Appendix
C
INITIAL EVALUATION
OF THE PATIENT WITH CHRONIC PAIN (ASSESSMENT AND DIAGNOSIS)
KEY
PRINCIPLES
- Recognize
the multiple dimensions of chronic pain—biological, psychological,
behavioral, familial, vocational, social, and medical legal.
- Identify
and understand the nature of the patient’s problem and,
where possible, the cause of the pain.
- Identify
and understand comorbid conditions that may affect treatment.
- Identify
and understand the patient’s expectations and goals.
Because
chronic pain affects multiple aspects of living, accurate multidimensional
diagnosis is a prerequisite for effective chronic pain management.
A comprehensive evaluation should address medical, physical, and
psychosocial issues.
The
treating physician should have a thorough knowledge of various common
chronic pain conditions and appropriate management options. While
these topics are outside the scope of the present document, the references
and appendices provide a starting point for practitioners interested
in acquiring this knowledge.
Depression
and anxiety are common comorbidi-ties of chronic pain, either preexisting
or as compli-cations of the pain itself. These disorders often require
consultation with a behavioral health specialist and/or psychiatrist.
Addiction is not commonly seen during chronic pain management, but
may exist prior to onset of pain or may develop during the course
of a painful disorder, and clinicians should assess for its presence
prior to the onset of treatment with controlled substances, and assess
for signs of addiction during the course of chronic treatment with
opioid analgesics or benzodiazepines.
HISTORY
The history, when properly obtained, can provide information about both the
physical and psychological aspects of pain. It should include:
- Pain
history
- Chronology
of the presenting complaint
- Mechanism
of onset
- Characterization
of pain
- Location
of pain; referral/radiation
- Quality
of pain (stabbing, burning, aching, etc.) A pain diagram
can be very useful here. This simple tool helps characterize
the location and nature of the pain
- Intensity
of pain: a numeric pain rating scale (0 = no pain; 10 = worst
pain imaginable) provides a frame of reference
- Duration
of pain
- Aggravating
and relieving factors
- Additional
symptoms—motor, sensory and autonomic changes
- Impact
of pain on sleep, mood, work, activities of daily living,
social function
- Special
needs of elderly patients and those with dementia
- History
of treatment—Previous surgical, pharmacological,
physical, psychological, and other treatments and their effectiveness
- Psychological
history—Screen for anxiety and depression, addiction,
somatoform disorder, personality disorder, other prior psychiatric
diagnoses, coping style, and personality traits
- Vocational
and medical legal issues and related expectations
- General
medical history
- Patient’s
ideas about the cause of pain
- Patient’s
goals for evaluation and treatment— Preprinted
forms can be helpful in acquiring the pain history. Patients
may complete the form in advance, which saves time during the
interview. An example is included in Appendix I.
EXAMINATION
A comprehensive examination of each patient is recommended, with direct examination
of the painful area(s). Where appropriate, the comprehensive examination
may include:
- Musculoskeletal
examination
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