3 Pain: Underreported, Underdiagnosed and Undertreated Ongoing pain has been underreported, underdiagnosed, and undertreated in nearly all health care settingsIndividuals with pain that reduces quality of life should be encouraged to seek helpComprehensive assessment and treatments likely to produce best resultsSpeaker’s NotesOngoing pain has been underreported, underdiagnosed and undertreated in nearly all health care settings. Individuals with pain that reduces quality of life should be encouraged to seek help.Because there are multiple contributors to and broad effects of chronic pain, comprehensive assessment and treatment are like to produce the best results.ReferenceInstitute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. The National Academies Press; Washington, DC: 2011.Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. The National Academies Press; Washington, DC: 2011.
4 Importance of Pain Assessment Pain is a significant predictor of morbidity and mortality.Screen for red flags requiring immediate investigation and/or referralIdentify underlying causePain is better managed if the underlying causes are determined and addressedRecognize type of pain to help guide selection of appropriate therapies for treatment of painDetermine baseline pain intensity to future enable assessment of efficacy of treatmentSpeaker’s NotesAppropriate assessment of patients presenting with pain is crucial in order to determine whether they are suffering from a condition that requires immediate management or referral. It can also help ensure optimal treatment of pain through identification of the underlying cause of the pain and recognition of the pathophysiologic mechanism behind the pain, which can help guide treatment selection. Finally, determining baseline pain intensity enables future assessment of treatment efficacy in order to guide titration and modification of the analgesic regimen.ReferencesForde G, Stanos S. Practical management strategies for the chronic pain patient. J Fam Pract 2007; 56(8 Suppl Hot Topics):S21-30.Sokka T, Pincus T. Pain as a Significant Predictor of Premature Mortality over 5 Years in the General Population, Independent of Age, Sex and Acutely Life-Threatening Diseases. Poster presentation at ACR 2005.Forde G, Stanos S. J Fam Pract 2007; 56(8 Suppl Hot Topics):S21-30; Sokka T, Pincus T. Poster presentation at ACR 2005.
5 Comprehensive Pain Assessment Assess effects of pain on patient’s functionCharacterize painlocation, distribution, duration, frequency, quality, precipitantsComplete risk assessmentTake detailed history (e.g., comorbidities, prior treatment)Clarify etiology, pathophysiologySpeaker’s NotesFor patients with chronic pain comprehensive assessment is essential.A comprehensive pain assessment has multiple components, including:Complete pain assessment of location, duration, frequency, quality, etc.Complete medication historyPhysical examAssessment of patient functionRisk assessmentMedical clarification of comorbidities, possible pain sources and aberrant painReferencesNational Pharmaceutical Council, Joint Commission on Accreditation on Healthcare Organizations. Pain: Current Understanding of Assessment, Management, and Treatments. Reston, VA: 2001.Passik SD, Kirsh KL. Opioid therapy in patients with a history of substance abuse. CNS Drugs 2004; 18(1):13-25.Conduct physical examinationNational Pharmaceutical Council, Joint Commission on Accreditation of Healthcare Organizations. Pain: Current Understanding of Assessment, Management, and Treatments. Reston, VA: 2001; Passik SD, Kirsh KL CNS Drug 2004; 18(1):13-25.
6 Nociceptive vs. Neuropathic Pain DefinitionPain caused by physiological activation of pain receptorsPain initiated or caused by a primary lesion or dysfunction in the peripheral or central somatosensory nervous systemMechanismNatural physiological transductionEctopic impulse generation, central sensitization, and othersLocalizationLocal + referred painConfined to innervation territory of the lesioned somatosensory nervous structureQuality of symptomsOrdinary painful sensationNew strange sensationsTreatmentGood response (conventional analgesics)Poor response (conventional analgesics)Speaker’s NotesThe characteristics of nociceptive and neuropathic pain are listed on the slide.In order to direct treatment appropriately, it is important to distinguish between the types of pain in each patient, bearing in mind that both types may co-exist in some instances.ReferenceSerra J. In: Serra J (ed). Tratado del dolor neuropático. Panamericana; Madrid, Spain: 2006.Serra J. In: Serra J (ed). Tratado del dolor neuropático. Panamericana; Madrid, Spain: 2006.
7 Nociceptive Pain Visceral Somatic Trauma Musculoskeletal injury Ischemic, e.g., myocardial infarctionAbdominal colicSpeaker’s Note:In our daily life there are many forms of acute pain, such as “somatic pain” of musculoskeletal origin due to sports injury /trauma, burn, incision (such as in post-operative pain) or infectious diseases (such as in pharyngitis, otitis, etc.).It may also be a “visceral pain” due to vascular occlusion such as in myocardial ischemia, visceral nociceptive/inflammatory pain due to stretching, hypoxia or inflammation of the hollow organs such as in abdominal colic, dysmenorrhea, etc. Trigeminal or C2-C3 nerve root irritation may lead to neurovascular inflammation in acute episodic headaches such as migraine.ReferenceFishman SM et al (eds). Bonica’s Management of Pain. 4th ed. Lippincott, Williams and Wilkins; Philadelphia, PA: 2010.Post-operative painBurn painInfection, e.g., pharyngitisDysmenorrheaFishman SM et al (eds). Bonica’s Management of Pain. 4th ed. Lippincott, Williams and Wilkins; Philadelphia, PA: 2010.
8 Recognizing Neuropathic Pain Post-stroke painPostherpetic neuralgiaDiabetic peripheral neuropathyCommon descriptorsShootingElectric shock-likeBurningTinglingNumbnessSpeaker’s NotesNeuropathic pain has been defined as “Pain caused by a lesion or disease of the somatosensory nervous system”. It can originate from the peripheral or central somatosensensory systems.Causes of peripheral neuropathic pain include diabetic peripheral neuropathic pain, human immunodeficiency virus (HIV)-induced neuropathic pain, post-surgical and post-traumatic nerve injury, postherpetic neuralgia and radiculopathies.Post-stroke pain, multiple sclerosis and spinal cord injuries are all examples of central neuropathic pain.Neuropathic pain is frequently described as a ‘shooting’, ‘electric shock-like’ or burning’ pain, commonly associated with ‘tingling’ and/or ‘numbness’.The painful region may not necessarily be the same as the site of injury (see lumbar radicular pain image). Pain occurs in the neurological territory of the affected structure (nerve, root, spinal cord, brain). In peripheral neuropathic pain, it is in the territory of the affected nerve or nerve root. In central neuropathic pain, it is related to the site of the lesion in the spinal cord or brain.ReferenceBaron R et al. Neuropathic pain: diagnosis, pathophysiological mechanisms, and treatment. Lancet Neurol 2010; 9(8):Chronic post-surgical painLumbar radicular pain1. Baron R et al. Lancet Neurol 2010; 9(8):
10 Pain History Location/distribution Onset Frequency/variation Intensity TypeAggravating and relieving factorsImpairment and disabilityPrevious pain treatmentsOther conditions/treatmentsResponse to treatmentMeaning of painSpeaker’s NotesA pain history should include questions that lead to a thorough understanding of the nature of the pain.ReferencesFerrell BA. Pain evaluation and management in the nursing home. Arch Intern Med 1995; 123(9):681-7.Haefeli M, Elfering A. Pain assessment. Eur Spin J 2006; 15(Suppl 1):S17-24.Ferrell BA. Arch Intern Med 1995; 123(9):681-7; Haefeli M, Elfering A. Eur Spin J 2006; 15(Suppl 1):S17-24.
11 Pain History Worksheet Site of painWhat causes or worsens the pain?Intensity and character of painAssociated symptoms?Pain-related impairment in functioning?Relevant medical historySpeaker’s NotesA pain history and examination worksheet can be used to gather a pain history. Patients can use such a worksheet to record their pain and functional impairment. Most worksheets will include pictures of the human body (front and back) on which patients can mark the areas where they feel pain. Worksheets will cover various aspects of pain, such as:Site of painWhat causes or worsens the pain? (e.g., activity)Intensity and character of painRate severity on a scale of 0 (no pain) to 10 (worst possible pain) and evaluate changes in severityDescribe the painCheck whether the pain is continuous or intermittentAssociated symptomsEffect of pain on sleepCurrent level of depressionIs the pain associated with other symptoms?Pain-related impairment in functioning? (no limitation, mild limitation or significant limitation)Relevant medical historyReference:Ayad AE et al. Expert panel consensus recommendations for the pharmacologic treatment of acute pain in the middle east region. J Int Med Res 2011; 39(4):Ayad AE et al. J Int Med Res 2011; 39(4):
12 Locate the PainSpeaker’s NotesBody maps can help locate the pain.In cases of nociceptive pain of somatic origin, the pain is generally well localized to the injured area. However, in cases of neuropathic pain, body maps may be useful for the precise systematization of pain according to individual dermatomes.It should be noted that in cases of referred pain, the location of the pain and of the injury or nerve lesion/dysfunction may not be correlated.ReferencesGilron I et al. Neuropathic pain: a practical guide for the clinician. CMAJ 2006; 175(3):Walk D et al. Quantitative sensory testing and mapping: a review of nonautomated quantitative methods for examination of the patient with neuropathic pain. Clin J Pain 2009; 25(7):Body maps are useful for the precise location of pain symptoms and sensory signs.**In cases of referred pain, the location of the pain and of the injury or nerve lesion/dysfunction may not be correlatedGilron I et al. CMAJ 2006; 175(3):265-75; Walk D et al. Clin J Pain 2009; 25(7):
13 Clinical Assessment of Pain Functional AssessmentPsychological AssessmentMedication HistoryDoes the pain interfere with activities?Does the patient have concomitant depression, anxiety, or mental status changes?Does the patient have sleep disorders or a history of substance abuse/dependence?What medications have been tried in the past?Which medications have helped?Which medications have not helped?Speaker’s NotesClinical assessment of pain should include functional and psychological assessments and medication history.ReferenceWood S. Assessment of pain. Nursing Times.net Available at: management/assessment-of-pain/ article. Accessed: October 7, 2013.Wood S. Assessment of pain. Nursing Times.net Available at: Accessed: October 7, 2013.
14 Central sensitization/ dysfunctional pain Evaluate Impact of Pain on FunctioningPainCentral sensitization/ dysfunctional painNeuropathic painNociceptive painFunctional impairmentSpeaker’s NotesAlthough most pain disorders begin with injury or disease, their course and outcome are affected by emotional, behavioral and social factors. An individual’s emotional reaction to, and capacity to cope with, the fluctuating course of chronic pain disorders and their complications, such as physical impairment, disability, and loss of role functioning will also affect outcome.Chronic pain significantly interferes with sleep, with most studies showing a positive correlation between pain intensity and degree of sleep disturbance. Many chronic pain patients also have signs and symptoms of depression and anxiety; sleep deprivation can lead to anxiety, and depression can be both the cause and result of sleep deprivation. As lack of sleep and poor mood can both contribute to increased pain intensity, this can lead to a vicious cycle of increasing pain, fatigue and anxiety/depression. The inter- relationship between these three factors, as shown on this slide, is complex, but must be considered carefully if treatment for chronic pain is to be satisfactory.Chronic pain, sleep disturbances, and depression/anxiety must be addressed if patients are to be restored to optimal functionality. Physicians must evaluate all aspects of pain, sleep and mood in patients with chronic pain. Management and treatment should address both the pain and the comorbidities, to improve daily functioning, and enhance quality of life.ReferenceNicholson B, Verma S. Comorbidities in chronic neuropathic pain. Pain Med 2004; 5(Suppl 1):S9-27.Anxiety anddepressionNicholson B, Verma S. Pain Med 2004; 5(Suppl 1):S9-27.
15 Pain Assessment: PQRST Mnemonic Provocative and Palliative factorsQualityRegion and RadiationSeverityTiming, TreatmentSpeaker’s NotesThe PQRST mnemonic can be used to assess pain:Assess Provocative (aggravating) and Palliative (relieving) factorsAssess the Quality of the pain: Burning, stabbing, stinging, dull, sharp, throbbing, shooting, aching, tingling, heaviness, tightnessAssess the Region (location) of the pain, RadiationAssess the Severity of the pain (use pain intensity scale)Assess the Timing of the pain (when does it occur, how long does it persist), as well as Treatments that have been triedReferenceBudassi Sheehy S, Miller Barber J (eds). Emergency Nursing: Principles and Practice. 3rd ed. Mosby; St. Louis, MO: 1992.Budassi Sheehy S, Miller Barber J (eds). Emergency Nursing: Principles and Practice. 3rd ed. Mosby; St. Louis, MO: 1992.
16 Pain Assessment Tools Unidimensional Tools Visual Analog Scale Verbal Pain Intensity ScaleFaces Pain Scale0–10 Numeric Pain Intensity ScaleMultidimensional ToolsBrief Pain InventoryMcGill Pain QuestionnaireSpeaker's NotesThe intensity of a patient’s pain can be measured with either unidimensional or multidimensional tools.Unidimensional tools include:Visual Analogue Scale: patient visually selects a point on a 10 cm scale with two anchoring points (no pain, worst pain imagined)Verbal Pain Intensity Scale: patient chooses from a list of adjectives of increasing pain intensity (no pain, mid, moderate, severe pain)Faces Pain Scale: mainly for children or those with a language barrier; expression ranges from no pain to severe pain0–10 Numeric Pain Intensity Scale: patient selects a point from 0–10 (no pain, worst pain) that best represents his/her pain scoreExamples of some multidimensional tools are:Brief Pain Inventory – short form takes 5 minutes to complete, long form takes 10 minutes to complete; assesses severity of pain, impact of pain on daily function, location of pain, pain medications and amount of pain relief in the past 24 hours or the past weekMcGill Pain Questionnaire – Comprises 3 classes of words that describe the sensory, affective and evaluative aspects of pain and a 5-point pain intensity scaleReferencesBieri D et al. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain 1990; 41(2):Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore 1994; 23(2):Farrar JT et al. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001; 94(2):International Association for the Study of Pain. Faces Pain Scale – Revised. Available at: pain.org/Content/NavigationMenu/GeneralResourceLinks/FacesPainScaleRevised/default.htm. Accessed: July 15, 2013.Kremer E et al. Measurement of pain: patient preference does not confound pain measurement Pain 1981; 10(2):241-8.Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975; 1(3):Bieri D et al. Pain 1990; 41(2):139-59; Cleeland CS, Ryan KM. Ann Acad Med Singapore 1994; 23(2):129-38; International Association for the Study of Pain. Faces Pain Scale – Revised. Available at: Accessed: July 15, 2013; Farrar JT et al. Pain 2001; 94(2):149-58; Kremer E et al. Pain 1981; 10(2):241-8; Melzack R. Pain 1975; 1(3):
17 Determine Pain Intensity Simple Descriptive Pain Intensity ScaleMild painModerate painSevere painVery severe painNo painWorst pain0–10 Numeric Pain Intensity Scale12345678910No painModerate painWorst possible painSpeaker’s NotesVarious pain scales have been developed to help assess pain intensity, which can help guide treatment selection and adjustment.This slide displays three of the most common pain intensity scales. The selection of which scale to use may depend on the literacy, numeracy and cognitive abilities of the patient. For instance, the more visual Faces Pain Scale may be the most useful in young children, especially those under three years of age, or in elderly patients suffering from cognitive decline.ReferencesInternational Association for the Study of Pain. Faces Pain Scale – Revised. Available at: GeneralResourceLinks/FacesPainScaleRevised/default.htm. Accessed: July 15, 2013.Iverson RE et al. Practice advisory on pain management and prevention of postoperative nausea and vomiting. Plast Reconstr Surg 2006; 118(4):Faces Pain Scale – RevisedInternational Association for the Study of Pain. Faces Pain Scale – Revised. Available at: Accessed: July 15, 2013; Iverson RE et al. Plast Reconstr Surg 2006; 118(4):
18 Brief Pain Inventory Speaker's Notes There are two formats of the Brief Pain Inventory – the short form takes 5 minutes to complete, the long form takes 10 minutes to complete.The Brief Pain Inventory assesses severity of pain, impact of pain on daily function, location of pain, pain medications and amount of pain relief in the past 24 hours or the past week.ReferenceCleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore 1994; 23(2):Cleeland CS, Ryan KM. Ann Acad Med Singapore 1994; 23(2):
19 McGill Pain Questionnaire Speaker's NotesThe McGill Pain Questionnaire comprises three classes of words that describe the sensory, affective and evaluative aspects of pain and a five-point pain intensity. The respondent is given the questionnaire with the words grouped into 20 subclasses. An interviewer then instructs respondents to choose one word from each subclass if a word within that class fits their present pain. If no word fits, then no word should be chosen from that subclass. Each word within the pain rating index has an assigned value based on its placement within the subclass.ReferenceMelzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975; 1(3):Melzack R. Pain 1975; 1(3):
20 Neuropathic Pain Screening Tools LANSSDN4NPQpainDETECTID PainSymptomsPricking, tingling, pins and needlesxXElectric shocks of shootingHot or burningNumbnessPain evoked by light touchingPainful cold or freezing painClinical examinationBrush allodyniaRaised soft touch thresholdAltered pin prick threshold}Neuropathic pain screening tools rely largely on common verbal descriptors of painSelect tool(s) based on ease of use and validation in the local languageSpeaker’s NotesThis slide summarizes the screening tools currently used for neuropathic pain.Screening methods for neuropathic pain consist mostly of characteristic verbal descriptors, though some have simple bedside examinations in addition. Examples of the latter are the LANSS pain scale and the DN4 questionnaire, which have an approximate accuracy of 80% (for LANSS) and 90% (for ND4), compared with expert clinical judgment in identifying patients with neuropathic pain. Screening methods, however, are not a substitute for good clinical assessment and are not intended to be diagnostic methods.ReferencesBennett MI et al. Using screening tools to identify neuropathic pain. Pain 2007; 127(3):Haanpää M et al. NeuPSIG guidelines on neuropathic pain assessment. Pain 2011; 152(1):14-27.}Some screening tools also include bedside neurological examinationDN4 = Douleur Neuropathique en 4 Questions (DN4) questionnaire; LANSS = Leeds Assessment of Neuropathic Symptoms and Signs; NPQ = Neuropathic Pain QuestionnaireBennett MI et al. Pain 2007; 127(3): ; Haanpää M et al. Pain 2011; 152(1):14-27.
21 Sensitivity and Specificity of Neuropathic Pain Screening Tools NameDescriptionSensitivity*Specificity*Interview-basedNPQ10 sensory-related items + 2 affect items66%74%ID-Pain5 sensory items + 1 pain locationNRpainDETECT7 sensory items + 2 spatial characteristics items85%80%Interview + physical testsLANSS5 symptom items + 2 clinical exam items82–91%80–94%DN47 symptom items + 3 clinical exam items83%90%Speaker’s NotesThis slide summarizes the screening tools currently used for neuropathic pain, providing the sensitivity and specificity for each, when available.ReferenceBennett MI et al. Using screening tools to identify neuropathic pain. Pain 2007; 127(3):Tests incorporating both interview questions and physical tests have higher sensitivity and specificity than tools that rely only on interview questions*Compared with clinical diagnosisDN4 = Douleur neuropathic en 4 questions; LANSS = Leeds Assessment of Neuropathic Symptoms and Signs; NPQ = Neuropathic Pain Questionnaire; NR = not reportedBennett MI et al. Pain 2007; 127(3):
22 LANSS Scale Completed by physician in office Differentiates neuropathic from nociceptive pain5 pain questions and 2 skin sensitivity testsIdentifies contribution of neuropathic mechanisms to painValidatedSpeaker’s NotesThis slide shows the LANSS scale, which was developed to distinguish neuropathic symptoms and signs from those arising through nociceptive pain.The LANSS scale is based on an analysis of sensory description and examination of sensory dysfunction, and provides immediate information in the clinical setting.Patients are given five descriptions of different types of pain and are asked whether each description matches the pain they have experienced over the previous week. Skin sensitivity is assessed by comparing the painful area with a contralateral or adjacent non-painful area for the presence of allodynia and an altered pinprick threshold.A maximum total score of 24 can be achieved. If the patient scores less than 12, neuropathic mechanisms are unlikely to be contributing to their pain; if the patient scores 12 or more, neuropathic mechanisms are likely to be contributing to their pain.The scale can distinguish patients with neuropathic pain from those with nociceptive pain, and may help to individualize treatment according to specific pain mechanisms. The scale has been validated and may have utility as a diagnostic tool in both clinical practice and in clinical trials.ReferenceBennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs. Pain 2001; 92(1-2):LANSS = Leeds Assessment of Neuropathic Symptoms and SignsBennett M. Pain 2001; 92(1-2):
23 NPQThe NPQ has been developed to assess patients’ neuropathic pain symptoms and to discriminate between neuropathic and non-neuropathic painThe NPQ measures similar items to the other questionnaires, but also assesses circumstances that cause change in pain (e.g., touch)Further research is required to determine its clinical usefulness and distinguish it from the other questionnairesSpeaker’s NotesThe NPQ was developed to assess patients’ neuropathic pain symptoms and to discriminate between neuropathic and non-neuropathic pain.The terminology frequently used by patients to describe their pain is taken into account as well as the factors that may underlie patients’ descriptions of their pain.The NPQ has also been adapted as a short-form assessment tool.Although further research is required to fully validate the NPQ, it shows promise as a useful clinical assessment tool.NPQ has the ability to provide a quantitative measure for the descriptors important in the diagnosis and assessment of neuropathic pain. Consequently, it can be used for monitoring of neuropathic pain treatments and as an outcome measure.ReferencesBennett MI et al. Using screening tools to identify neuropathic pain. Pain 2007; 127(3):Krause SJ, Backonja MM. Development of a neuropathic pain questionnaire. Clin J Pain 2003; 19(5):NPQ = Neuropathic Pain QuestionnaireBennett MI et al. Pain 2007; 127(3): ; Krause SJ, Backonja MM. Clin J Pain 2003; 19(5):.
24 DN4 Completed by physician in office Differentiates neuropathic from nociceptive pain2 pain questions (7 items)2 skin sensitivity tests (3 items)Score 4 is an indicator for neuropathic painValidatedSpeaker’s NotesThis slide shows the DN4 diagnostic questionnaire, which was developed by The French Neuropathic Pain Group to differentiate neuropathic pain from non-neuropathic pain.The DN4 scale is based on an analysis of sensory description and examination of sensory dysfunction, and provides immediate information in the clinical setting.Patients are given seven descriptions of different types of pain or pain-related symptoms and are asked whether their pain is associated with the characteristic or symptom described (yes/no). The presence of touch hypoesthesia, pricking hypoesthesia and brushing pain is noted (yes/no).The scale has been validated and may have utility as a diagnostic tool in both clinical practice and in clinical trials.ReferenceBouhassira D 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(1-2):29-36.DN4 = Douleur neuropathique en 4 questions Bouhassira D et al. Pain 2005; 114(1-2):29-36.
25 painDETECT Patient-based, easy-to-use screening questionnaire Developed to distinguish between neuropathic pain and non-neuropathic pain*Validated: high sensitivity, specificity and positive predictive accuracySeven questions about quality and three about severity of painQuestions about location, radiation and time courseSpeaker’s NotesThis slide illustrates the validated painDETECT questionnaire, which was developed by German pain experts in co-operation with the German Research Network on Neuropathic Pain.As low back pain patients constitutes an important subgroup of chronic pain patients, the objective of the painDETECT questionnaire was to establish a simple, validated screening tool to detect neuropathic pain components in chronic low back pain patients.In the questionnaire, patients are asked to rate the severity of their pain, describe the clinical course by selecting a pattern from diagrams provided and to show the main pain areas on a body diagram and show where the pain is radiating. Patients also answer seven questions about positive and negative neuropathic pain symptoms. This screening tool does not employ a physical examination by the doctor.ReferenceFreynhagen R et al. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin 2006; 22(10):*Validation was in patients with low back painFreynhagen R et al. Curr Med Res Opin 2006; 22(10):
26 ID Pain Patient-completed screening tool Includes 6 yes/no questions and pain-location diagramDeveloped to differentiate between nociceptive and neuropathic painValidatedSpeaker’s NotesThe ID pain questionnaire is a patient-completed screening tool that was designed to differentiate between nociceptive and neuropathic pain.If patients have more than one painful area, they are to consider the one area that is most relevant to them when answering the ID Pain questions. Scoring is from –1 to 5. Higher scores are more indicative of pain with a neuropathic component. A score of 3 or higher indicates likely presence of neuropathic pain and justifies a more detailed evaluation.ReferencePortenoy R. Development and testing of a neuropathic pain screening questionnaire: ID Pain. Curr Med Res Opin 2006; 22(8):Portenoy R. Curr Med Res Opin 2006; 22(8):
28 Comprehensive Physical Examination Is Important Conduct comprehensive physical and neurological exams when evaluating and identifying patient’s subjective complaints of pain1Should serve to verify preliminary impression from history and guide the selection of laboratory and imaging studies2Confirm or exclude underlying causesSpeaker’s NotesA comprehensive physical and neurological examination should be performed when evaluating and identifying the patient’s subjective complaints of pain.1 It should serve to verify the preliminary impression from the history and guide the selection of laboratory and imaging studies, as well as confirm or exclude underlying causes such as rheumatoid arthritis, diabetic neuropathy, spinal disorders, HIV, and herpes viruses.ReferencesAmerican Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology 1997; 86(4):Brunton S. Approach to assessment and diagnosis of chronic pain. J Fam Pract 2004; 53(10 suppl):S3-S10.1. American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology 1997; 86(4): ; 2. Brunton S. J Fam Pract 2004; 53(10 suppl):S3-10.
29 Examples of Bedside Tests for Neuropathic Pain Touch tests can detectDifferences in skin temperatureHypersensitivityUnpleasant abnormal sensationsSensory deficitTests to evoke painResponse is the presence of positive sensory symptomsExamples include touch, pinprick, pinch, and etiology-specific testsSpeaker’s NotesSimple bedside tests can be used by clinicians to differentiate neuropathic pain from nociceptive pain. These include assessment of the patient’s response to touch and to evoked pain.Touch tests can detect:Differences in skin temperature (hypo- or hyperthermia)Hypersensitivity (allodynia, e.g., gauze test)Unpleasant abnormal sensations (dysesthesia)Sensory deficit (hypoesthesia)Tests to evoke pain determine the presence of positive sensory symptoms:Touch (allodynia)Pinprick, pinch (hyperalgesia)Etiology-specific tests (e.g., straight-leg raise)ReferencesBaron R, Tölle TR. Assessment and diagnosis of neuropathic pain. Curr Opin Support Palliat Care 2008; 2(1):1-8.Gilron I et al. Neuropathic pain: a practical guide for the clinician. CMAJ 2006; 175(3):Haanpää ML et al. Assessment of neuropathic pain in primary care. Am J Med 2009; 122(10 Suppl):S13-21.Baron R, Tölle TR. Curr Opin Support Palliat Care 2008; 2(1):1-8; Gilron I et al. CMAJ 2006; 175(3):265-75; Haanpää ML et al. Am J Med 2009; 122(10 Suppl):S13-21.
30 Look: Simple Bedside Tests Stroke skin with brush,cotton or apply acetoneSharp, burningsuperficial painALLODYNIALight manual pinprick withsafety pin or sharp stickSpeaker’s NotesThis slide describes several simple assessments, that can readily be employed in the physician’s office, for allodynia (pain due to a stimulus that does not normally provoke pain) and hyperalgesia (increased pain from a stimulus that normally provokes pain). In each case, the control would be the identical stimulus applied to the unaffected contralateral side.Mechanical allodynia can be assessed by stroking the skin with a brush, gauze or cotton. Patients with mechanical allodynia might complain that the brushing of fabric such as a shirt over their skin is painful and that they avoid being touched by others, wear shoes or even socks.Cold allodynia may be tested by applying acetone to the skin.Mechanical hyperalgesia can be evaluated by using a safety pin or sharp stick to the skin. Patients with pinprick hyperalgesia may complain of very increased painful sensation with this evoked nociceptive stimuli.ReferencesBaron R. Peripheral neuropathic pain: from mechanisms to symptoms. Clin J Pain 2000; 16(2 Suppl):S12-20.Jensen TS, Baron R. Translation of symptoms and signs into mechanisms in neuropathic pain. Pain 2003; 102(1-2):1-8.Very sharp,superficial painHYPERALGESIABaron R. Clin J Pain 2000; 16(2 Suppl):S12-20; Jensen TS, Baron R. Pain 2003; 102(1-2):1-8.
32 Pain Diagnostics Plain X-rays with multiple views MRI CT CT myelogram Nerve conduction velocityElectromyographySpeaker’s NotesThis slide provides examples of pain diagnostics. Other modalities can also be used depending on pain presentation.MRI is the best method for most screening, while CT is useful if bony pathology is suspected and CT myelogram is useful for patients with previous surgery.ReferenceBrunton S. Approach to assessment and diagnosis of chronic pain. J Fam Pract 2004; 53(10 Suppl):S3-10.CT = computed tomography; MRI = magnetic resonance imagingBrunton S. J Fam Pract 2004; 53(10 Suppl):S3-S10.
33 Newer Neuropathic Pain Assessment Techniques Arrows = IENFs, arrowheads = dermal nerve bundles. Bright-field immunohistochemistry in 50 µm sections stained with anti-PGP 9.5 antibody. Bar = 80 µm.Patient with diabetic small-fibre neuropathy3Proximal thighDistal legNewer, more objective assessment techniques for neuropathic pain include:Laser-evoked potentialsSkin biopsyQuantitative sensory testingSpeaker’s NotesPain is a complex experience that is dependent on cognitive, emotional and educational factors. Given the subjective nature of pain, tools that provide a more objective assessment of pain may be required.This slide lists some newer assessment techniques for neuropathic pain.ReferencesJovin Z et al. Assessment of neuropathic pain and clinical evaluation of patients with suspected neuropathic pain. Curr Top Neurol Psychiatr Relat Discip 2010; 18(2):30-7.Lauria G, Devigili G. Skin biopsy: a new tool for diagnosing peripheral neuropathy. Nature Clin Practice Neurol 2007; 3(10):IENF = intra-epidermal nerve fiberJovin Z et al. Curr Top Neurol Psychiatr Relat Discip 2010; 18(2):30-7; Lauria G, Devigili G. Nature Clin Practice Neurol 2007; 3(10):
34 Laser-Evoked Potentials How They WorkPotential Place in PracticeDetect dysfunction of pain and temperature pathways, which are the basis of neuropathic pain development2Laser-generated radiant heat pulses selectively excite free nerve endings in the superficial skin layers3Brain responses are recorded4Late laser evoked potentials reflect activity of Aδ nerve endings in superficial skin layers1Laser evoked potential magnitudes may accurately gauge subjective experience of pain4Easiest, most reliable, and most sensitive neurophysiological way to assess the function of nociceptive pathways1EFNS has recommended the use of laser evoked potentials as an ancillary tool in the evaluation of neuropathic pain2Use in diagnosis currently limited by availability of equipment2Speaker’s NotesLaser-evoked potentials are the easiest, most reliable, and most sensitive neurophysiological way to assess the function of nociceptive pathways.1 Laser-evoked potentials detect dysfunction of pain and temperature pathways, which are the basis of neuropathic pain development.2Laser-generated radiant heat pulses selectively excite free nerve endings in the superficial skin layers.3 Late laser-evoked potentials reflect the activity of the Aδ nerve endings in the superficial skin layers.1 Brain responses are recorded.4Laser-evoked potentials reliably assess damage to peripheral and central nociceptive systems.1 The magnitude of laser-evoked potentials might be an accurate index of the subjective experience of pain.4Finding a laser-evoked potential suppression helps diagnose neuropathic pain1 and EFNS has recommended the use of laser-evoked potentials as an ancillary tool in the evaluation of neuropathic pain.2 However, its use in diagnosis currently limited by availability of equipment.2It is unknown whether laser-evoked potentials may be used to help identify patients who are not yet in pain but who are likely to develop a neuropathic pain condition.2ReferencesCruccu G et al. EFNS guidelines on neuropathic pain assessment: revised Eur J Neurol 2010; 17(8):Garcia-Larrea L, Godinho F. Diagnostic role of laser evoked potentials in central neuropathic pain. Eur Neurolog Disease 2007; 2:39-41Truini A et al. Laser-evoked potentials: normative values. Clin Neurophysiol 2005; 116(4):821-6.Garcia-Larrea L et al. Laser-evoked potential abnormalities in central pain patients: the influence of spontaneous and provoked pain. Brain 2002; 125(Pt 12):EFNS = European Federation of Neurological SocietiesCruccu G et al. Eur J Neurol 2010; 17(8):1010-8; Garcia-Larrea L, Godinho F. Eur Neurolog Disease 2007; 2:39-41;Truini A et al. Clin Neurophysiol 2005; 116(4):821-6; Garcia-Larrea L et al. Brain 2002; 125(Pt 12):
35 Skin BiopsyCircular punch is used to excise a hairy skin sample, usually from distal part of the legLidocaine used as a topical anestheticNo sutures are requiredNo side effectsWound heals quicklySpeaker’s NotesTo obtain a skin biopsy, a 3-mm disposable circular punch is used, under sterile conditions, to excise a hairy skin sample, usually from the distal part of the leg. Lidocaine used as a topical anesthetic. No sutures are required, there are no side effects, and the wound heals quickly.Skin biopsy can be used to investigate small calibre sensory nerves in the epidermis and dermis, including somatic unmyelinated intra-epidermal nerve fibers. Early symptoms of diabetic peripheral neuropathy and other peripheral neuropathies are due to degeneration of small somatic nerve fibers.Routine neurophysiological exams do not detect these changes but skin biopsy does, which may allow for earlier diagnosis of neuropathic pain.Skin biopsy is safe, almost painless, and inexpensive. Skin biopsy is reliable, reproducible, and unaffected by the severity of neuropathy. Skin biopsy can be repeated within the same nerve territory. This allows for evaluation of the progression of neuropathy and assessment of treatment effects.ReferencesLauria G et al. EFNS guidelines on the use of skin biopsy in the diagnosis of peripheral neuropathy. Eur J Neurol 2005; 12(10):Lauria G, Devigili G. Skin biopsy as a diagnostic tool in peripheral neuropathy. Nature Clin Practice Neurol 2007; 3(10):Lauria G, Lombardi R. Skin biopsy: a new tool for diagnosing peripheral neuropathy. BMJ 2007; 334(7604):Lauria G et al. Eur J Neurol 2005; 12(10):747-58; Lauria G, Devigili G. Nature Clin Practice Neurol 2007; 3(10):546-57;Lauria G, Lombardi R. BMJ 2007; 334(7604):
36 Quantitative Sensory Testing How It WorksLimitationsInvolves measuring the responses evoked by mechanical and thermal stimuli of controlled intensity2Stimuli are applied to the skin in ascending and descending order3Mechanical sensitivity: assessed using plastic filaments and pin prick sensation with weighted needles3Vibration sensitivity: assessed using an electronic vibrameter3Thermal sensitivity: assessed using a probe that operates on a thermoelectric principle3Relies on the patient’s subjective assessment of pain3Outcomes of quantitative sensory testing and bedside testing do not necessarily coincide2Quantitative sensory testing abnormalities cannot be taken as conclusive demonstration of neuropathic pain4 because they also occur in other conditions, such as rheumatoid arthritis3Time consuming and requires expensive equipment4Results can be influenced by various factors (e.g., model or make of equipment, room temperature, site of stimulus, patient characteristics)2Speaker’s NotesQuantitative sensory testing is a standardized quantitative testing tool for the somatosensory evaluation of patients with neuropathic pain.1 Quantitative sensory testing was developed to complement the traditional neurological bedside exam.2Quantitative sensory testing involves measuring the responses evoked by mechanical and thermal stimuli of controlled intensity.2 Stimuli are applied to the skin in ascending and descending order:3Mechanical (tactile) sensitivity is assessed using plastic filaments and pin prick sensation with weighted needles3Vibration sensitivity is assessed using an electronic vibrameter3Thermal sensitivity is assessed using a probe that operates on a thermoelectric principle3Quantitative sensory testing has been used for early diagnosis and follow up in small fiber neuropathies and early detection of diabetic nephropathy.3 The outcomes of quantitative sensory testing and bedside testing do not necessarily coincide2 and quantitative sensory testing remains complementary to bedside testing. Bedside testing determines the site of threshold measurements prior to quantitative sensory testing.2 Quantitative sensory testing abnormalities cannot be taken as conclusive demonstration of neuropathic pain3 because uantitative sensory testing abnormalities also occur in non-neuropathic pain conditions, such as rheumatoid arthritis.1Quantitative sensory testing is time consuming and requires expensive equipment.3 In addition, quantitative sensory testing results can be influenced by various factors (e.g., model or make of equipment, room temperature, site of stimulus, patient characteristics).2ReferencesRolke R et al. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values. Pain 2006; 123(3):Hansson P et al. Usefulness and limitations of quantitative sensory testing: clinical and research application in neuropathic pain states. Pain 2007; 129(3):256-9.Jovin Z et al. Assessment of neuropathic pain and clinical evaluation of patients with suspected neuropathic pain. Curr Top Neurol Psychiatr Relat Discip 2010; 18(2):30-7.Cruccu G, Truini A. Assessment of neuropathic pain Neurol Sci 2006; 27(Suppl 4):SRolke R et al. Pain 2006; 123(3):231-43;Hansson P et al. Pain 2007; 129(3):256-9;Jovin Z et al. Curr Top Neurol Psychiatr Relat Discip 2010; 18(2):30-7;Cruccu G, Truini A. Neurol Sci 2006; 27(Suppl 4):S
38 Pain Diagnosis Confirm or exclude underlying causes There is no single diagnostic test for painMultiple tests may not be helpfulSpeaker’s NotesThere is no single diagnostic test for pain. However, multiple tests may not be helpful.ReferencesAmerican Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Practice guidelines for chronic pain management. Anesthesiology 1997; 86(4):Brunton S. Approach to assessment and diagnosis of chronic pain. J Fam Pract 2004; 53(10 Suppl):S3-10.American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology 1997; 86(4): ; Brunton S. J Fam Pract 2004; 53(10 Suppl):S3-10.
39 Identify and Treat Underlying Cause Whenever possible, it is important to identify and treat the underlying cause of pain!Speaker’s NotesRemind the participants that, whenever possible, it is important to identify and treat the underlying cause of pain.ReferenceForde G, Stanos S. Practical management strategies for the chronic pain patient. J Fam Pract 2007; 56(8 Suppl Hot Topics):S21-30.Forde G, Stanos S. J Fam Pract 2007; 56(8 Suppl Hot Topics):S21-30.
40 Evaluate for patients presenting with pain the presence of red flags! Be Alert for Red FlagsEvaluate for patients presenting with pain the presence of red flags!Speaker’s NotesIt is also important to screen patients presenting with pain for red flags indicative of a serious underlying condition. Depending on the condition suspected, clinicians should then initiate appropriate investigations or refer the patient to a specialist.ReferenceLittlejohn GO. Musculoskeletal pain. J R Coll Physicians Edinb 2005; 35(4):340-4.Initiate appropriate investigations/ management or refer to specialistLittlejohn GO. J R Coll Physicians Edinb 2005; 35(4):340-4.
42 Assessment and Diagnosis: Summary Assessment of pain is critical and should include:Location, duration, frequency, quality, severity, etc.Medication historyPhysical examAssessment of patient functionPsychological assessmentRisk assessmentComorbiditiesDetermination of type(s) of painSpeaker’s NotesThis slide can be used to summarize the key messages of this section.