Practical Pain Assessment
Session #2Roman D. Jovey, MD
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Learning Objectives1. Describe a practical classification system for pain.2. Discuss the important elements of a pain assessment.3. Understand the advantages of using validated “tools” to gather assessment information.4. Differentiate nociceptive pain vs, neuropthic pain and the presence of central sensitization
Pain– AMultidimensionalPhenomenon
•Painseverityisnotaccountedforsolelybythedegreeofphysiologicalpathology
• Painexperienceisacomplexinteractionamongone’sgenotype,previouslearninghistories,andenvironmental,socioeconomic,cognitive,emotionalandbehaviouralfactors
Biological
Psychological Social
Spiritual
PainAssessment
•ComprehensivePainHistory
• FocusedPhysicalExam
• Investigations
•Makingadiagnosis
90% of the diagnosis of chronic painis in the history and physical exam
Assessing pain is not always straightforward
Functional Brain Imaging in Pain
Borsook D. et al. Molecular Pain 2007; 3:25
f-MRI Changes in chronic pain
Pain Categories by Mechanism
NEUROPATHIC
MIXED
SomaticNOCICEPTIVE(Inflammatory)
Superficial
Visceral
Deep
Central
Peripheral
Other
AshbyMAetal,1992;NicholsonB,2006;BallantyneJC,2003
Pain Classification
• Nociceptive = noxious stimulus or damage outside the nervous system
• Neuropathic = damage within the somatosensory nervous system
LANSS, DN4
“Other” pain syndromes• Not clearly neuropathic• Not clearly nociceptive• May have elements of both• Pain seems out of proportion to the identifiable “damage”
• Pathogenesis uncertain
Central Sensitization Exam
LatremoliereandWoolfe.JPain.2009;10(9)895-926.
DescriptionPatient history Reports of pain that spread beyond the initial
area of injuryPrimary/secondary brush allodynia
Painful response to lightly brushing the skin inside the initial area of injury (primary) or outside of the area of injury (secondary)
Temporal summation with wind up
Repeated painful stimuli, like a pinprick (usually tested as 1 per second for 10 seconds) results in an augmented pain response so that following repetitive pinpricks the intensity of the pain rating at the end is graded much higher than a single stimulus
After pain Describes the sensation when, after the pinprick is removed, patients continue to feel as if the pin is still in their skin
Mechanistic Characterization of Pain
Peripheral(nociceptive)
■ Inflammation or mechanical damage in tissues
■ Classic examples■ Acute pain due to
injury■ Osteoarthritis■ Rheumatoid arthritis■ Cancer pain
Peripheral Neuropathic
■ Damage or dysfunction of peripheral nerves
■ Classic examples■ Diabetic neuropathic
pain■ Post-herpetic
neuralgia
Centralized Pain
■ Characterized by central disturbance in pain processing (diffuse hyperalgesia/allodynia)
■ Classic examples■ Fibromyalgia■ Irritable bowel
syndrome■ TMJD■ Tension headache
Clauw IASP 2016
Centralization Continuum
Peripheral Centralized
Acute pain Osteoarthritis SC disease Fibromyalgia RA Ehler’s Danlos Tension HA
Low back pain TMJD IBS
Clauw IASP 2016
Mechanisms of CNCP
Nociceptive = noxious stimulus or damage outside the nervous system
Neuropathic = damage (or dysfunction) within the nervous system
Centralized = dysfunction in the CNS or in descending inhibitory pathways
Classification of Pain by Primary Mechanism
Phillips, K and Clauw, D Best Practice & Research Clinical Rheumatology 25 (2011) 141–154.
NociceptiveInflammation or
mechanical damage in tissues
“Centralized” Pain
Characterized by central disturbance in
pain processing (diffuse
hyperalgesia/allodynia)
Neuropathic
Damage or dysfunction of
peripheral nerves
Any combination of mechanisms may be
present in a patient with CNCP
Initial Assessment of Pain: Goals• What is the severity?• What is the mechanism? Central sensitization?• Is there a treatable uinderlying cause?• Are there “red flags” for serious illness?• What are the psychosocial contributing factors?• Is there an addiction/misuse risk? • What is the impact on the patient’s functioning?
Elements of a Comprehensive Pain Assessment
1. Current pain descriptions (including pain scoring)2. Previous pain history (including treatments & results)3. Other concurrent medical / psych problems4. Current treatments, effectiveness and side effects5. Psychosocial factors (family, work, income,
relationships, catastrophizing, perceived injustice)6. Addiction/misuse risk 7. Current functioning (sleep, weight, mood, libido)8.Patient’s beliefs and expectations9.Physical exam10.Investigations
Pain Description - OPQRST
• O- Onset and evolution.
• P – Pattern, location, timing, ie constant or intermittent. Does it radiate?
• Q – Quality of pain – What is the nature of the pain, i.e. sharp, shooting, aching, etc.?
• R – Relieving / exacerbating factors. What makes it better or worse? Does it change with activities / position, anxiety, stress?
• S – Severity on a 0-10 scale (Worst, least, average)
• T – Timing – Is the onset sudden or gradual? How often does it occur and how long does it last? Does it usually occur at a particular time of day?
Ellen• 67 year old female• Progressive pain and stiffness left knee over 4 years• Stopped hiking and cycling• Gets stiffness after inactivity• Difficulty climbing stairs• Getting leg weakness - fell once• Uses cane (reluctantly) at times• Bilateral aching, burning neck and shoulder pain
getting worse• “Too much bother to get out much”
Ellen• Hypertension - on diuretic + ACE inhibitor• Type 2 diabetes - on Metformin• Depression - stable on SSRI• Remote “stomach ulcer”; no GI bleed• No family history arthritis• Liver function normal; Renal function: eGFR 65• No benefit to date from
– Acetaminophen 4000 mg/d– OTC Ibuprofen 200mg 2-3 / day– Heat, ice, liniments
Brief Pain Inventory – BPI
Brief Pain Inventory (Short Form) - Modified
Name _________________________________________ Date __________________________________ On the diagram below, shade in the areas where you feel pain. Put an “X” on the areas where it hurts the most. (S=sharp/stabbing, B=burning, N=numbness, P=pins and needles, A=aching, Arrows = shooting pain. Use colours if you have more than one type of pain)
What things make your pain feel worse ? What things make your pain feel better? What treatments or medications are you currently receiving for your pain:
Ellen Dec 1, 2015
X X XA/S
Acetaminophen 1000 mg 4 times per day Glucosamine 500 mg three times per dayIbuprofen 200 mg 2-3 times per day
walking, kneeling, stairs
Ibuprofen, heat, rest, massage
No GI S/E
Denies N, P
A A
XX
Brief Pain Inventory – BPIPlease rate your pain by circling the one number that best describes your pain at its WORST in the past
24 hours. Worst pain
No 0 1 2 3 4 5 6 7 8 9 10 you can pain imagine
Please rate your pain by circling the one number that best describes your pain at its LEAST in the past 24 hours. Worst pain
No 0 1 2 3 4 5 6 7 8 9 10 you can pain imagine
Please rate your pain by circling the one number that best describes your pain on the AVERAGE.
Worst pain No 0 1 2 3 4 5 6 7 8 9 10 you can pain imagine
Please rate your pain by circling the one number that tells how much pain you have RIGHT NOW.
Worst pain No 0 1 2 3 4 5 6 7 8 9 10 you can pain imagine
In the last 24 hours, how much relief have your pain treatments or medications provided? Please circle the one percentage that shows most how much RELIEF you have received.
No relief 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Complete relief
Circle the one number that describes how, during the past 24 hours, pain has interfered with your:
A. General Activity: Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes
B. Mood:
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes C. Walking Ability:
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes
D. Normal Work (includes both work outside the home and housework)
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes E. Relations with other people:
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes F. Sleep:
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes G. Enjoyment of Life:
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes
With permission: Pain Research Group
MD Anderson Cancer Center, 1997
Brief Pain Inventory – BPIPlease rate your pain by circling the one number that best describes your pain at its WORST in the past
24 hours. Worst pain
No 0 1 2 3 4 5 6 7 8 9 10 you can pain imagine
Please rate your pain by circling the one number that best describes your pain at its LEAST in the past 24 hours. Worst pain
No 0 1 2 3 4 5 6 7 8 9 10 you can pain imagine
Please rate your pain by circling the one number that best describes your pain on the AVERAGE.
Worst pain No 0 1 2 3 4 5 6 7 8 9 10 you can pain imagine
Please rate your pain by circling the one number that tells how much pain you have RIGHT NOW.
Worst pain No 0 1 2 3 4 5 6 7 8 9 10 you can pain imagine
In the last 24 hours, how much relief have your pain treatments or medications provided? Please circle the one percentage that shows most how much RELIEF you have received.
No relief 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Complete relief
Circle the one number that describes how, during the past 24 hours, pain has interfered with your:
A. General Activity: Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes
B. Mood:
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes C. Walking Ability:
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes
D. Normal Work (includes both work outside the home and housework)
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes E. Relations with other people:
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes F. Sleep:
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes G. Enjoyment of Life:
Does not interfere 0 1 2 3 4 5 6 7 8 9 10 Completely interferes
With permission: Pain Research Group
MD Anderson Cancer Center, 1997
42/70
6.0
Is there a neuropathic component to Ellen’s pain?
or(Is there any evidence for central
sensitization?)
Neuropathic pain often has both positive and negative symptoms
Positive sensory symptoms Negative sensory symptomsBurning sensation Reduced or absent touch perception
Stabbing sensations Reduced or absent pain perception
Squeezing or band-like sensations Instability
Neuropathic pain or allodynia(pain with fabric brushing skin)
Motor symptoms: weakness
NeuropathicPainScreeningTools
•LANSS
•DN4
• NPQ
•PainDETECT
•IDPain
s-LANSS
s-LANSS
12
s-LANSS
What else do we want to document before creating a
treatment plan?
FunctionalAssessment
•Functionalassessmentispatientspecific– Whatcans/heNOTdobecauseofpain?
•Work,school,hobby,social,interpersonal…
•Allowsforfunctionalgoals– Arethefunctionalgoalsreasonable?
• Trackstreatmentgoals– Similartodyslipidemia,diabetes…
How do we measure function / QOL?
• Tools– BPI-I, PDI , Roland Morris Scale, SF12v2,
• Patient self-report– a day in the life…, employment, household activities
• Significant other’s report (same or different?)
• Formal functional testing–“Up & Go” test, grip strength, walk 1 min test, FAEs
Younger J. Curr Pain Headache Rep 2009; 13(1):39-43Chen J. Iowa Ortho Jour 2007; 27: 121-7
Wittink H. Clin J Pain 2005; 21(3):197-199
FunctionalStatusinOlderPersons
Maintenance of independent function and living is critically important to older people and a major goal of
care
BPI-Interference or Pain Disability Index
38 / 70
5.4 / 7
Pain Assessment - Examination
Physical Examination - Pain
• Observe posture, gait, pain behaviours• Tenderness, trigger points• Focused MSK neurological exam
– signs of neuropathic pain
• Disuse atrophy / weakness / stiffness
MSK Focus CourseDr. Julia Alleyne
University of Toronto
www.mskcourses.net
Youtube MSK Exam videos:Rheum boyVia ChristiOxford Medical Videos
Examining for Neuropathic Pain
Tools for a NeP Exam• brush• pin or sharp toothpick• reflex hammer• 256Hz tuning fork• hot and cold water
https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=3546
Ellen• Physical Exam:
– BMI 29, BP 135/90– General & neurologic exam
normal– Myofascial TrPts neck and
shoulder girdle and left knee periarticular tissues + brush allodynia L upper leg
– Antalgic gait– Decreased L knee ROM
with marginal osteophytes– Quadriceps wasting
Myofascial Trigger Points
…are hyperirritable spots in the fascia surrounding skeletal muscle. They are associated with palpable nodules in taut bands of muscle fibers.
Travell & Simons. Myofascial Pain. The Trigger Point Manual, 1998
Copeland. Fibromyalgia and Chronic Myofascial Pain. 2001
1. DeLune V. Treating trigger points reduces pain from knee osteoarthritis . Available from: http://www.positivehealth.com/article/bodywork/treating-trigger-points-reduces-pain-from-knee-osteoarthritis.
Trigger points referring to the anterior knee
Trigger point referral to posterior knee
46
Gastrocnemius trigger points
Hamstring trigger points
“The continuous input from nociceptive afferents can drive the spinal circuits, leading to neuronal reorganization and sensitization, and maintain a chronic pain state.”“Proper management of MTPs may prevent and reverse the development of pain propagation in chronic pain conditions due to the dampening down of the afferent nociceptive barrage”
Myofascial Pain is not Typically Opioid Responsive and can Cause Central Sensitization if Untreated
• Spray and stretch• Trigger point injections
• Dry needling• Acupuncture
• Gunn technique• Exercise• Yoga
• Postural corrections
Resources to Learn about Trigger Points
www.triggerpoints.net
www.ihe.ca/research-programs/hta/aagap/lbp
https://thewellhealth.ca/low-back-pain/
What about “tests” in people with chronic pain?
Investigations in CNCP• 90% of the diagnosis is in the Hx & P/E• Most investigations only confirm clinical suspicions• Sometimes useful in finding treatable underlying
diseases– DM, B12 deficiency, Rheumatoid Arthritis, CT Diseases
• Lack of sensitivity of current diagnostic studies– Z-joint pathology in chronic whiplash pain
• Potential for harm from overcalling imaging studies– “bulging disks” “arthritis in the spine” “degenerative disks”
“Knee pain is an imprecise marker of radiographic knee osteoarthritis but this depends on the extent of radiographic views used. Radiographic knee osteoarthritis is likewise an imprecise
guide to the likelihood that knee pain or disability will be present.”
Imaging tests for lower back pain: when you need them– and when you
don't
Released April 2, 2014
• A history of cancer• Unexplained weight loss• Fever• Recent infection• Loss of bowel control• Abnormal reflexes or loss of muscle power or
feeling in the legs
www.choosingwiselycanada.org/materials/imaging-tests-for-lower-back-pain-when-you-need-them-and-when-you-dont/
CORE Imaging Criteria
James:X-rays: mild-moderate degenerative changes lumbar spineMRI: mild-mod DDD at multiple levels –worse in lower levels, no stenosis or nerve-root impingement
“…scans show structure,patients report pain –
they are not the same.”
Jon Norman, BMJ, 2005
Summary• A simple mechanistic classification of chronic pain
includes: nociceptive and neuropathic • Central sensitization can affect all types of pain and
requires a different treatment approach • Using standard tools can help to make the pain
assessment more thorough and time efficient– CORE Tool for back pain
• Obtaining baseline function is important to assess future outcomes of treatment
• Look for myofascial trigger points in neck / back and knee pain
Questions?