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.
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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)
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Precipitating factors - Ask questions about factors that provoke or intensify pain; this information may provide clues concerning possible etiologies or associated disorders
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Alleviating factors - Ask the patient if any factors help to alleviate the pain; for example, rest may decrease pain of musculoskeletal origin
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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
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Radiation of pain - Ask the patient if the pain spreads or radiates; spreading or radiating pain is a characteristic of neuropathic pain
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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. [18]
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. [19]
Obtain history specific to the following systems and related disorders:
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Musculoskeletal
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Neurologic
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Gynecologic and obstetric
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Urologic
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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. [20]
A report by Nygaard et al on women with chronic pelvic pain found that those patients in the study who had been subject to abuse had a greater tendency toward analgesic use, obstructed defecation syndrome, anxiety, and subjective health complaints. [21]
Sternbach's 6 D 's of CPS are as follows:
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Dramatization of complaints
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Drug misuse
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Dysfunction/disuse
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Dependency
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Depression
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Disability
A literature review by Ravat et al indicated that in persons with chronic pain—specifically, complex regional pain syndrome type 1, upper limb pain, hand and wrist pain, carpal tunnel syndrome, facial pain, knee osteoarthritis, or leg pain—laterality judgement is impaired. [22]
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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Sagittal magnetic resonance imaging (MRI) scan of the cervical spine in a patient with cervical radiculopathy. This image reveals a C6-C7 herniated nucleus pulposus.
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Axial magnetic resonance imaging (MRI) scan of the cervical spine in a patient with cervical radiculopathy. This image reveals a C6-C7 herniated nucleus pulposus.
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Osteoarthritis of the knee, Kellgren stage III.
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Nerve irritation in the herniated disk occurs at the root (sciatic radiculitis). In piriformis syndrome, the irritation extends to the full thickness of the nerve (sciatic neuritis).
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Changes in the hand caused by rheumatoid arthritis. Photograph by David Effron MD, FACEP.
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Oblique view of the cervical spine demonstrates 2 levels of foraminal stenosis (white arrows) resulting from facet hypertrophy (yellow arrow) and uncovertebral joint hypertrophy.
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T1-weighted sagittal magnetic resonance imaging (MRI) scan of the cervical spine in a patient with rheumatoid arthritis shows basilar invagination with cranial migration of an eroded odontoid peg. There is minimal pannus. The tip of the peg indents the medulla, and there is narrowing of the foramen magnum, due to the presence of the peg. Inflammatory fusion of several cervical vertebral bodies is shown.
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Schematic anatomical representations, sympathetic chain and stellate ganglion.
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Stellate block, important anatomical landmarks (surface and cross-sectional views).
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Pertinent anatomy for lumbar sympathetic block (cross-sectional view).
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Severe colitis noted during colonoscopy. The mucosa is grossly denuded, with active bleeding noted. This patient had her colon resected very shortly after this view was obtained.
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Active endometriosis with red and powder-burn lesions; adhesions from old scarring are present.
