SOAP. – Chronic Pain

Chronic Pain

Moya Cook, Jill C.  Cash, and Kathleen Bradbury-Golas

Definition

1. See section Acute Pain for general statements about pain.
2. Chronic pain is defined as alteration in comfort that persists longer than 3 months (or longer than the anticipated healing time).
3. The pain may be continuous or recurrent and of sufficient duration and intensity. Legitimate chronic pain interferes with a patient’s ability to function with normal daily activities and decreases quality of life.
4. Chronic pain can be chronic cancer pain , where there is an expected end (either with cure or death) or chronic non-malignant pain, where there is no predictable ending or cure.

Incidence

1. Pain syndromes are commonly seen in clinical practice and are the third most widespread health problem in the United States. As of 2012, chronic pain cost the American people about $635 billion a year in healthcare expenses, disability costs, and lost productivity. Approximately 20% to 30% of adults in the United States experience chronic pain. As the U.S. population continues to age, more people develop pain-associated medical conditions (obesity, diabetes mellitus [DM]), and the average life expectancy increases, the primary care provider will be providing care for more chronic diseases and handling more chronic pain patients:
2. Women are affected more than men by two to one.
3. Onset is usually in the fourth, fifth, or sixth decades and is often associated with marked functional disability.

Pathogenesis

1. Skeletal muscle pain is pain in soft tissue involving the neck, shoulders, trunk, arms, low back, hips, and lower extremities. Myofascial pain syndrome relates to the fascia surrounding the muscle tissue.
2. Inflammatory pain is caused by chemicals, such as prostaglandins, leading to the stimulation of the pain receptors. Examples include arthritis, infection, tissue injury, and postoperative pain.
3. Mechanical/compressive pain is the direct result of the muscle, ligament, and tendon causing strain, leading to the stimulation of the pain receptors. Diagnosis may be based on diagnostic imaging results that may include fracture, obstruction, dislocation, or compression of tissue by tumor, cyst, or bony structure.
4. Neuropathic pain involves dysfunction of the somatosensory system. The most common types are diabetic neuropathy, sciatica from nerve root compression, trigeminal neuralgia, and postherpetic neuralgia.
5. Nociceptive pain is caused by nociceptors, a type of sensory neuron that receives the pain signal. Mechanical/compressive and inflammatory pain are examples of this type of pain. They both respond well to opioids, with the exception of arthritis. However, opioids should not be the initial management, as other modalities may be just as effective.

Predisposing Factors

1. Age 30 to 50 years.
2. Female gender.
3. History of having seen many physicians.
4. Frequent use of several nonspecific medications.
5. Depression—major depressive disorder is the single most important prevalent chronic pain morbidity.
6. Personality, including moods, fears, expectations, coping efforts, and resources

Common Complaints

1. Specific to site of pain.
2. Emotional distress related to fear, maladaptive or inadequate support systems, and other coping resources.
3. Treatment-induced complications.
4. Overuse of drugs.
5. Inability to work.
6. Financial complications.
7. Disruption of usual activities.
8. Sleep disturbances.
9. Pain becomes primary life focus.

Other Signs and Symptoms

1. Pain lasts longer than 3 months.
2. There may be anger and loss of faith or trust in the healthcare system. This type of patient frequently takes too many medications, stays in bed a great deal, has seen many physicians, has lost skills, and experiences little joy in either work or play.

Subjective Data

1. Elicit a clear description of the onset, location, quality, intensity, and time course of pain and any factors that aggravate or relieve it. Use the acronym OLD CARTS-U. O = onset, L = location, D = duration, C = characteristics, A = aggravating triggers, R = relieving triggers, T = timing, S = severity, U = YOU, What do YOU think is going on? What have YOU done to relieve it?
2. Self-reporting pain assessment tools should be used early in the process of patient evaluation. Use the tool at each office visit to see progression or regression. Lack of pain assessment is a barrier to good pain control. Consider the age of the patient; his or her physical, emotional, and cognitive status; and preference when choosing the self-reporting pain assessment tool:
3. Verbal rating scales rate pain as mild, moderate, or severe.
4. Numeric rating scales rate pain intensity from 0 to 10. They are patient friendly and quick to complete.
5. The Faces Scale is useful for pediatric and cognitively impaired patients. Multicultural translations may be downloaded at wongbakerfaces.org.
6. There are also several scales that combine different dimensions of the pain experience. Examples include the McGill Pain Questionnaire (long and short versions).
7. Determine the extent to which the patient is suffering, disabled, and unable to enjoy usual activity. It is important to inquire about activities of daily living (ADLs) and functional limitations. Disability refers to the inability to do one’s usual activities as a result of impairment. There is no gold standard for assessing disability as each organization has different requirements for evaluation and documentation.
8. Obtain a complete review of systems, including nausea, numbness, weakness, insomnia, loss of appetite, dysphoria, malaise, fatigue, or depression signs and symptoms.
9. Obtain a complete family and social history. Address spiritual and cultural issues. Evaluation of the risk for opioid dependence/abuse in this population is essential. There are several instruments that can be used, such as The Screening Instrument for Substance Abuse Potential.
10. Obtain the patient’s medical history relevant to the pain, including diagnosis, testing, treatments, and outcomes.
11. Obtain a pain history to identify the patient’s attitudes, beliefs, level of knowledge, and previous experiences with pain. Are previously used methods for pain control helpful? What is the patient’s attitude toward the use of certain pain medications? Often, the patient will discuss certain adverse side effects or allergies from undesired pain medication.

Physical Examination

1. Check temperature, pulse, respirations, and blood pressure.
2. Inspect:
3. Observe overall appearance.
4. Note affect and ability to express self and pain.
5. Note facial grimaces with movement.
6. Note gait, stance, and movements.
7. Inspect area at pain site.
8. Auscultate:
9. Auscultate heart and lungs.
10. Auscultate neck and abdomen.
11. Palpate: Palpate affected area of pain.
12. Percuss:
13. Percuss chest.
14. Percuss abdomen.
15. Perform musculoskeletal exam:
16. Perform a complete musculoskeletal exam, concentrating on the area of pain.
17. Note limitations in range of motion.

When performing a musculoskeletal exam, identify the location of pain, presence of trigger points, evidence of injury or trauma, edema, erythema, warmth, heat, lesions, petechiae, tenderness, decreased range of motion, pain with movement, crepitus, laxity of ligaments or cords, spasms, or guarding.

1. Neurologic exam:
2. Perform complete neurologic exam.
3. Note the patient’s affect and mood. Is patient cooperative during exam?
4. Identify change in sensory function, skin tenderness, weakness, muscle atrophy, and/or loss of deep tendon reflexes (DTRs).
5. Functional assessment:
6. The baseline functional assessment provides objective measurable data on a patient’s physical abilities and limitations. It can be used to determine if the patient’s efforts are valid and complaints are reliable.
7. The information may be used to identify areas of impairment, establish specific functional goals, and measure the effectiveness of treatment interventions.
8. This objective data may be used in worker compensation cases, returning to work status, federal disability, and motor vehicle accident lawsuits.
9. Know the resources in your area that are trained to perform functional assessments. Physical therapists and occupational therapists are the best qualified to perform the assessments.

Diagnostic Tests

1. None are required unless clearly indicated to rule out the organic cause of pain:
2. Remember that pain previously diagnosed as chronic pain syndrome can be organic and vice versa. Organic causes must always be evaluated and excluded.
3. Health insurance usually requires plain radiography ordered first for muscle, inflammatory, or skeletal pain. Plain radiography will diagnose a fracture. Additional studies may be recommended by the radiologist if a lesion/abnormality is seen on plain radiography.
4. MRI and CT are ordered if the plain radiography is negative and the patient continues to complain of pain.
5. Electromyography and nerve conduction studies are used to evaluate neuropathic pain. Numerous serum and urine studies should also be considered if the neuropathic pain is undiagnosed.
6. Consider using a depression assessment tool such as the Beck Depression Inventory or Patient Health Questionnaire 9 (PHQ9). These tools can be administered at a subsequent appointment to follow the patient’s symptoms.

Differential Diagnosis

1. Pain disorder.
2. Pain related to a disease with no cure.
3. Somatization disorder.
4. Conversion disorder.
5. Hypochondriasis.
6. Depression.
7. Chemical dependency.
8. Fibromyalgia.

Plan

1. General interventions:
2. Treatment is multidimensional and should not be focused on pharmacological treatment alone.
3. Offer hope and potential for improvement of pain control and of function but not always cure.
4. The pain is real to the patient, and acceptance of the problem must occur before a mutually agreed on treatment plan can be initiated.
5. Depression is a common emotional disturbance in chronic pain patients and is treatable. Consider oral therapy. See section Depression in Chapter 25.
6. Identify specific and realistic goals for therapy such as having a good night’s sleep, going shopping, or returning to work. Patient discussion needs to include the idea that the goal may be decreasing pain intensity, not eliminating pain.
7. Carefully assess the level of pain using available tools such as a daily pain diary or other pain assessment scales.
8. Avoid pain reinforcement such as sympathy and attention to pain. Provide positive response to productive activities. Improving activity tolerance assists in desensitizing the patient to pain.
9. Shift the focus from the pain to accomplishing daily assigned self-help tasks. The accomplishment of these tasks functions as positive reinforcement.