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Chronic Pain Syndrome Clinical Presentation

  • Author: Manish K Singh, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
 
Updated: May 13, 2016
 

History

Because of the complex etiology and the frequent presence of associated disorders, a general and open-minded approach to the assessment of the patient is needed. Obtaining the history of patients whose symptoms suggest chronic pain syndrome (CPS) is important. A thorough history is necessary for the physician to direct further evaluation and appropriate consultations and to avoid repeating invasive and expensive procedures.

A detailed review of the musculoskeletal, reproductive, GI, urologic, and neuropsychological systems must be obtained. As needed, specific questions should be asked of particular patients, depending on their associated disorders.

Focus the history on a characterization of the patient's pain. Obtaining the characteristics of the pain helps to establish appropriate diagnostic and therapeutic plans.

  • Pain location - The location of pain is an important part of the history; ask the patient to describe the type of pain and the location on a pain diagram (anterior/posterior and lateral view of human picture)
  • Precipitating factors - Ask questions about factors that provoke or intensify pain; this information may provide clues concerning possible etiologies or associated disorders
  • Alleviating factors - Ask the patient if any factors help to alleviate the pain; for example, rest may decrease pain of musculoskeletal origin
  • Quality of pain - Ask the patient to describe the quality of pain; various terms can be used to describe the quality of pain, including throbbing, pounding, shooting, pricking, boring, stabbing, lancinating, sharp, cutting, lacerating, pressing, cramping, crushing, pulling, pinching, stinging, burning, splitting, penetrating, piercing, squeezing, and dull aching
  • Radiation of pain - Ask the patient if the pain spreads or radiates; spreading or radiating pain is a characteristic of neuropathic pain
  • Severity or intensity of pain - Use some type of rating system to evaluate pain severity or intensity with a degree of objectivity and reproducibility; different types of pain scales may be used, with numerical scales being more useful and reliable (the visual analog scale [VAS] is one of the commonly used numerical scales)

The Pain Sensitivity Questionnaire can be used to measure general pain perception (pain perception outside the clinical pain site) in patients with chronic pain.[14]

A 2012 meta-analysis indicates that athletes exhibit higher pain tolerance than normally active subjects, suggesting that regular physical activity is associated with alterations in the perception of pain.[15]

Obtain history specific to the following systems and related disorders:

  • Musculoskeletal
  • Neurologic
  • Gynecologic and obstetric
  • Urologic
  • GI

In addition, a good psychosocial or psychosexual history is needed when organic diseases are excluded or coexisting psychiatric disorders are suggested. Obtain sufficient history to evaluate depression; anxiety disorder; somatization; physical or sexual abuse; drug abuse/dependence; and family, marital, or sexual problems. Somatization is a commonly associated psychologic disorder in women with chronic pain. Somatization scales can be used for evaluation.[16]

Sternbach's 6 D 's of CPS are as follows:

  • Dramatization of complaints
  • Drug misuse
  • Dysfunction/disuse
  • Dependency
  • Depression
  • Disability
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Physical

Good rapport, tolerance, and an open-minded approach are important when evaluating any patient with chronic pain. A thorough systematic examination usually leads to an appropriate diagnosis and therapy. Patients often have Waddell signs. The disability is usually out of proportion to the impairment and the objective findings.

A patient with chronic pain syndrome (CPS) may exhibit exaggerated pain behavior. Sensations may seem to be hysterical or appear nonanatomic or nonphysiologic, but the patient always should be taken seriously and appropriate conservative steps should be taken.

Detailed examination of the musculoskeletal system is important. Examination of various other systems (eg, GI, urologic, neurologic) also should be performed.

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Contributor Information and Disclosures
Author

Manish K Singh, MD Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience

Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Headache Society, American Association of Physicians of Indian Origin, American Medical Association, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jashvant Patel, MBBS, MS, MD 

Jashvant Patel, MBBS, MS, MD is a member of the following medical societies: Alberta Medical Association, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Society of Regional Anesthesia and Pain Medicine, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Rollin McCulloch Gallagher, MD, MPH Clinical Professor, Departments of Psychiatry and Anesthesiology, Director for Health Policy and Primary Care, Penn Pain Medicine, University of Pennsylvania School of Medicine; National Program Director for Pain Management, Veterans Health Administration; Editor-in-Chief, PAIN MEDICINE

Rollin McCulloch Gallagher, MD, MPH is a member of the following medical societies: Academy of Psychosomatic Medicine, American Academy of Pain Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Milton J Klein, DO, MBA Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital and Ohio Valley General Hospital

Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Martin K Childers, DO, PhD Professor, Department of Neurology, Wake Forest University School of Medicine; Professor, Rehabilitation Program, Institute for Regenerative Medicine, Wake Forest Baptist Medical Center

Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology

Disclosure: Allergan pharma Consulting fee Consulting

Richard Salcido, MD Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine

Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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