Assessment and DiagnosisAssessment and Diagnosisof Pain Disordersof Pain Disorders

Assessment and DiagnosisAssessment and Diagnosisof Pain Disordersof Pain Disorders

Pain Assessment: GoalsPain Assessment: GoalsPain Assessment: GoalsPain Assessment: Goals

• Characterize the painCharacterize the pain

• Identify pain syndrome Identify pain syndrome

• Infer pathophysiologyInfer pathophysiology

• Evaluate physical and Evaluate physical and psychosocial comorbiditiespsychosocial comorbidities

• Assess degree and nature of disabilityAssess degree and nature of disability

• Develop a therapeutic strategyDevelop a therapeutic strategy

Comprehensive Pain AssessmentComprehensive Pain AssessmentComprehensive Pain AssessmentComprehensive Pain Assessment

• HistoryHistory

• Physical examinationPhysical examination

• Appropriate laboratory and Appropriate laboratory and radiologic testsradiologic tests

Pain and DisabilityPain and DisabilityPain and DisabilityPain and Disability

NociceptionNociception

Other physical symptomsOther physical symptomsPhysical impairmentPhysical impairment

NeuropathicNeuropathic Psychologic Psychologic Social isolationSocial isolationmechanismsmechanisms processesprocesses Family distressFamily distress

Sense of loss or inadequacySense of loss or inadequacy

Adapted with permission from Portenoy RK. Adapted with permission from Portenoy RK. LancetLancet. 1992;339:1026.. 1992;339:1026.

Pain

Disability

Pain History Pain History Pain History Pain History

• Temporal featuresTemporal features——onset, duration, course, onset, duration, course, patternpattern

• IntensityIntensity——average, least, worst, and current painaverage, least, worst, and current pain

• LocationLocation——focal, multifocal, generalized, referred, focal, multifocal, generalized, referred, superficial, deepsuperficial, deep

• QualityQuality——aching, throbbing, stabbing, burningaching, throbbing, stabbing, burning

• Exacerbating/alleviating factorsExacerbating/alleviating factors——position, position, activity, weight bearing, cutaneous stimulationactivity, weight bearing, cutaneous stimulation

PathophysiologyPathophysiologyPathophysiologyPathophysiology

• Nociceptive painNociceptive pain

• Neuropathic painNeuropathic pain

• Idiopathic painIdiopathic pain

• Psychogenic painPsychogenic pain

• Commensurate with Commensurate with identifiable tissue damage identifiable tissue damage

• May be abnormal, unfamiliar May be abnormal, unfamiliar pain, probably caused by pain, probably caused by dysfunction in PNS or CNS dysfunction in PNS or CNS

• Pain, not attributable to Pain, not attributable to identifiable organic or identifiable organic or psychologic processespsychologic processes

• Sustained by psychologic Sustained by psychologic factorsfactors

Pain Assessment ToolsPain Assessment ToolsPain Assessment ToolsPain Assessment Tools

• Pain intensity scalesPain intensity scales– Verbal ratingVerbal rating– Numeric scaleNumeric scale– Visual analogue scaleVisual analogue scale– Scales for childrenScales for children

• Multidimensional pain measuresMultidimensional pain measures– Brief Pain InventoryBrief Pain Inventory– McGill Pain QuestionnaireMcGill Pain Questionnaire

Pain SyndromesPain SyndromesPain SyndromesPain Syndromes

• Acute painAcute pain

• Chronic painChronic pain

• Breakthrough painBreakthrough pain

• Recent onset, transient, Recent onset, transient, identifiable causeidentifiable cause

• Persistent or recurrent Persistent or recurrent pain, beyond usual course pain, beyond usual course of acute illness or injuryof acute illness or injury

• Transient pain, severe or Transient pain, severe or excruciating, over excruciating, over baseline of moderate pain baseline of moderate pain

Identify Pain SyndromesIdentify Pain SyndromesIdentify Pain SyndromesIdentify Pain Syndromes

• Syndrome identification can direct assessment and Syndrome identification can direct assessment and predict treatment efficacypredict treatment efficacy

• Cancer pain syndromesCancer pain syndromes• Bone painBone pain• Pathologic fracturePathologic fracture• Cord compressionCord compression• Bowel obstructionBowel obstruction

• Noncancer-related pain syndromes Noncancer-related pain syndromes • Atypical facial painAtypical facial pain• Failed low-back syndromeFailed low-back syndrome• Chronic tension headacheChronic tension headache• Chronic pelvic pain of unknown etiologyChronic pelvic pain of unknown etiology

Neuropathic Pain: Clinical AssessmentNeuropathic Pain: Clinical AssessmentNeuropathic Pain: Clinical AssessmentNeuropathic Pain: Clinical Assessment

• A comprehensive diagnostic approach to A comprehensive diagnostic approach to patients affected by neuropathic painpatients affected by neuropathic pain– Medical historyMedical history

– Examinations: general, neurologic, regional Examinations: general, neurologic, regional

– Diagnostic workup: imaging studies, Diagnostic workup: imaging studies, laboratory tests, nerve/skin biopsies, laboratory tests, nerve/skin biopsies, electromyography/nerve-conduction velocity electromyography/nerve-conduction velocity (EMG-NCV) studies, selected nerve blocks (EMG-NCV) studies, selected nerve blocks

Medical HistoryMedical HistoryMedical HistoryMedical History

Ask patient about complaints suggestive of Ask patient about complaints suggestive of • Neurologic deficits:Neurologic deficits: persistent numbness persistent numbness

in a body area or limb-weakness, for in a body area or limb-weakness, for example, tripping episodes, inability to example, tripping episodes, inability to open jars open jars

• Neurologic sensory dysfunction:Neurologic sensory dysfunction: touch- touch-evoked pain, intermittent abnormal evoked pain, intermittent abnormal sensations, spontaneous burning and sensations, spontaneous burning and shooting painsshooting pains

Neurologic and Regional ExaminationsNeurologic and Regional ExaminationsNeurologic and Regional ExaminationsNeurologic and Regional Examinations

In patients with neuropathic pain, In patients with neuropathic pain, examination should focus on the anatomic examination should focus on the anatomic pattern and localization of the abnormal pattern and localization of the abnormal sensory symptoms and neurologic deficitssensory symptoms and neurologic deficits

Diagnostic Workup: Lab TestsDiagnostic Workup: Lab TestsDiagnostic Workup: Lab TestsDiagnostic Workup: Lab Tests

• Complete blood cell count with differential, Complete blood cell count with differential, erythrocyte sedimentation rate, chemistry profileerythrocyte sedimentation rate, chemistry profile

• Thyroid-function tests, vitamin BThyroid-function tests, vitamin B1212 and folate, and folate, fasting blood sugar, and glycosylated hemoglobinfasting blood sugar, and glycosylated hemoglobin

• Serum protein electrophoresis with immunofixationSerum protein electrophoresis with immunofixation• Lyme titers, hepatitis B and C, HIV screeningLyme titers, hepatitis B and C, HIV screening• Antinuclear antibodies, rheumatoid factor, Antinuclear antibodies, rheumatoid factor,

Sjögren’s titers (SS-A, SS-B), antineutrophil Sjögren’s titers (SS-A, SS-B), antineutrophil cytoplasmic antibodycytoplasmic antibody

Diagnostic Workup: Lab TestsDiagnostic Workup: Lab TestsDiagnostic Workup: Lab TestsDiagnostic Workup: Lab Tests

• CryoglobulinsCryoglobulins

• Antisulfatide antibody titers, anti-HU titersAntisulfatide antibody titers, anti-HU titers

• Heavy metals serum and urine screensHeavy metals serum and urine screens

• Cerebrospinal fluid study for demyelinating Cerebrospinal fluid study for demyelinating diseases and meningeal carcinomatosisdiseases and meningeal carcinomatosis

Diagnostic Workup: Electrophysiologic Diagnostic Workup: Electrophysiologic StudiesStudies

Diagnostic Workup: Electrophysiologic Diagnostic Workup: Electrophysiologic StudiesStudies

EMG-NCV and QSTEMG-NCV and QST

• To localize pain-generator/nerve or root To localize pain-generator/nerve or root lesion lesion

• To rule outTo rule out– Axonal vs focal segmental demyelinationAxonal vs focal segmental demyelination

– Underlying small-fiber or mixed Underlying small-fiber or mixed polyneuropathy polyneuropathy

BiopsiesBiopsiesBiopsiesBiopsies

• Nerve (eg, sural nerve):Nerve (eg, sural nerve): to diagnose to diagnose vasculitis, amyloidosis, sarcoidosis, etc.vasculitis, amyloidosis, sarcoidosis, etc.

• Skin:Skin: to evaluate density of unmyelinated to evaluate density of unmyelinated fibers within dermis and epidermisfibers within dermis and epidermis

Back Pain and Sciatica: Back Pain and Sciatica: Comprehensive AssessmentComprehensive Assessment

Back Pain and Sciatica: Back Pain and Sciatica: Comprehensive AssessmentComprehensive Assessment

• HistoryHistory– MedicalMedical– PsychosocialPsychosocial– FamilyFamily– Previous trialsPrevious trials

• General examinationGeneral examination– MusculoskeletalMusculoskeletal– NeurologicNeurologic

Back Pain and Sciatica:Back Pain and Sciatica:Pain AssessmentPain Assessment

Back Pain and Sciatica:Back Pain and Sciatica:Pain AssessmentPain Assessment

• DescriptionDescription

• DurationDuration

• IntensityIntensity

• Alleviating factors Alleviating factors

• Aggravating factorsAggravating factors

Assessment of Patients With Assessment of Patients With Low Back, Hip, and Leg PainLow Back, Hip, and Leg PainAssessment of Patients With Assessment of Patients With Low Back, Hip, and Leg PainLow Back, Hip, and Leg Pain

• Neurologic examNeurologic exam– DTRs, strength, sensitivity, gaitDTRs, strength, sensitivity, gait

• Regional exam of spine and legRegional exam of spine and leg– Inspection for scoliosis or skin rash, Inspection for scoliosis or skin rash,

palpation for bone tendernesspalpation for bone tenderness

• Sciatic- and femoral-nerve stretching testsSciatic- and femoral-nerve stretching tests– SLR, reverse and contralateral SLR maneuverSLR, reverse and contralateral SLR maneuver

Assessment of Patients With Assessment of Patients With Low Back, Hip, and Leg PainLow Back, Hip, and Leg PainAssessment of Patients With Assessment of Patients With Low Back, Hip, and Leg PainLow Back, Hip, and Leg Pain

• Provocative mechanical joint testsProvocative mechanical joint tests– Truncal flexion for discogenic pain or spine Truncal flexion for discogenic pain or spine

instabilityinstability

– Truncal extension for facet joint diseaseTruncal extension for facet joint disease

– Patrick’s maneuver for hip disease (FABER Patrick’s maneuver for hip disease (FABER test of both hips for SI joint disease) test of both hips for SI joint disease)

Back Pain and Sciatica: Back Pain and Sciatica: Imaging EvaluationImaging Evaluation

Back Pain and Sciatica: Back Pain and Sciatica: Imaging EvaluationImaging Evaluation

• Lumbosacral x-ray studies with flexion/ Lumbosacral x-ray studies with flexion/ extension/oblique viewsextension/oblique views

• MRI of the spineMRI of the spine

• CT with 3-D reconstructionCT with 3-D reconstruction

• CT plus myelographyCT plus myelography

Assessment of Chronic Back Pain and Assessment of Chronic Back Pain and Sciatica: Diagnostic BlocksSciatica: Diagnostic Blocks

Assessment of Chronic Back Pain and Assessment of Chronic Back Pain and Sciatica: Diagnostic BlocksSciatica: Diagnostic Blocks

• Facet blocks to rule out facet joint painFacet blocks to rule out facet joint pain

• Provocative diskograms or disk blockade Provocative diskograms or disk blockade to rule out discogenic pain and pain to rule out discogenic pain and pain associated with segmental spinal associated with segmental spinal instability instability

• Selective root blocks to determine location Selective root blocks to determine location of root pain generator of root pain generator

Assessment of Acute Back PainAssessment of Acute Back Painand Sciatica: “Red Flags”and Sciatica: “Red Flags”

Assessment of Acute Back PainAssessment of Acute Back Painand Sciatica: “Red Flags”and Sciatica: “Red Flags”

• Nighttime pain, fever, Nighttime pain, fever, weight loss, history of weight loss, history of cancercancer

• Fever, IV drug abuseFever, IV drug abuse

• Bladder, bowel Bladder, bowel dysfunction; leg dysfunction; leg weaknessweakness

• TraumaTrauma

• NeoplasmNeoplasm

• Infection (diskitis, Infection (diskitis, epidural abscess)epidural abscess)

• Cauda-equina syndromeCauda-equina syndrome

• Compression FxCompression Fx

History History Possible DiagnosisPossible Diagnosis

Back Pain and SciaticaBack Pain and SciaticaBack Pain and SciaticaBack Pain and Sciatica

MRI of the spine if patient demonstratesMRI of the spine if patient demonstrates

• ““Red flags”Red flags”

• Neurologic deficits or progressive Neurologic deficits or progressive neurologic signs and symptomsneurologic signs and symptoms

• Pain persisting more than 6 wk Pain persisting more than 6 wk

Headache EvaluationHeadache EvaluationHeadache EvaluationHeadache Evaluation

• History (duration, onset, frequency)History (duration, onset, frequency)• Is there a family history of headache?Is there a family history of headache?• Are there any known causes of headache?Are there any known causes of headache?• What is the typical location(s)?What is the typical location(s)?• What does the pain feel like?What does the pain feel like?• What makes it worse?What makes it worse?• What makes it better?What makes it better?• What are the results of past evaluations?What are the results of past evaluations?• Are there associated symptoms? Exam findings?Are there associated symptoms? Exam findings?• What is the patient’s sex?What is the patient’s sex?

Headache: Diagnostic Red FlagsHeadache: Diagnostic Red FlagsHeadache: Diagnostic Red FlagsHeadache: Diagnostic Red Flags

• Rash, meningeal signs, or feverRash, meningeal signs, or fever

• Onset after age 50Onset after age 50

• Onset in a person with HIV or cancerOnset in a person with HIV or cancer

• Abrupt onset Abrupt onset

• Worsening painWorsening pain

• Signs of focal neurologic diseaseSigns of focal neurologic disease