Management of chronic pain in one of the most difficult areas in medicine because of the complexities associated with diagnosis, associated changes in both central and peripheral nervous system (called sensitization) and associated psychological changes.

Pain is defined as chronic when it lasts for more than one month following the usual recovery period of the disease/injury that caused the pain (American pain association), some refers pain lasting for more than 3 months as chronic pain. Chronic sensitization is the universal feature of chronic pain.

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While approaching a patient in pain clinic through history, physical examination and investigations following basic things should be kept in mind

• Red flags – it is very important to rule out serious conditions like fracture, malignancy, infection as the primary cause of pain, as missing these signs may lead to long term morbidity and mortality.

• Symptoms may be more than the signs, i.e. disproportionate to the actual injury there might be more complains.

• Associated psychological changes may increase the difficulty in history and examination.

• There may be no/mild abnormality on imaging (X-RAY, CT, MRI) but persisting pain, or in certain situations there may be some changes in imaging investigations but that are not matching with the patient’s symptoms. Under these situations diagnosis should rely more on patient’s symptoms.(e.g. there may be patients with back pain where MRI imaging is showing thecal indentation by the disc but no radicular pain symptoms.)

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Basic Pain History –

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• History taking in pain patients should include following points in addition to general history taking

• Location – pain may be generalized or localized to certain areas of the body.

• Intensity – VAS and numeric analogue scale are commonly used.

• Nature of pain – Pain is commonly divided in nociceptive, neuropathic and mixed variety. Nociceptive pain is usually in response to a primary disease/injury (thus it works as an alarm) where as neuropathic nature of pain is having certain characters as follows –

• Pain in the area of neuro-deficit.

• Allodynia, Hyperalgesia

• Character of pain: Burning, shooting, electric shock-like, stabbing pain.

• Associated symptoms: Numbness, tingling, pruritus, feeling of pins & needles.

• Common example of primary neuropathic pain is lumbosacral radicular pain, Trigeminal neuralgia etc. All nociceptive pain if continues for prolonged duration it gets some of the neuropathic characters due to chronic sensitization.

• Under certain situations pain may be carried by sympathetic fibers (e.g. - CRPS Type I). Sympathetically mediated pain has characters like redness, edema, painful joint movements, increased/decreased skin temperature, fall of hairs.

• Relation with posture –

•  Certain pain intensity changes with the change of posture of patient. e.g. – Spinal Pain increases on forward bending – discogenic pain, pain of vertebral compression fracture.

• Spinal Pain increases on backward bending - Facet joint arthopathy, Lumbar canal stenosis.

• Pain increases on sitting – SI Joint arthopathy, Discogenic pain.

• Change in intensity in morning / evening - 

• Morning increase in pain is associated in patients with inflammatory arthopathy, planter fasciitis, rheumatoid arthritis etc.

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Assessment of psychological status –

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• Assessment and treatment of psychological status is an important part of patient management which is done in association with a psychologist/ or psychiatrist but simple assessment tools such as PHQ9 may be used for the initial assessment of depression. Depression is commonly associated with chronic pain conditions. In patients of fibromyalgia depression is a part of the disease.

• Physical examination and investigations -

• Apart from general and systemic physical examinations specific tests are to be performed in suspected patients. A general outline for physical examination for specific common pain conditions charted below.

 

 

 

 

 

 

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