Assessment and diagnosis

Overview

Pain: Underreported, Underdiagnosed and Undertreated Ongoing 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 Comprehensive assessment and treatments likely to produce best results Speaker’s Notes Ongoing 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. Reference Institute 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.

Importance of Pain Assessment Pain is a significant predictor of morbidity and mortality. Screen for red flags requiring immediate investigation and/or referral Identify underlying cause Pain is better managed if the underlying causes are determined and addressed Recognize type of pain to help guide selection of appropriate therapies for treatment of pain Determine baseline pain intensity to future enable assessment of efficacy of treatment Speaker’s Notes Appropriate 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. References Forde 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.

Comprehensive Pain Assessment Assess effects of pain on patient’s function Characterize pain location, distribution, duration, frequency, quality, precipitants Complete risk assessment Take detailed history (e.g., comorbidities, prior treatment) Clarify etiology, pathophysiology Speaker’s Notes For 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 history Physical exam Assessment of patient function Risk assessment Medical clarification of comorbidities, possible pain sources and aberrant pain References National 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 examination National 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.

Nociceptive vs. Neuropathic Pain Definition Pain caused by physiological activation of pain receptors Pain initiated or caused by a primary lesion or dysfunction in the peripheral or central somatosensory nervous system Mechanism Natural physiological transduction Ectopic impulse generation, central sensitization, and others Localization Local + referred pain Confined to innervation territory of the lesioned somatosensory nervous structure Quality of symptoms Ordinary painful sensation New strange sensations Treatment Good response (conventional analgesics) Poor response (conventional analgesics) Speaker’s Notes The 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. Reference Serra 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.

Nociceptive Pain Visceral Somatic Trauma Musculoskeletal injury Ischemic, e.g., myocardial infarction Abdominal colic Speaker’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. Reference Fishman SM et al (eds). Bonica’s Management of Pain. 4th ed. Lippincott, Williams and Wilkins; Philadelphia, PA: 2010. Post-operative pain Burn pain Infection, e.g., pharyngitis Dysmenorrhea Fishman SM et al (eds). Bonica’s Management of Pain. 4th ed. Lippincott, Williams and Wilkins; Philadelphia, PA: 2010.

Recognizing Neuropathic Pain Post-stroke pain Postherpetic neuralgia Diabetic peripheral neuropathy Common descriptors Shooting Electric shock-like Burning Tingling Numbness Speaker’s Notes Neuropathic 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. Reference Baron R et al. Neuropathic pain: diagnosis, pathophysiological mechanisms, and treatment. Lancet Neurol 2010; 9(8):807-19 . Chronic post-surgical pain Lumbar radicular pain 1. Baron R et al. Lancet Neurol 2010; 9(8):807-19.

History

Pain History Location/distribution Onset Frequency/variation Intensity Type Aggravating and relieving factors Impairment and disability Previous pain treatments Other conditions/treatments Response to treatment Meaning of pain Speaker’s Notes A pain history should include questions that lead to a thorough understanding of the nature of the pain. References Ferrell 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.

Pain History Worksheet Site of pain What causes or worsens the pain? Intensity and character of pain Associated symptoms? Pain-related impairment in functioning? Relevant medical history Speaker’s Notes A 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 pain What causes or worsens the pain? (e.g., activity) Intensity and character of pain Rate severity on a scale of 0 (no pain) to 10 (worst possible pain) and evaluate changes in severity Describe the pain Check whether the pain is continuous or intermittent Associated symptoms Effect of pain on sleep Current level of depression Is the pain associated with other symptoms? Pain-related impairment in functioning? (no limitation, mild limitation or significant limitation) Relevant medical history Reference: 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):1123-41. Ayad AE et al. J Int Med Res 2011; 39(4):1123-41.

Locate the Pain Speaker’s Notes Body 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. References Gilron I et al. Neuropathic pain: a practical guide for the clinician. CMAJ 2006; 175(3):265-75. 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):632-40. 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 correlated Gilron I et al. CMAJ 2006; 175(3):265-75; Walk D et al. Clin J Pain 2009; 25(7):632-40.

Clinical Assessment of Pain Functional Assessment Psychological Assessment Medication History Does 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 Notes Clinical assessment of pain should include functional and psychological assessments and medication history. Reference Wood S. Assessment of pain. Nursing Times.net 2008. Available at: http://www.nursingtimes.net/nursing-practice/clinical-zones/pain- management/assessment-of-pain/1861174.article. Accessed: October 7, 2013. Wood S. Assessment of pain. Nursing Times.net 2008. Available at: http://www.nursingtimes.net/nursing-practice/clinical-zones/pain-management/assessment-of-pain/1861174.article. Accessed: October 7, 2013.

Central sensitization/ dysfunctional pain Evaluate Impact of Pain on Functioning Pain Central sensitization/ dysfunctional pain Neuropathic pain Nociceptive pain Functional impairment Speaker’s Notes Although 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. Reference Nicholson B, Verma S. Comorbidities in chronic neuropathic pain. Pain Med 2004; 5(Suppl 1):S9-27. Anxiety and depression Nicholson B, Verma S. Pain Med 2004; 5(Suppl 1):S9-27.

Pain Assessment: PQRST Mnemonic Provocative and Palliative factors Quality Region and Radiation Severity Timing, Treatment Speaker’s Notes The PQRST mnemonic can be used to assess pain: Assess Provocative (aggravating) and Palliative (relieving) factors Assess the Quality of the pain: Burning, stabbing, stinging, dull, sharp, throbbing, shooting, aching, tingling, heaviness, tightness Assess the Region (location) of the pain, Radiation Assess 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 tried Reference Budassi 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.

Pain Assessment Tools Unidimensional Tools Visual Analog Scale Verbal Pain Intensity Scale Faces Pain Scale 0–10 Numeric Pain Intensity Scale Multidimensional Tools Brief Pain Inventory McGill Pain Questionnaire Speaker's Notes The 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 pain 0–10 Numeric Pain Intensity Scale: patient selects a point from 0–10 (no pain, worst pain) that best represents his/her pain score Examples 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 week McGill Pain Questionnaire – Comprises 3 classes of words that describe the sensory, affective and evaluative aspects of pain and a 5-point pain intensity scale References Bieri 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):139-59. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore 1994; 23(2):129-38. 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):149-58. International Association for the Study of Pain. Faces Pain Scale – Revised. Available at: http://www.iasp- 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):277-99. 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: http://www.iasp-pain.org/Content/NavigationMenu/GeneralResourceLinks/FacesPainScaleRevised/default.htm. 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):277-99.

Determine Pain Intensity Simple Descriptive Pain Intensity Scale Mild pain Moderate pain Severe pain Very severe pain No pain Worst pain 0–10 Numeric Pain Intensity Scale 1 2 3 4 5 6 7 8 9 10 No pain Moderate pain Worst possible pain Speaker’s Notes Various 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. References International Association for the Study of Pain. Faces Pain Scale – Revised. Available at: http://www.iasp-pain.org/Content/NavigationMenu/ 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):1060-9. Faces Pain Scale – Revised International Association for the Study of Pain. Faces Pain Scale – Revised. Available at: http://www.iasp-pain.org/Content/NavigationMenu/GeneralResourceLinks/FacesPainScaleRevised/default.htm. Accessed: July 15, 2013; Iverson RE et al. Plast Reconstr Surg 2006; 118(4):1060-9.

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. Reference Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore 1994; 23(2):129-38. Cleeland CS, Ryan KM. Ann Acad Med Singapore 1994; 23(2):129-38.

McGill Pain Questionnaire Speaker's Notes The 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. Reference Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975; 1(3):277-99. Melzack R. Pain 1975; 1(3):277-99.

Neuropathic Pain Screening Tools LANSS DN4 NPQ painDETECT ID Pain Symptoms Pricking, tingling, pins and needles x X Electric shocks of shooting Hot or burning Numbness Pain evoked by light touching Painful cold or freezing pain Clinical examination Brush allodynia Raised soft touch threshold Altered pin prick threshold } Neuropathic pain screening tools rely largely on common verbal descriptors of pain Select tool(s) based on ease of use and validation in the local language Speaker’s Notes This 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. References Bennett MI et al. Using screening tools to identify neuropathic pain. Pain 2007; 127(3):199-203. Haanpää M et al. NeuPSIG guidelines on neuropathic pain assessment. Pain 2011; 152(1):14-27. } Some screening tools also include bedside neurological examination DN4 = Douleur Neuropathique en 4 Questions (DN4) questionnaire; LANSS = Leeds Assessment of Neuropathic Symptoms and Signs; NPQ = Neuropathic Pain Questionnaire Bennett MI et al. Pain 2007; 127(3):199-203; Haanpää M et al. Pain 2011; 152(1):14-27.

Sensitivity and Specificity of Neuropathic Pain Screening Tools Name Description Sensitivity* Specificity* Interview-based NPQ 10 sensory-related items + 2 affect items 66% 74% ID-Pain 5 sensory items + 1 pain location NR painDETECT 7 sensory items + 2 spatial characteristics items 85% 80% Interview + physical tests LANSS 5 symptom items + 2 clinical exam items 82–91% 80–94% DN4 7 symptom items + 3 clinical exam items 83% 90% Speaker’s Notes This slide summarizes the screening tools currently used for neuropathic pain, providing the sensitivity and specificity for each, when available. Reference Bennett MI et al. Using screening tools to identify neuropathic pain. Pain 2007; 127(3):199-203. Tests incorporating both interview questions and physical tests have higher sensitivity and specificity than tools that rely only on interview questions *Compared with clinical diagnosis DN4 = Douleur neuropathic en 4 questions; LANSS = Leeds Assessment of Neuropathic Symptoms and Signs; NPQ = Neuropathic Pain Questionnaire; NR = not reported Bennett MI et al. Pain 2007; 127(3):199-203.

LANSS Scale Completed by physician in office Differentiates neuropathic from nociceptive pain 5 pain questions and 2 skin sensitivity tests Identifies contribution of neuropathic mechanisms to pain Validated Speaker’s Notes This 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. Reference Bennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs. Pain 2001; 92(1-2):147-57. LANSS = Leeds Assessment of Neuropathic Symptoms and Signs Bennett M. Pain 2001; 92(1-2):147-57.

NPQ The NPQ has been developed to assess patients’ neuropathic pain symptoms and to discriminate between neuropathic and non-neuropathic pain The 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 questionnaires Speaker’s Notes The 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. References Bennett MI et al. Using screening tools to identify neuropathic pain. Pain 2007; 127(3):199-203. Krause SJ, Backonja MM. Development of a neuropathic pain questionnaire. Clin J Pain 2003; 19(5):306-14. NPQ = Neuropathic Pain Questionnaire Bennett MI et al. Pain 2007; 127(3):199-203; Krause SJ, Backonja MM. Clin J Pain 2003; 19(5):306-14. .

DN4 Completed by physician in office Differentiates neuropathic from nociceptive pain 2 pain questions (7 items) 2 skin sensitivity tests (3 items) Score 4 is an indicator for neuropathic pain Validated Speaker’s Notes This 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. Reference Bouhassira 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.

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 accuracy Seven questions about quality and three about severity of pain Questions about location, radiation and time course Speaker’s Notes This 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. Reference Freynhagen R et al. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin 2006; 22(10):1911-20. *Validation was in patients with low back pain Freynhagen R et al. Curr Med Res Opin 2006; 22(10):1911-20.

ID Pain Patient-completed screening tool Includes 6 yes/no questions and pain-location diagram Developed to differentiate between nociceptive and neuropathic pain Validated Speaker’s Notes The 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. Reference Portenoy R. Development and testing of a neuropathic pain screening questionnaire: ID Pain. Curr Med Res Opin 2006; 22(8):1555-65. Portenoy R. Curr Med Res Opin 2006; 22(8):1555-65

Physical Examination

Comprehensive Physical Examination Is Important Conduct comprehensive physical and neurological exams when evaluating and identifying patient’s subjective complaints of pain1 Should serve to verify preliminary impression from history and guide the selection of laboratory and imaging studies2 Confirm or exclude underlying causes Speaker’s Notes A 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. References American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology 1997; 86(4):995-1004 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):995-1004; 2. Brunton S. J Fam Pract 2004; 53(10 suppl):S3-10.

Examples of Bedside Tests for Neuropathic Pain Touch tests can detect Differences in skin temperature Hypersensitivity Unpleasant abnormal sensations Sensory deficit Tests to evoke pain Response is the presence of positive sensory symptoms Examples include touch, pinprick, pinch, and etiology-specific tests Speaker’s Notes Simple 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) References Baron 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):265-75. 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.

Look: Simple Bedside Tests Stroke skin with brush, cotton or apply acetone Sharp, burning superficial pain ALLODYNIA Light manual pinprick with safety pin or sharp stick Speaker’s Notes This 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. References Baron 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 pain HYPERALGESIA Baron R. Clin J Pain 2000; 16(2 Suppl):S12-20; Jensen TS, Baron R. Pain 2003; 102(1-2):1-8.

Imaging and Other Tests

Pain Diagnostics Plain X-rays with multiple views MRI CT CT myelogram Nerve conduction velocity Electromyography Speaker’s Notes This 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. Reference Brunton S. Approach to assessment and diagnosis of chronic pain. J Fam Pract 2004; 53(10 Suppl):S3-10. CT = computed tomography; MRI = magnetic resonance imaging Brunton S. J Fam Pract 2004; 53(10 Suppl):S3-S10.

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 neuropathy3 Proximal thigh Distal leg Newer, more objective assessment techniques for neuropathic pain include: Laser-evoked potentials Skin biopsy Quantitative sensory testing Speaker’s Notes Pain 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. References 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. Lauria G, Devigili G. Skin biopsy: a new tool for diagnosing peripheral neuropathy. Nature Clin Practice Neurol 2007; 3(10):546-57. IENF = intra-epidermal nerve fiber Jovin 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):546-57.

Laser-Evoked Potentials How They Work Potential Place in Practice Detect dysfunction of pain and temperature pathways, which are the basis of neuropathic pain development2 Laser-generated radiant heat pulses selectively excite free nerve endings in the superficial skin layers3 Brain responses are recorded4 Late laser evoked potentials reflect activity of Aδ nerve endings in superficial skin layers1 Laser evoked potential magnitudes may accurately gauge subjective experience of pain4 Easiest, most reliable, and most sensitive neurophysiological way to assess the function of nociceptive pathways1 EFNS has recommended the use of laser evoked potentials as an ancillary tool in the evaluation of neuropathic pain2 Use in diagnosis currently limited by availability of equipment2 Speaker’s Notes Laser-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.2 Laser-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.4 Laser-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.4 Finding 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.2 It 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.2 References Cruccu G et al. EFNS guidelines on neuropathic pain assessment: revised 2009. Eur J Neurol 2010; 17(8):1010-8. Garcia-Larrea L, Godinho F. Diagnostic role of laser evoked potentials in central neuropathic pain. Eur Neurolog Disease 2007; 2:39-41 Truini 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):2766-81. EFNS = European Federation of Neurological Societies Cruccu 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):2766-81.

Skin Biopsy Circular punch is used to excise a hairy skin sample, usually from distal part of the leg Lidocaine used as a topical anesthetic No sutures are required No side effects Wound heals quickly Speaker’s Notes To 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. References Lauria G et al. EFNS guidelines on the use of skin biopsy in the diagnosis of peripheral neuropathy. Eur J Neurol 2005; 12(10):747-58. Lauria G, Devigili G. Skin biopsy as a diagnostic tool in peripheral neuropathy. Nature Clin Practice Neurol 2007; 3(10):546-57. Lauria G, Lombardi R. Skin biopsy: a new tool for diagnosing peripheral neuropathy. BMJ 2007; 334(7604):1159-62. 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):1159-62.

Quantitative Sensory Testing How It Works Limitations Involves measuring the responses evoked by mechanical and thermal stimuli of controlled intensity2 Stimuli are applied to the skin in ascending and descending order3 Mechanical sensitivity: assessed using plastic filaments and pin prick sensation with weighted needles3 Vibration sensitivity: assessed using an electronic vibrameter3 Thermal sensitivity: assessed using a probe that operates on a thermoelectric principle3 Relies on the patient’s subjective assessment of pain3 Outcomes of quantitative sensory testing and bedside testing do not necessarily coincide2 Quantitative sensory testing abnormalities cannot be taken as conclusive demonstration of neuropathic pain4 because they also occur in other conditions, such as rheumatoid arthritis3 Time consuming and requires expensive equipment4 Results can be influenced by various factors (e.g., model or make of equipment, room temperature, site of stimulus, patient characteristics)2 Speaker’s Notes Quantitative 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.2 Quantitative 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:3 Mechanical (tactile) sensitivity is assessed using plastic filaments and pin prick sensation with weighted needles3 Vibration sensitivity is assessed using an electronic vibrameter3 Thermal sensitivity is assessed using a probe that operates on a thermoelectric principle3 Quantitative 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.1 Quantitative 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).2 References Rolke R et al. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values. Pain 2006; 123(3):231-43. 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):S288-90. Rolke 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):S288-90.

Diagnosis

Pain Diagnosis Confirm or exclude underlying causes There is no single diagnostic test for pain Multiple tests may not be helpful Speaker’s Notes There is no single diagnostic test for pain. However, multiple tests may not be helpful. References American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Practice guidelines for chronic pain management. Anesthesiology 1997; 86(4):995-1004. 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):995-1004; Brunton S. J Fam Pract 2004; 53(10 Suppl):S3-10.

Identify and Treat Underlying Cause Whenever possible, it is important to identify and treat the underlying cause of pain! Speaker’s Notes Remind the participants that, whenever possible, it is important to identify and treat the underlying cause of pain. Reference Forde 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.

Evaluate for patients presenting with pain the presence of red flags! Be Alert for Red Flags Evaluate for patients presenting with pain the presence of red flags! Speaker’s Notes It 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. Reference Littlejohn GO. Musculoskeletal pain. J R Coll Physicians Edinb 2005; 35(4):340-4. Initiate appropriate investigations/ management or refer to specialist Littlejohn GO. J R Coll Physicians Edinb 2005; 35(4):340-4.

Summary

Assessment and Diagnosis: Summary Assessment of pain is critical and should include: Location, duration, frequency, quality, severity, etc. Medication history Physical exam Assessment of patient function Psychological assessment Risk assessment Comorbidities Determination of type(s) of pain Speaker’s Notes This slide can be used to summarize the key messages of this section.