Evaluation of chronic pain in adults
- Ellen WK Rosenquist, MD
Ellen WK Rosenquist, MD
- Section Editor — Acute and Chronic Pain
- Assistant Professor of Anesthesiology
- Department of Pain Management
- Cleveland Clinic Foundation
Chronic pain affects more than 100 million people in the United States [1,2] and accounts for 20 percent of outpatient visits, 12 percent of all prescriptions, and over 100 billion dollars in direct and indirect expenses . Pain-related expenditures (direct costs and lost wages) in the United States exceed those for cancer, heart disease, and diabetes combined . The use and misuse of opioids for management of chronic pain is a major concern, with problems arising from their multiple adverse side effects including drug dependency, from drug diversion, and from under-treatment of chronic pain symptoms for fear of opioid abuse. Chronic pain is thus a major medical and social issue, affecting the quality of life of individual patients, their friends and families, the work force, and society in general.
A comprehensive pain evaluation is essential to developing an effective plan for treatment. Although there are unique aspects to every individual's pain complaints, there are many common elements to the pain evaluation, irrespective of the pain complaint. An appropriate history and physical examination are vital to a proper evaluation. Laboratory studies, imaging, and other diagnostic testing may be appropriate in selected situations.
The evaluation of patients complaining of persistent pain is discussed here. The classification of chronic pain and overview of its treatment are discussed separately. (See "Overview of the treatment of chronic non-cancer pain".)
COMMON CAUSES OF CHRONIC PAIN
Although pain is one of the most common presenting symptoms to the primary care clinician, only a percentage of patients ultimately develop a chronic pain syndrome. In a study based on a survey of representative population in the United States from 1999 to 2002 (the National Health and Nutrition Examination Survey, NHANES), chronic pain (defined as >three months of pain) was reported as follows: back pain 10.1 percent, leg/foot pain 7.1 percent, arm/hand pain 4.1 percent, headache 3.5 percent, chronic regional pain 11.1 percent, widespread pain 3.6 percent; the majority of patients who reported chronic pain reported more than one type of pain .
Chronic pain can be considered to be in one of four categories. Identifying which of these categories the patient falls into is helpful in designing an appropriate treatment plan, although multifactorial causes of chronic pain are not uncommon. These pain categories can be considered to be :To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Available at http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx (Accessed on January 02, 2013).
- Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J Pain 2015; 16:769.
- Alford DP, Krebs EE, Chen IA, et al. Update in pain medicine. J Gen Intern Med 2010; 25:1222.
- Pizzo PA, Clark NM. Alleviating suffering 101--pain relief in the United States. N Engl J Med 2012; 366:197.
- Hardt J, Jacobsen C, Goldberg J, et al. Prevalence of chronic pain in a representative sample in the United States. Pain Med 2008; 9:803.
- Institute for Clinical Systems Improvement. Health care guideline: Assessment and management of chronic pain. Fourth edition November 2009. http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/pain__chronic__assessment_and_management_of__guideline_.html (Accessed on December 09, 2010).
- Lorenz KA, Sherbourne CD, Shugarman LR, et al. How reliable is pain as the fifth vital sign? J Am Board Fam Med 2009; 22:291.
- Keller S, Bann CM, Dodd SL, et al. Validity of the brief pain inventory for use in documenting the outcomes of patients with noncancer pain. Clin J Pain 2004; 20:309.
- Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore 1994; 23:129.
- Dworkin RH, Turk DC, Revicki DA, et al. Development and initial validation of an expanded and revised version of the Short-form McGill Pain Questionnaire (SF-MPQ-2). Pain 2009; 144:35.
- Galer BS, Jensen MP. Development and preliminary validation of a pain measure specific to neuropathic pain: the Neuropathic Pain Scale. Neurology 1997; 48:332.
- Lynch ME, Clark AJ, Sawynok J. Intravenous adenosine alleviates neuropathic pain: a double blind placebo controlled crossover trial using an enriched enrolment design. Pain 2003; 103:111.
- Jensen MP, Dworkin RH, Gammaitoni AR, et al. Assessment of pain quality in chronic neuropathic and nociceptive pain clinical trials with the Neuropathic Pain Scale. J Pain 2005; 6:98.
- Bennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs. Pain 2001; 92:147.
- Bouhassira D, Attal N, Alchaar H, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 2005; 114:29.
- Okifuji A, Ackerlind S. Behavioral medicine approaches to pain. Med Clin North Am 2007; 91:45.
- Institute of Medicine. Relieving pain in America: A blueprint for transforming prevention, care, education, and research (2011) http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx (Accessed on April 29, 2013).
- Annagür BB, Uguz F, Apiliogullari S, et al. Psychiatric disorders and association with quality of sleep and quality of life in patients with chronic pain: a SCID-based study. Pain Med 2014; 15:772.
- Price DD. Psychological and neural mechanisms of the affective dimension of pain. Science 2000; 288:1769.
- Closs SJ, Briggs M. Patients' verbal descriptions of pain and discomfort following orthopaedic surgery. Int J Nurs Stud 2002; 39:563.
- Clark L, Jones K, Pennington K. Pain assessment practices with nursing home residents. West J Nurs Res 2004; 26:733.
- Hathaway SR, McKinly JC. The Minnesota multiphasic personality inventory manual, Psychological Corporation, New York 1967.
- Long CJ. The relationship between surgical outcome and MMPI profiles in chronic pain patients. J Clin Psychol 1981; 37:744.
- BECK AT, WARD CH, MENDELSON M, et al. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:561.
- Hadjistavropoulos T, Herr K, Turk DC, et al. An interdisciplinary expert consensus statement on assessment of pain in older persons. Clin J Pain 2007; 23:S1.
- AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc 2002; 50:S205.
- Feldt KS, Ryden MB, Miles S. Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture. J Am Geriatr Soc 1998; 46:1079.
- Bruckenthal P. Assessment of pain in the elderly adult. Clin Geriatr Med 2008; 24:213.
- Nahin RL, Fitzpatrick AL, Williamson JD, et al. Use of herbal medicine and other dietary supplements in community-dwelling older people: Baseline data from the ginkgo evaluation of memory study. J Am Geriatr Soc 2006; 54:1725.
- Corran, TM, GIbson, et al. Comparison of chronic pain experience between younger and elderly patients. In: Proceedings of the 7th World Congress on Pain, Progress in Pain Research and Management, Gebhart, GF, Hammond, DL, Jenson, TS (Eds), IASP Press, Seattle 1994. Vol 2, p.895.
- McCraken, LM. Age, pain, and impairment: Results from two clinical samples. In: Abstracts: 7th World Congress on Pain, IASP Press, Seattle 1993. p.99.
- Kaasalainen S, Coker E, Dolovich L, et al. Pain management decision making among long-term care physicians and nurses. West J Nurs Res 2007; 29:561.
- AMDA. Clinical practice guideline: Pain management (revised 2009). www.amda.com/tools/cpg/chronicpain.cfm.
- Herr K, Coyne PJ, Key T, et al. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Manag Nurs 2006; 7:44.
- Bjoro K, Herr K. Assessment of pain in the nonverbal or cognitively impaired older adult. Clin Geriatr Med 2008; 24:237.
- Herr K, Bjoro K, Decker S. Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review. J Pain Symptom Manage 2006; 31:170.
- Hadjistavropoulos T. Assessing pain in older persons with severe limitations in ability to communicate. In: Pain in Older Persons, Gibson SJ, Weiner DK (Eds), IASP Press, Seattle 2005. p.135.
- Stolee P, Hillier LM, Esbaugh J, et al. Instruments for the assessment of pain in older persons with cognitive impairment. J Am Geriatr Soc 2005; 53:319.
- Zwakhalen SM, Hamers JP, Abu-Saad HH, Berger MP. Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatr 2006; 6:3.
- van Herk R, van Dijk M, Baar FP, et al. Observation scales for pain assessment in older adults with cognitive impairments or communication difficulties. Nurs Res 2007; 56:34.
- Feldt KS. The checklist of nonverbal pain indicators (CNPI). Pain Manag Nurs 2000; 1:13.
- Lefebvre-Chapiro S. The Doloplus 2 scale - evaluating pain in the elderly. Eur J Palliat Care 2001; 8:191.
- Fuchs-Lacelle S, Hadjistavropoulos T. Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Manag Nurs 2004; 5:37.
- American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc 2009; 57:1331.
- Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc 2003; 4:9.
- Payen JF, Bru O, Bosson JL, et al. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 2001; 29:2258.
- Gélinas C, Fillion L, Puntillo KA, et al. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care 2006; 15:420.
- COMMON CAUSES OF CHRONIC PAIN
- Pain characteristics
- Associated symptoms
- Pain impact
- - Activities of daily living
- Pain intensity scales
- Previous evaluation and/or treatment
- Patient perceptions and psychological factors
- PHYSICAL EXAMINATION
- DIAGNOSTIC TESTING
- Blood tests
- Other testing
- REFERRAL TO A PAIN SPECIALIST
- SPECIAL CONSIDERATIONS IN SPECIFIC POPULATIONS
- Psychiatric comorbidity
- Older adults
- - Medication history
- - Functional assessment
- - Psychosocial assessment
- - Beliefs and attitudes about pain
- - Long-term care facilities
- Nonverbal or cognitively impaired adults
- INFORMATION FOR PATIENTS