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11 Articles in Volume 16, Issue #7
A Perspective on Tapentadol Therapy
Acupuncture to Treat Brachial Plexopathy and CRPS
Behavioral Medicine: How to Incorporate Into Pain Management
EpiPens and Opioids: Common Ground
Fibromyalgia and Coexisting Chronic Pain Syndromes
Life-Saving Naloxone: Review of Currently Approved Products
Medical Foods Hold Promise In Chronic Pain Patients
Moving Beyond Pain Scales: Building Better Assessment Tools for Today’s Pain Practitioner
Moving Toward an (Almost) Opioid-Free Emergency Department
No Perfect Medicine—What You Need to Know About NSAIDs and Opioids
Prescribing Opioids: How New Policies Are Affecting Medical Specialties

Moving Beyond Pain Scales: Building Better Assessment Tools for Today’s Pain Practitioner

Setting clear goals and regularly re-evaluating the pain management plan is vital to helping chronic pain patients gain improvements in quality of life and function.

Pain reduction has been one of the primary goals of pain treatment for decades.1-3 Traditionally, reduction in pain was measured by asking patients to rate their pain on a 0 to 10 visual analog scale (VAS) or numeric pain scale (NPS). A 2-point change in the patient’s pain rating (before and after therapy) was considered a successful treatment.  

More recently, physicians have added improvement in function as a goal of therapy.1-3 Although not clearly defined, the term function tends to include whether the patient was able to complete activities of daily living. Another popular assessment tool that incorporates elements of both these tools has been the 5-A assessment system: (1) analgesia; (2) activity; (3) adverse events; (4) aberrant behavior; and (5) affect (Table 1).2-4

However, advances in pain management have expanded our understanding of chronic pain management and central sensitization, resulting in the need for new tools to assess control of the autonomic nervous system, normalization of the endocrine system, and elimination of excess neuroinflammation. Also, there are new assessments of pain reduction in addition to the pain score, and the term “function” has heretofore been poorly defined.  

This article summarizes some of the new goals and assessments to assist practitioners in selection of pharmacologic and nonpharmacologic measures. This article also highlights some of the refinements in assessing pain reduction and improvement in functions. It is emphasized that the goals and assessment of treatment success are paramount, regardless of any specific treatment agent or measure.1,5 Also, it seems important to identify and clarify new goals and assessments, as pain management is maturing into a fixture in every community.

Better Than a Pain Score

The 0 to 10 VAS and NPS have proved invaluable in many settings, such as emergency rooms, and at the initial evaluation of a chronic pain patient. Unfortunately, the 0-10 pain score has not proved to be a reliable indicator of pain relief and control in the chronic pain patient who is in medical management. The patient naturally wants a zero score, and patients tend to always report a high pain score even when they have clearly improved and lowered their pain threshold.

I highly recommend assessments related to pain lessening or reduction in addition to the pain score (see Table 2). My favored assessment tool is asking about the attainment of pain-free hours. Equally important is a reduction of pain flares, including their severity and frequency. For example, typical questions would be “Has a pain flare(s) been severe enough to seek help in an emergency room or hospital?” and “Is the time between flares lengthening?”

The importance of reducing these pain flare episodes is multifactorial. Sleep time episodes increase in length when baseline pain is reduced. Poorly controlled baseline pain as well as pain flares may incapacitate patients so they spend the better part of a day in bed or on the couch. Chronic pain patients clearly understand the meaning of bed- and couch-bound days.

Function: Goals and Assessments

While the goal of improved function is found in every guideline of pain treatment, it is poorly defined and conceptualized. For example, the first two points in the new Centers for Disease Control and Prevention (CDC) guidelines mentions “function.” The first recommendation states: “consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks to the patient.” In the second recommendation, these statements are made: “Before starting opioid therapy for chronic pain, providers should establish treatment goals with all patients, including realistic goals for pain and function,” and “Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.”

Despite improvement in “function” now included in our national guidelines, the term is not defined. For example, there can be patient improvement or deterioration in physical, mental, social, or vocational function. It can also refer to “activity function” in that a common goal of treatment is to function well enough to carry out activities of daily living, which I define here as the ability to provide one’s own sanitation, hygiene, meals, finances, transportation, and socialization.  

Since “function” has essentially not been defined by any consensus in pain management, practitioners should set specific functional goals for individual patients related to physical, mental, social, or vocational activities. There are some scales, such as the “Pain, Enjoyment, and General Activity Scale,” which are short and givegood information. Many practitioners, including this author, make their own scales to assess various functions.

Since there is no universal consensus on what the term “function” means, here are some of my observations and assessments:  

  • Severe chronic pain, particularly if the pain is constant and centralized, will depress and immobilize a patient. Patients may socially withdraw, become quite reclusive, and spend many days in bed or on the couch.
  • Pain practitioners can assess activity and function quite well by simply asking verbal or written questions that inquire about activities of daily living, such as hygiene, nutrition, socializing, housekeeping, reading, sexual activity, and exercise.  
  • Patients may, unfortunately, want to put a good face on their activities of daily living to compliment or assuage the practitioner.  
  • It is recommended that functions and activities of daily living be specific and even quantitated. For example, a patient may report that her or she is doing “just fine,” but he or she is spending half of their days in bed and rarely leaves his or her house to socialize. Many also fail to eat or sleep at normal times.  
  • An accurate assessment of general functions and activities of daily living may often best be accomplished by interview of family members.

When pain is out of control, patients’ eating habits become atrocious. The patient may seldom eat, and when eating does occur, the meal will usually consist mainly of carbohydrates (sugars and starches). A regular eating habit of three meals a day with some protein intake is a good indicator of effective pain control.

Autonomic Nervous System Monitoring: Key to Proper Dosing  

Uncontrolled pain excessively stimulates the sympathetic component of the autonomic nervous system (SNS).6-9 Good pain control requires normalization of the SNS without sedating the patient. The most overt physical signs of overstimulation of the SNS are tachycardia, hypertension, dilated pupils (mydriasis), hyperhidrosis, hyperreflexia, and vasoconstriction manifested by cold extremities or isolated cold areas over muscle groups.  

Excess medication will not only suppress the SNS but also other components of the autonomic nervous system. Most prominent are muscle groups and involuntary nerve impairment. Suppression of the autonomic nervous system is typically manifested by droopy eyelids, slurred speech, and loss of balance. Patients will be sedated and give inappropriate, slow, or even no response to questions.

Some patients with marked SNS stimulation will develop Raynaud’s phenomenon (white or pale, cold fingers or hands). Symptoms of overstimulation of the SNS include nausea, diarrhea, frequent urination, dizziness, headache, and fatigue.  

It is recommended that some chart notation be made at every clinic visit indicating whether SNS and other autonomic nervous system functions are within or outside of normal range. Signs of SNS excess usually call for increased analgesia, while the presence of autonomic suppression usually dictates a reduction in medication (see Table 3). Normal findings usually mean that the current medical regimen is appropriate and effective.

Neuroinflammation Control

It is now known that chronic, severe pain will likely become imbedded in the central nervous system and produce neuroinflammation. The mechanism is caused by activation of microglial cells in the spinal cord and brain.10 Just as with inflammation in peripheral muscles and joints, markers or waste products from neuroinflammation enter the serum and can be measured.11 Neuroinflammation, as with peripheral inflammation, has acute and chronic phases. Cytokines and interleukins rise in the serum in the acute or early phases of neuroinflammation and pain.12

At this time, there is no consensus on what acute markers should be evaluated in pain management. Interleukin profiles are now commercially available, and elevations of some appear in severe, chronic pain patients, likely because neuroinflammation is ongoing. A few late-stage neuroinflammatory markers have been identified in chronic pain patients and include myeloperoxidase, alpha 1 antitrypsin, and tumor necrosis factor. Unfortunately, these markers are not yet easily accessible to pain practitioners through normal commercial channels.  

Neuroinflammation will, however, often raise the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, which are readily available as part of blood tests.13 These two markers can be initially determined, and, if high, can be a marker that can be used to help guide pain control. If they are elevated, a goal of ongoing treatment should be to develop a medical regimen that normalizes them.

Pain patients with neuroinflammation will usually report episodes of heat and sweating, sometimes alternating with cold episodes. A history of frequency and severity of these episodes can help assess pain control effectiveness.

Endocrine Abnormalities

Severe, chronic pain causes hyperstimulation or “overdrive” of the endocrine system.14 Initially, hormones such as pituitary adrenocorticotropin (ACTH), cortisol, pregnenolone, and dehydroepiandrosterone (DHEA) become elevated in the serum. If severe pain is not controlled, the pituitary and adrenal glands may not be able to keep up with the stress, and, consequently, some hormone serum levels will drop below normal range. Good pain control will usually normalize the endocrine system—although hormone supplementation will be required in some cases.

Hormone profiles are now readily available through commercial channels. Finger-stick technology has recently become available. Normalization of the endocrine system should now be a goal of pain management, as low levels of some hormones such as testosterone and pregnenolone interfere with analgesic medications and impair any functional goals that may be established for the patient. Endocrine homeostasis provides energy, motivation, and mentation that allow the patient to physically and mentally function.

Summary

Too often, practitioners may initiate and carry out pain treatment without setting treatment goals and/or performing assessments to measure the achievement in reaching the goals. In the recent past, pain treatment has focused primarily on lowering the pain score, with some emphasis on function and performing activities of daily living. Some practitioners have adopted the 5-A system of monitoring. Unfortunately, the term “function” is ill defined in governmental and association guidelines. Function includes those that are physical, mental, social, and vocational.  

Each patient needs a specific, well-defined functional goal. New goals based on research and clinical experience in recent years include normalization of the autonomic nervous and endocrine systems. The pathologic impact of severe chronic pain on these systems can be profound and may even shorten the life of a pain patient.  

Neuroinflammation is the newest complication to be discovered with severe, chronic pain. It must be controlled and hopefully eliminated, as it causes tissue destruction and may spread pain to new sites and progressively impair the pain patient. At this time, neuroinflammatory markers are being developed to help select treatment agents or protocols to eliminate neuroinflammation. A goal of monitoring and suppressing neuroinflammation should be part of contemporary pain management.

Last updated on: September 20, 2016
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