In this particular section, I will review the clinical pearls in the evaluation of patients with chronic pain. Taking a detailed history is critical when evaluating patients with chronic pain. It is important to discern the particular location of the pain as well as the onset, quality, severity, duration, and degradation of the symptoms. It is also very important to ask patients what factors alleviate or aggravate the pain. Please keep in mind that it is also important to ask for any other associated signs or symptoms that you may feel are relevant to the particular case. It is also useful to ask about any prior medication or treatments that the patients have tried that have been successful or that they have failed. In addition to getting a detailed HPI, it is important to get a pertinent history on past medical history, surgical history, psychiatric history, as well as any relevant family history and social history. Evaluating patients with chronic pain, there are multiple pain assessment tools that are available. One of the most common tools that is often used in pain clinics is a pain diagram or pain drawing. This requires a patient to identify the specific locations of the pain as well as to identify the quality of the pain. This is a sample pain diagram of a patient who has completed the pain diagram. As you can see in this particular case, the patient has identified multiple areas of pain complaints. However, one can potentially infer some patterns of neuropathic symptoms localized in the left upper extremity where the patient identifies numbness and tingling, as well as some similar possible symptoms in the left lower extremity. The patient also identifies some somatic complaints of achy and sharp stabbing pain along the midline of the spine and along the paraspinal region. Pain is a subjective phenomenon and there is no single assessment tool that fits for all patients. The pain assessment tool for intensity should be tailored to your patient and the clinical setting. This slide outlines some common pain assessment tools including a simple descriptive pain intensity scale which requests the patient to identify the intensity of pain using descriptive terms from no pain to mild to moderate to worsening severe pain symptoms. Patients can also be requested to use a numeric rating scale where the patients identify their pain on a 0 to 10 numeric scale with 0 being no pain and 10 being the worst possible pain. Some clinics may also use a visual analog scale where the patient marks on a analog scale of pain intensity from no pain to the most intense pain possible. Some clinics may also use the pain faces scale as seen on the right-hand side of the slide. One can also consider using multiple measures or a multi-dimensional measurement of pain. As part of the comprehensive assessment of patients with chronic pain, it is important to evaluate the impact of the pain on the patient's function and quality of life. Some of the important elements to ask your patients would include the impact of the pain on their mobility as well as their activities of daily living. It is also important to ask if the pain is impacting their ability to exercise as well as to perform their job duties. It's also important to identify if there's any adverse impact of the chronic pain on the patient's social activities. Chronic pain can also have a significant impact globally on the patient in terms of their sleep, their anxiety, and their mood. So it is important to ask questions about any associated sleep disturbances from the pain as well as any aspects of negative emotions or negative thinking that could impact their chronic pain and their day-to-day activities. It is also important to dive into some of their coping resources and their support system, and it is very important to ask about substance abuse, physical or sexual abuse, and suicide risk in patients with chronic pain. Clinicians can also use formal assessment tools when evaluating the patients with chronic pain, and there are many tools out there, and I am highlighting one that is sometimes used called the brief pain inventory. This tool can be used to evaluate the patient's chronic pain and its impact on their daily function and quality of life. The BPI or the brief pain inventory dives into the impact of the pain on the patient's mood, sleep, general activity, their ability to walk, their relationship with others, as well as their enjoyment of life. And what can be useful in this type of assessment tool or potentially other assessment tools is that you can follow the trend and evaluate the response of the patient's pain treatments over time by asking the patient about their pain treatment. You can also evaluate the patient's pain treatments over time by asking them to complete this inventory over a chronological period of time. A thorough neuromuscular examination can be very useful in evaluating patients with chronic pain and in establishing the best diagnosis. In terms of the general physical examination, it is important to assess the general observation of the patient as well as their vital signs, their mental status exam, as well as a focused musculoskeletal and neurologic exam. Other important areas of the exam include regional examination for provocation maneuvers to potentially elicit the pain or symptoms, as well as a regional exam looking for things such as allodynia, atrophy, or dystrophic changes in certain chronic pain conditions. Some patients with chronic pain can have non-organic etiology for their pain. Waddell's signs are some examples of physical exam techniques that can be utilized to help suggest the presence of a non-organic source of pain. Superficial tenderness involves the finding of tenderness over a wide area of the lumbar skin to light touch or pinch in a patient with low back pain, for example. A non-anatomical tenderness example would be a patient who exhibits deep tenderness over a wide area that crosses over non-anatomic boundaries. Simulation testing can also be utilized in some cases. For example, the axial loading technique can be used in a patient who presents with back pain. In this situation, the examiner axially loads the patient who is standing and the examiner presses downward vertically on the patient's head, eliciting lumbar pain. There are several distraction techniques that can also be utilized. One example is the distracted straight leg raise test. This test is considered positive when the patient reports radicular pain symptoms on formal straight leg raise testing, such as in the supine or seated position. However, the pain is markedly reduced on performing the same straight leg raise test while the patient is distracted. Another example of a Waddell's sign is regional neurological disturbance. One example would be if a patient exhibits generalized weakness or cogwheel giving away that cannot be explained by a neuroanatomic basis. Finally, overreaction is another Waddell's sign in which a patient can potentially demonstrate a exaggerated painful response to a stimulus that is not reproduced when the same stimulus is given at a later time. Beyond the history and physical examination that is important in patients with chronic pain, it is also important to consider any diagnostic testing or imaging or intervention that may help further identify the diagnosis. Unfortunately, there are many patients who have a nonspecific pain diagnosis and this leads to very nonspecific treatments and ultimately nonspecific outcomes. So it is very important to use your clinical skills in history gathering and physical examination to reach a definitive diagnosis if possible and also to identify and utilize appropriate testing in a resourceful manner in order to help with patients outcomes.

evaluation

chronic pain

detailed history

pain assessment tools

impact of chronic pain