously. Because interventions are based on the type and severity of pain, a thorough assessment of each pain experience is critical to the success of designing optimal pain management.40

Psychometric Testing for 
Neuropathic Pain
Arriving at a proper diagnosis is key to the formulation of a treatment plan. For example, someone diagnosed with a type of neuropathic pain may require different treatment options than someone with other types of chronic pain conditions. If the clinical evaluation is not revealing or is uncertain, screening tools may be used to identify neuropathic pain and possible direct treatment. The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), Douleur Neuropathique en 4 questions, and Neuropathic Pain Questionnaire are validated screening tests and have been shown to discriminate neuropathic pain from other types of chronic pain with up to 80% sensitivity and specificity.41 Of note is that the LANSS is designed as a screening tool, but also has shown sensitivity to change in assessing treatment effects.42

Conclusions

The patient with chronic pain has many comorbidities and consequences that require a comprehensive assessment. There are numerous scales and questionnaires that may assist the clinician with the physical examination and history. Developing a personalized “step approach” allows a thorough evaluation to take place. Organizing the clinical information into different perspectives directs attention to specific causes of the patient’s disorder and dysfunction. Patient-centered case formulations using standardized approaches and metrics provide more comprehensive health care to the patient suffering with disabling and refractory chronic pain syndromes. Addressing each pertinent perspective of the patient with chronic pain leads to a more effective treatment plan and successful management.

Last updated on: April 15, 2015
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