- The starting point for effective pain management is a comprehensive clinical assessment.1
- A detailed case history, physical examination and utilisation of patient-reported outcomes are essential in accurately evaluating pain.2
A comprehensive clinical assessment of patients presenting with chronic pain comprises taking a thorough history (including a clinical interview to gauge the patient’s current pain status, general medical history, treatment history and psychosocial factors) and assessing the pain using both a physical examination and patient-reported assessment tools.1,2 Clinicians should assess the ‘whole person’, rather than just the pain.1,2 Findings from these assessments may explain the presence and severity of symptoms and functional impairment, point towards a diagnosis and support the development of a management plan or need for further testing.1
A detailed case history is required to reveal all pathological and psychological factors that may contribute to the pain that a patient experiences.3 An effective assessment of a patient’s history takes the multidimensional nature of chronic pain into account and not only covers information about the pain itself but also records any associated comorbidities, previous and current treatments, and family disease history.3,4
Assessment of a patient’s current illness should include questions about the location, quality, intensity, onset, frequency and course of the pain; sensory and affective components; exacerbating and relieving factors; and any additional symptoms such as motor, sensory or autonomic changes.3,4
General medical history
In addition to a history of current illness, a comprehensive pain assessment also entails the gathering of information on family history, comorbidities, medical history, history of allergies, social history (including substance use or misuse), previous diagnostic tests as well as prior and current treatments.4
Other diseases may affect pain and influence the choice of medication. A complete list of current and prior medications should be sought to avoid drug–drug interactions and side effects from prescribed medications. Understanding the effectiveness of prior pharmacological and surgical interventions may help to indicate which future treatments may be most appropriate.3
Assessment of a patient’s psychosocial history includes questions about the presence of psychological symptoms (e.g. anxiety, depression, anger), psychiatric disorders, personality traits or states, and coping strategies.4 This is important as negative psychosocial factors (e.g. distress, trauma) may worsen pain and pain-related outcomes, while positive factors (e.g. active coping skills) may improve these outcomes.1
The impact of chronic pain on the patient’s everyday activities, mood, sleep, behaviour and relationships should be thoroughly assessed.2,4 For this, tools such as the ACT-UP (Activity, Coping, Think, Upset, People’s responses) acronym can be used to guide patient interviews:2
- Activity: how is your pain affecting your life (i.e. sleep, appetite, physical activities and relationships)?
- Coping: how do you deal/cope with your pain (what makes it better/worse)?
- Think: do you think your pain will ever get better?
- Upset: have you been feeling worried (anxious)/depressed (down, blue)?
- People’s responses: how do people respond when you have pain?
The physical pain examination should include an appropriately directed neurological and musculoskeletal evaluation.4 Depending on the clinical profile, physicians may also perform interventional diagnostic procedures (e.g. selective nerve root block, medial branch block, facet joint injection, sacroiliac joint injections or provocative discography).4
Patient-reported assessment tools
Patient-reported pain measures have become a very important part of the assessment of chronic pain.2 The most commonly used unidimensional patient-reported measures of pain intensity are the numerical rating scale (NRS) and the verbal rating scale (VRS).2 The NRS asks patients to rate their typical pain on a scale from 0 (no pain) to 10 (worst pain), while the VRS uses verbal descriptors (e.g. mild, moderate, severe).2
However, these unidimensional tools do not account for contextual details, such as the location of the pain or the circumstances in which the pain arises.2 Daily pain diaries can be used to gain more accurate information of patient experiences, which are reported in real time rather than recalled.2
Pain intensity vs functionality
While pain intensity is often considered the primary aspect upon which the impact of pain is measured, physical function is an important indicator of the impact of disease on the daily lives of people living with medical conditions.5 Understanding the difficulty patients with chronic pain experience in performing everyday tasks can be challenging; patient goals are individual and not necessarily aligned with standard clinical outcome measures.5,6 Most patients find the inability to perform daily activities much more important than the pain itself; in a study of patients with chronic low back pain, 76% of patients set goals related to physical functioning.6 Clinicians should consider a more collaborative approach with patients to determine treatment interventions that are informed by patient preferences.6 A simple approach when considering how pain is affecting a patient, is to ask questions such as "do you cope?" to stimulate discussion beyond pain intensity and to consider more holistic aspects of a patient's life.