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

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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?

drjovey@bell.net