Assessment of patients with chronic pain.

Chronic pain is a public health concern affecting 20-30% of the population of Western countries. Although there have been many scientific advances in the understanding of the neurophysiology of pain, precisely assessing and diagnosing a patient's chronic pain problem is not straightforward or well-defined. How chronic pain is conceptualized influences how pain is evaluated and the factors considered when making a chronic pain diagnosis. There is no one-to-one relationship between the amount or type of organic pathology and pain intensity, but instead, the chronic pain experience is shaped by a myriad of biomedical, psychosocial (e.g. patients' beliefs, expectations, and mood), and behavioural factors (e.g. context, responses by significant others). Assessing each of these three domains through a comprehensive evaluation of the person with chronic pain is essential for treatment decisions and to facilitate optimal outcomes. This evaluation should include a thorough patient history and medical evaluation and a brief screening interview where the patient's behaviour can be observed. Further assessment to address questions identified during the initial evaluation will guide decisions as to what additional assessments, if any, may be appropriate. Standardized self-reported instruments to evaluate the patient's pain intensity, functional abilities, beliefs and expectations, and emotional distress are available, and can be administered by the physician, or a referral for in depth evaluation can be made to assist in treatment planning.

Assessment of patients' reporting of pain: an integrated perspective.

A common assumption about pain is that it always results from the presence of underlying organic pathology. In the absence of objective pathology, an individual's report of pain may be ascribed to psychological causes. There is a wide variation in patient's experience of pain and organic factors alone cannot explain individual differences in patients' reports. Assessment of patients who report pain requires attention to psychosocial, behavioural, and organic factors. We describe a comprehensive approach to the assessment of psychological and behavioural variables that affect patients' reports of pain. We counter the duality of the somatogenic versus psychogenic perspective and suggest a more integrated assessment that encompasses not only the severity of pain and related physical pathology but also the person who is reporting the presence of pain.

Psychosocial and behavioral assessment of patients with temporomandibular disorders: diagnostic and treatment implications.

The literature on chronic pain reveals that several psychosocial and behavioral factors, in addition to physical pathology, play a role in reports of pain and disability. Therefore it is important to assess patients more broadly rather than focus exclusively on physical pathology. Understanding and treatment of temporomandibular disorders has been impeded by the lack of agreement on a classification system with which to make a differential diagnosis. Research supports the appropriateness of a dual-diagnostic approach for temporomandibular disorders based on physical and psychological axes. Treatment should be directed toward the physical diagnoses supplemented by treatment that targets relevant psychosocial characteristics. This approach encourages diagnosticians to think in terms of the two relevant axes and to customize treatment to physical and psychosocial characteristics and thus should foster better outcomes.

Effects of type of symptom onset on psychological distress and disability in fibromyalgia syndrome patients.

The purpose of the study was to investigate the differences between two types of onset (post-traumatic versus idiopathic) in pain, disability, and psychological distress in patients with fibromyalgia syndrome (FS). Forty-six FS patients with post-traumatic onset and 46 FM patients with idiopathic onset, who were matched in age and pain duration, were included in the study. All participants completed self-report inventories assessing their adaptation to the pain conditions, and during the medical examination, an examining physician completed an inventory (Medical Examination and Diagnostic Information Coding System; MEDICS) to indicate the degree of physical abnormality. The analysis revealed that the degrees of physical abnormality of the patients were comparable in the two groups. However, controlling for the involvement with financial compensation issues (e.g. disability, litigation), the post-traumatic FS patients reported significantly higher degrees of pain, disability, life interference, and affective distress as well as lower level of activity than did the idiopathic FS patients. Furthermore, evaluation of the treatment history in these patients revealed that a significantly larger number of the posttraumatic FS patients were receiving opioid medications and had been treated with nerve block, physical therapy, and TENS. The results suggest that (1) post-traumatic onset is associated with high level of difficulties in adaptation to chronic FS symptoms and (2) FS patients are a heterogeneous group of patients.

Perception of traumatic onset, compensation status, and physical findings: impact on pain severity, emotional distress, and disability in chronic pain patients.

The primary purposes of the present study were to investigate the roles of physical findings, financial compensation, and types of pain onset (i.e., trauma vs. insidious onset) on adaptation by chronic pain patients. Comparisons between patients who were receiving or seeking compensation and those who were not revealed that, despite comparable degrees of physical findings, the compensation status was associated with reports of (a) more severe pain, (b) greater disability, (c) higher levels of emotional distress, and (d) greater life interference. The compensation status of 74% of the patients was correctly classified by combination of pain severity, perceived disability, and life interference. Objective indices of physical findings did not significantly improve classification accuracy. In order to eliminate the possible confound of compensation, analyses of the relationship between the types of onset and chronic pain were conducted only for a subset of patients who were not receiving or actively seeking compensation. The results indicated that the patients who attributed their pain to a specific trauma reported significantly higher levels of emotional distress, life interference, and higher levels of pain severity than did the patients who indicated that their pain had an insidious or spontaneous onset, regardless of the extent of objective physical findings.

Facilitating the use of noninvasive pain management strategies with the terminally ill.

In this paper a number of issues that appear to transcend the range of noninvasive interventions described in this volume are examined. Specifically, we raise the important issue of barriers to treatment. Among those discussed are patients', their significant others', as well as health care providers' conceptualizations of and biases regarding pain and pain control. We emphasize that it is important not only to focus on the details of the specific techniques described but also on how most effectively to present information. We note that it is important to customize any noninvasive intervention to the specific needs of the patient and their significant others. We provide some suggestions as to how this might be accomplished. Finally, we discuss some attitudes and beliefs held by health care providers that may inhibit their use of the full range of noninvasive techniques that are available for managing pain.

Persistent pain and the injured worker: Integrating biomedical, psychosocial, and behavioral factors in assessment.

Health care providers are often asked to determine the level of impairment, degree of disability, and rehabilitation potential for injured workers. Compalints of persistent pain and especially compalaints that are: (1) not substantiated or that are disproportionate to physical pathology identified by physical examination and laboratory diagnostic procedures, or (2) that prove to be differentially responsive to identical treatments that are technically appropriate cause a great deal of frustration for health care providers and third-party payers. Much of the confusion in this area relates to the minimal association between (1) the extent of impairment and degree of disability, and (2) between the magnitude of physical pathology and severity of the pain report. In this paper, we discuss factors that contribute tothe frustration and confusion and propose a comprehensive biobehavioral model that integrates biomedical, psychosocial, and behavioral variables. We also present an assessment model, the Multiaxial Assessment of Pain (MAP) patients, and describe operationalizations of the primary components of this model.

Conceptual issues in the assessment of clinical pain.

A number of approaches to the clinical assessment of pain are examined. Emphasis is placed on the importance of matching assessment procedures with specific research or referral questions being addressed. The importance of a comprehensive approach in which cognitive, affective, and behavioral, as well as sensory-physiological dimensions are assessed is discussed drawing on three case examples. Methodological and conceptual issues of pain assessment are examined and guidelines for comprehensive pain assessment are offered.