DEFINATION Pain is an unpleasant feeling often caused by intense or damaging stimuli, such as stubbing a toe, burning a finger, putting

alcohol on a cut, and bumping the "funny bone."[1]The International Association for the Study of Pain's widely used definition states: "Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage".[2] Pain motivates the individual to withdraw from damaging situations, to protect a damaged body part while it heals, and to avoid similar experiences in the future.[3] Most pain resolves promptly once the painful stimulus is removed and the body has healed, but sometimes pain persists despite removal of the stimulus and apparent healing of the body; and sometimes pain arises in the absence of any detectable stimulus, damage or disease.[4] Pain is the most common reason for physician consultation in the United States.[5] It is a major symptom in many medical conditions, and can significantly interfere with a person'squality of life and general functioning.[6] Psychological factors such as social support, hypnotic suggestion, excitement, or distraction can significantly modulate pain's intensity or unpleasantness.

Types of Pain
Pain is divided into two types: 1. Acute pain 2. Chronic pain Acute pain is pain of sudden onset, lasting for hours to days and disappears once the underlying cause is treated. Acute pain has a clear cause. It could result from any illness, trauma, surgery or any painful medical procedures. Hence it is beneficial to the patient because but for the pain, the individual will ignore his illness resulting in complications and even death. Acute pain signals that there is something wrong and motivates the person to get help. For example- just because the nociception is caused by appendicitis, the person consults a doctor and undergoes surgery to get relieved. If pain is not there he will not seek medical advice and his appendix may burst and form a mass which is more difficult to treat. Thus acute pain can be beneficial. Examples of acute pain include: • • • • • the pain of heart attack acute appendicitis bone fracture muscle sprain prolapsed intervertebral disc of the spine

Chronic pain is the pain that starts as an acute pain and continues beyond the normal time expected for resolution of the problem or persists or recurs for various other reasons It is not therapeutically beneficial to the patient.

In acute pain, attention is focused to treat the cause of pain whereas in chronic pain, the emphasis is laid upon reducing the pain to give relief, limit disability and improve function. About 9% of the US population and 18% of the European population suffer from chronic pain. It is rarely accompanied by signs of sympathetic nervous system arousal. The severity and extent of chronic pain may be out of proportion to the original injury and may continue long past the period in which the damage tissue has healed. Chronic pain is pain that has outlived its usefulness and is no longer beneficial. Acute & Chronic Pain Treatment Goals Acute and chronic pains have different treatment goals. The primary goal of acute pain treatment is to diagnose the source and remove it. With chronic pain, the main goals are to minimize the pain and maximize the person’s functioning. Complete relief of pain is rare in chronic pain. The more realistic goal is to decrease the level of pain to a tolerable level that allows the person focus on everyday activities. The treatment of chronic pain is multidisciplinary that blends physical, emotional, intellectual and social skills. Returning to work is clearly a desirable goal, but in fact, only 50% percent of patients who undergo comprehensive multidisciplinary pain rehabilitation are able to return to work. Chronic pain is further divided into: 1. Nociceptive pain 2. Neuropathic pain Nociceptive pain: Nociceptive pain is pain arising from damage to tissues other than nerve fibers. It is also called tissue pain. The undamaged nerve cells called nociceptors carry the sensation to spinal cord from where it is relayed to the brain. It is called somatic pain if it results from injury to muscles, tendons and ligaments. Somatic pain is usually well localized. It is called visceral pain if it results from injury to the internal organs like stomach, gall bladder and urinary bladder. Visceral pain is usually diffuse and non-localizing. Somatic pain in turn is classified in to cutaneous somatic pain if the pain arises from the skin and deep somatic pain if it is from deeper musculoskeletal tissues. The various causes of joint pain are grouped under musculoskeletal pain. Neuropathic Pain: Neuropathic pain is the pain caused by the lesion in the nervous system when they are structurally or functionally damaged. It is called central pain if the lesion is the central nervous system. It is called peripheral neuropathic pain if the lesion is in the peripheral nervous system. The neuropathic pain is described as severe, sharp, lancinating, lightning-like, stabbing, burning, cold, numbness, tingling or weakness. It may be felt traveling along the nerve path from the spine down to the arms/hands or legs/feet. It does not respond to the routine analgesics. Keep in mind that nociceptive and neuropathic pain can co-exist in the same patient in certain conditions like Sciatica.

Many other types of pain are also described. • • • • • • • • • • • • • Malignant pain Breakthrough pain Allodynia Hyperalgesia Paresthesia Hyperpathia Complex Regional Pain Syndrome I Complex Regional Pain Syndrome II Phantom limb pain Psychogenic pain Anesthesia dolorosa Anginal pain Idiopathic pain

Malignant pain: Malignant pain is the pain suffered by the patients with cancer. The pain can be either due to the disease itself or due to the treatment given for cancer like surgery, radiotherapy and chemotherapy. Breakthrough pain: When pre-existing chronic pain is aggravated, it results in breakthrough pain needing adjustments in treatment to obtain relief. In other words, breakthrough pain is the pain that results from the worsening of the previously present chronic pain for which the person is on regular treatment. It usually comes on quickly and may last from a few minutes to an hour. The reason for this worsening of pain cannot be understood or anticipated by the person. The routine doses of analgesic never help and a readjustment of the analgesic doses is necessary along with the modification of the physical activities. Allodynia: Allodynia is a pain that results from the stimulus which does not normally evoke any pain sensation. Many people aquire allodynia after they've been in pain for quite some time and they become hypersensitive to touch. Hyperalgesia: Hyperalgesia is an increased response to a stimulus which is normally painful. Paresthesia: Paresthesia is abnormal sensation which is described as “pins and needles”. It can occur either spontaneously or evoked by certain stimuli.

but it often differs from any sensation previously experienced. This results from abnormal connections between various nerves. stiff and atrophied.Hyperpathia: Hyperpathia is a painful syndrome resulting from an abnormally painful reaction to a stimulus. The stimulus in most of the cases is repetitive with an increased pain threshold. . The brain misinterprets the nerve signals as coming from the amputated limb. The phantom limb pain is described as squeezing. The person affected usually complains of cool. cold. Sometimes psychogenic factors may worsen a pre-existing physical pain. Though it is termed psychogenic the person suffers from real pain. becoming atrophic later. Anesthesia dolorosa: Anesthesia dolorosa is the pain that is felt in the part of the body that is numb to any other sensation. or crushing sensations. it is called idiopathic pain. It is described as a feeling of oppression or tightness. The skin of the person affected is classically cold. moist and swollen. Psychogenic pain: Psychogenic pain is seen in persons with psychological disorders. Phantom limb pain: Phantom limb pain is the pain that is felt in the amputated part of the body. They have persistent pain without any evidence of physical cause of pain. The pain does not correspond to the distribution of a single nerve and it is worsened by movement. Pain threshold can be defined as the least experience of pain which a subject can recognize. It occurs due to disruption of the blood supply to the heart muscle. Anginal pain: Anginal pain is the pain of cardiac origin. Complex Regional Pain Syndrome I: Complex Regional Pain syndrome I also called as Reflex Sympathetic Dystrophy is a continuous pain in the form of either allodynia or hyperalgesia in the extremities resulting from trauma which is associated with sympathetic hyperactivity. Complex Regional Pain Syndrome II: Complex Regional Pain Syndrome II also called as Causalgia is a burning type of pain along the distribution a partially damaged peripheral nerve. burning. This pain is also called chronic pain syndrome. clammy skin which later becomes pale. The pain extends beyond the distribution of the nerve. Idiopathic pain: When a reasonable cause for the pain cannot be made out.

palliative medicine and psychiatry. is much more difficult and may require the coordinated efforts of a pain management team. that chronic pain should be considered a disease in its own right.[74] [75] Sweet oral liquid moderately reduces the incidence and duration of crying caused by immunization injection in children between one and twelve months of age.[70] Elsewhere. neurology.[80] 3. take less pain medication.clinical psychologists. which typically includes medical practitioners. About 35% of people report marked relief after receiving a saline injection they believe to have been morphine.[81] An analysis of the 13 highest quality studies of pain treatment with acupuncture.[68] The International Association for the Study of Pain advocates that the relief of pain should be recognized as a human right. Medication Acute pain is usually managed with medications such as analgesics and anesthetics.Psychological Individuals with more social support experience less cancer pain. however.[82] There is interest in the relationship between vitamin D and pain. occupational therapists. but it does not account for all of the effect.MANAGEMENT Inadequate treatment of pain is widespread throughout surgical wards. pain medicine is a subspecialty under disciplines such asanesthesiology. so anxiety reduction may account for some of the effect. sham and no acupuncture. physician assistants. 1. This "placebo" effect is more pronounced in people who are prone to anxiety. physiatry.[67] and women's pain is more likely to be undertreated than men's.[78] It is possible for many chronic pain sufferers to become so absorbed in an activity or entertainment that the pain is no longer felt. Management of chronic pain. report less labor pain and are less likely to use epidural anesthesia during childbirth or suffer from chest pain after coronary artery bypass surgery. published in January 2009 in the British Medical Journal. accident and emergency departments. and nurse practitioners. and they produce progressively weaker effects with repeated administration. from neonates to the frail elderly.[69] It is a specialty only in China and Australia at this time. and the CBT method employed seems to have no effect on outcome. physiotherapists. Placebos are more effective in intense pain than mild pain.[72] Sugar taken orally reduces the total crying time but not the duration of the first cry in newborns undergoing a painful procedure (a single lancing of the heel).[65] This neglect is extended to all ages. and in end of life care. but the .[77] Suggestion can significantly affect pain intensity. in the management of all forms of chronic pain including cancer pain.[79] Cognitive behavioral therapy (CBT) is effective in reducing the suffering associated with chronic pain in some patients but the reduction in suffering is quite modest.[66] African and Hispanic Americans are more likely than others to suffer needlessly in the hands of a physician. or is greatly diminished. in general practice. It does not moderate the effect of pain on heart rate[73] and a recent single study found that sugar did not significantly affect painrelated electrical activity in the brains of newborns one second after the heel lance procedure. concluded there is little difference in the effect of real. and that pain medicine should have the full status of a specialty.[76] 2. intensive care units.Alternative medicine Pain is the most common reason for people to use complementary and alternative medicine.

an increase in confusion or display of aggressive behaviors or agitation. Analysis of MPI results by Turk and Rudy (1988) found three classes of chronic pain patient: "(a) dysfunctional. 1. observation becomes critical. Quality can be established by having the patient complete the McGill Pain Questionnaire indicating which words best describe their pain.[59] To assess intensity. other than in osteomalacia. and relatively high levels of activity. may signal that discomfort exists. A change in condition that deviates from baseline such as moaning with movement or when manipulating a body part. as well as an increase or decrease in vocalizations. though the number of patients enrolled in the studies was low."[60] Combining the MPI characterization of the person with their IASP five-category pain profile is recommended for deriving the most useful case description. and limited range of motion are also potential pain indicators. such as those with dementia. with 0 being no pain at all. analgesics."[84] A 2003 meta-analysis of randomized clinical trials found that spinal manipulation was "more effective than sham therapy but was no more or less effective than general practitioner care.[83] A 2007 review of 13 studies found evidence for the efficacy of hypnosis in the reduction of pain in some conditions. considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions. and most lacked credible controls for placebo and/or expectation. In patients who possess language but are incapable of expressing themselves effectively.[85] ASSESSMENT A person's self report is the most reliable measure of pain.[58] A definition of pain widely employed in nursing. existing whenever he says it does". and specific behaviors can be monitored as pain indicators. and 10 the worst pain they have ever felt. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain. bringing up issues of power to detect group differences.evidence so far from controlled trials for such a relationship. people with a common perception that significant others were not very supportive of their pain problems. was introduced by Margo McCaffery in 1968: "Pain is whatever the experiencing person says it is. reported that pain interfered with much of their lives. and further assessment is necessary. changes in routine behavior patterns and mental status changes. the patient may be asked to locate their pain on a scale of 0 to 10. relatively low levels of pain and perceived interference. Behaviors such as facial grimacing and guarding indicate pain. and (c) adaptive copers. emphasizing its subjective nature and the importance of believing patient reports. is unconvincing. Patients experiencing pain may exhibit withdrawn social behavior and possibly experience a decreased appetite and decreased nutritional intake. people who perceived the severity of their pain to be high. physical therapy. reported a higher degree of psychological distress caused by pain. In nonverbal patients When a person is non-verbal and cannot self report pain. (b) interpersonally distressed. with health care professionals tending to underestimate severity. patients who reported high levels of social support. exercise. . 2.Multidimensional pain inventory The Multidimensional Pain Inventory (MPI) is a questionnaire designed to assess the psychosocial state of a person with chronic pain. and reported low levels of activity. or back school" in the treatment of low back pain.

A thorough pain assessment is critical. while other cultures (e. 4. exacerbating and relieving factors. nurses must be able to assess and treat pain in elderly persons. They may feel certain pain treatment is against their religion. as the information obtained guides the plan of care. elders are at great risk for undertreatment of pain. intensity. Many Asians do not want to lose respect in society by admitting they are in pain and need help. including both pharmacologic and non-pharmacologic therapies. pattern of occurrence (continuous. Other barriers to reporting An aging adult may not respond to pain in the way that a younger person would. 3. CONCLUSION Due to barriers in the health care system. and society.As an aid to diagnosis Pain is a symptom of many medical conditions.. For example. Lynette Menefee tackles pressing issues in pain management with one of the nation's leading practitioners. with women expected to be emotional and show pain and men stoic.[62] Cultural barriers can also keep a person from telling someone they are in pain. keeping pain to themselves. location. Religious beliefs may prevent the individual from seeking help. Principal Investigator and Project Director for the Pain and Emergency Medicine . Knowing the time of onset. Part II An Interview with Knox Todd. A non-verbal pain assessment should be conducted involving the parents.D.).[61] Gender can also be a factor in reporting pain. the patient. etc. Dr. The older adult may refrain from reporting pain because they are afraid they will have to have surgery or will be put on a drug they become addicted to. Their ability to recognize pain may be blunted by illness or the use of multiple prescription drugs. or they may feel the pain is deserved punishment for past transgressions. etc.Gender differences are usually the result of social and cultural expectations. Menefee speaks again with Knox Todd. walking. grooming. This month. Pre-term babies are more sensitive to painful stimuli than full term babies. Many people fear the stigma of addiction and avoid pain treatment so as not to be prescribed addicting drugs. Depression may also keep the older adult from reporting they are in pain. etc. M. To meet the special pain-related needs of this fastest growing segment of the population. M. Jewish) feel they should report pain right away and get immediate relief.g. The older adult may also quit doing activities they love because it hurts too much.) of the pain will help the examining physician to accurately diagnose the problem. and quality (burning. intermittent. so communicate distress by crying. sharp.Infants feel pain but they lack the language needed to report it. Dr. chest pain described as extreme heaviness may indicate myocardial infarction. or may feel there is something impolite or shameful in complaining about pain. They may not report pain because they feel it is a sign that death is near.D. Pain Management in the Emergency Room. Each month. believing the pain should be borne in silence. while chest pain described as tearing may indicate aortic dissection. who will notice changes in the infant not obvious to the health care provider.) may also be indicators that the older adult is experiencing pain. Decline in self-care activities (dressing. They may not want others to see them as weak.

we conducted a series of studies documenting tremendous ethnic disparities in the use of analgesics for patients with long-bone fractures. M. a condition that most of us will agree is consistently painful. This work was conducted in the early 1990’s and was the first to recognize ethnic pain management disparities. you have certainly had the opportunity to be exposed to patients with pain and different pain management options. Todd is also on the faculty at Emory University School of Medicine. one of my mentors involved me in a study examining cultural determinants of disease management among Hispanics with symptoms referable to the gallbladder. How did this topic come to your awareness? 2: Whom do you think is treated differently by emergency department physicians? 3: Can you give us an example from your experience of differing treatment based on ethnicity? 4: What steps can clinicians take to reduce the possibilities of prescribing different pain treatment based on ethnicity? 5: What would you like other physicians to know about pain treatment in emergency departments? -------------------------------------------------------------------------------------------------------------------------Dr.: My early clinical experience was in Texas and California and I became interested in patient/physician communication barriers resulting from differences in language and culture that affected members of minority groups. I was particularly interested in the role of translators. In this interview he continues his converstaion about pain management in the emergency room setting as well as ethnic disparities in the treatment of pain.D. you have certainly had the opportunity to be exposed to patients with pain and different pain management options. This phenomenon is clearly not limited to emergency departments. How did this topic come to your awareness? Knox Todd. Dr. Todd. I began my emergency medicine training and soon noted that cries of pain from our trauma resuscitation room were most often in Spanish. Additional studies by our group . You have also written articles on ethnic disparities in pain management. As an emergency medicine physician.Initiative. I found remarkable differences in the amount of morphine administered to Hispanics when compared to whites. Briefly. Our findings received a good deal of attention at the time and many researchers have reported similar disparities in multiple clinical arenas. On review of our trauma registry records. our studies found that whites with long-bone fractures were much more likely to be treated with analgesics than both Hispanics and African-Americans. Lynette Menefee: Dr. despite the fact that Hispanics constituted a minority of our trauma patient volume. With that background. In Texas. -------------------------------------------------------------------------------------------------------------------------Questions 1: As an emergency medicine physician. In following up on this finding. You have also written articles on ethnic disparities in pain management. it’s great to talk with you again.

who was finding it difficult to fill my prescription.suggested that these treatment disparities could not be explained by language. The patient then signed out “against medical advice” and left the department before we saw him. The result could easily have been a preventable death. LM: Can you give us an example from your experience of differing treatment based on ethnicity? KT: I can give you a couple from personal experience. we have yet to develop the research to fully support this finding. we have relatively high quality evidence of disparate treatment patterns for the very young. in the face of a life and limb-threatening condition. This experience taught me something about our naiveté and the relative desirability of street versus prescribed opioid. I discharged her with a prescription for Dilaudid. there are few situations more rewarding than solving relatively simple problems in the emergency department within a short period of time. feeling that I was a swell clinician. There was little negotiation on this point. and for specific clinical conditions. Much more troubling was that on exam I found crepitance in the upper extremity leading to a diagnosis of necrotizing fasciitis. In Atlanta. non-verbal and cognitively impaired patients do not fare well. LM: Whom do you think is treated differently by emergency department physicians? KT: Beyond ethnicity. we had chosen a path of no negotiation. Would the situation have been different if the patient shared more characteristics with the treating intern? I suspect that it would. or a differential ability of physicians to assess pain in minority groups. Her analgesic regimen was clearly inadequate and after achieving control of her pain with intravenous opioids. Anecdotally. It was an easy diagnosis and perfectly explained his severe pain. After her oncology appointment (during which pain did not seem to be the focus of much discussion) she presented with her daughter to the emergency department with uncontrolled pain. I asked the daughter to drive back to my part of town. where her prescription was filled. seeming much more comfortable than his prior description. (It is likely that this random. however. when one of my interns treated an African-American man with extreme arm pain who was demanding pain relief. LM: What steps can clinicians take to reduce the possibilities of prescribing different pain treatment based on ethnicity? . The emergency department treatment of sickle cell crisis is particularly problematic. This was prior to Morrison’s influential publication documenting similar problems in New York City. the patient reappeared. I received the first of what were to be multiple phone calls from her daughter. After multiple conversations with multiple pharmacists. Thus. I cared for an African-American woman in her sixties with metastatic cancer. He had obviously gone to the parking lot and self-administered what was left of his personal opioid supply. Four pharmacies in her (minority) neighborhood simply did not carry Dilaudid.) Within an hour. intermittent reinforcement keeps medical students coming to our specialty in large numbers. The young man was an intravenous drug user and the intern refused to administer opioids without a complete examination. the elderly. The second case is more complex. with the potential for more lethal consequences. While talking to the intern. What had begun as a gratifying case became a further recognition of how far we have to go. patients’ expressions of pain. It occurred while in Los Angeles. Incidentally.

It is troubling that ten years after our first study documenting ethnic disparities in pain treatment. disagreements between patients and physicians occur because underlying concerns of either party remain unvoiced. we should routinely measure and report pain-related treatment and outcomes variables by ethnicity. ethnic disparities become less apparent. Simply monitoring and reporting such measures may have an impact. standardized protocols and policies. and evidence-based guidelines to drive and standardize our practice. take them seriously. LM: What would you like other physicians to know about pain treatment in emergency departments? KT: I think the first advice would be to more completely involve the patient in treatment decisions. In order to monitor our progress in this area. Core questions to be answered as part of a pain assessment: • • • • • • What is the type or category of pain? Is there a primary cause of the pain? What additional factors are contributing to the pain? Are treatments available for the primary cause of the pain? Are treatments available for the additional factors which contribute to the pain? Are there other medical or psychosocial conditions which should influence the choice of treatment? B. Although the first goal is laudable.KT: From the recent Institute of Medicine report we hear the usual calls to increase the diversity of the physician work force and conduct cultural competence training. we have yet to conduct a similar study using a nationally representative sample of emergency departments. OVERVIEW A A. Listen to patient concerns. MD I. Too often. It is this approach that holds the most immediate promise and highlights the potential value of quality improvement efforts. The Assessment of the Patient with Pain Written by Steven Richeimer. The methodology of the pain assessment: • • • • • • • History Past medical history Current medications Physical examination Special tests Psychological evaluation Differential diagnosis . and be open in dealing with problematic patients by explaining your thought processes. Studies by emergency physicians suggest that as we raise the standard for treatment of all patients. we do not expect immediate results and as for the second. There is a tremendous need for health services research in this area to document what works and advocacy to put proven interventions into practice. the value of cultural competency training is unproven at best.

impending injury. III. and the pain may persist for months or years beyond the apparent healing of any damaged tissues. or actual injury. These psychological factors may lead to an exaggerated or histrionic presentation of the pain problem. Nociceptive Pain -This is the typical pain that we have all experienced. In this setting. therefore. etc. and tends to have a less robust response to treatment with opioids. cognitive and affective responses. Neuropathic pain is frequently chronic. such as light touch--is also a common characteristic of neuropathic pain. it is valuable to give some focused attention to the specifics of the methodology for assessing this problem. as opposed to somatic pain which is more constant and well localized. Visceral pain is a subtype of nociceptive pain. CORE QUESTIONS TO BE ANSWERED AS PART OF A PAIN ASSESSMENT A. Persistent allodynia--pain resulting from a nonpainful stimulus. The pain is typically perceived as related to the specific stimulus (hot. Neuropathic Pain -Neuropathic pain is the result of a malfunction somewhere in the nervous system. The pain frequently has burning. It is universal that psychological factors play a role in the perception and complaint of pain. and possibly voluntary action. Nociceptive pain is usually time limited--arthritis is a notable exception--and tends to respond well to treatment with opioids. Nociceptors in the affected area are activated and then transmit signals via the peripheral nerves and the spinal cord to the brain. INTRODUCTION The basics of the assessment of pain are the same as the assessment of other medical complaints. Yet pain is the most common complaint that presents to the primary care practitioner. but this injury may not clearly involve the nervous system. pain signals no longer represent ongoing or impending injury. 2. It tends to be paroxysmal and poorly localized. . lancinating. Psychogenic Pain-The use of this category should be reserved for those rare situations where it is clear that no somatic disorder is present. 3. sharp. or electric shock qualities. It is the signal of tissue irritation. What is the type or category of pain? 8 1. followed by perception.II. The site of the nervous system injury or malfunction can be either in the peripheral or in the central nervous system. Complex spinal reflexes (withdrawal) may be activated. The pain is often triggered by an injury.) or with an aching or throbbing quality.

but even when they report similar degrees of pain. Usually. as precisely as possible. and peripheral neuropathy may respond to tricyclic antidepressants. including chronic myofascial pain. the human body is a complex machine which is separate and distinct from the mind and the process of perception. Myofascial pain is probably secondary to nociceptive input from the muscles. tear. or foreign body? Is there inflammation caused by an underlying arthritic or autoimmune disorder? Myofascial pain may indicate abnormal acute or chronic muscle stresses. therefore. Mood disorder-Depressive disorders are found in approximately 50% of chronic pain patients. An initial nervous system dysfunction or injury may trigger the neural release of inflammatory mediators and subsequent neurogenic inflammation. C. independent of what is occurring in the body. obstruction. but the injury in that case is actually to the nervous system. neuromas may respond to excision or ablation." however. it would be a mistake to ignore the depression. Frequently. Neuropathic pain may also be caused by injury. We now know that environmental and mental factors can be so critical that they can actually trigger or abolish the experience of pain. and other neuropathic etiologies. Nociceptive pain indicates ongoing or impending injury. . Furthermore. suffering should not be considered synonymous with pain. they may have vastly different amounts of suffering. identification and removal or treatment of the problem is critical. Nerves can be infiltrated or compressed by tumors. 33 The patient may say. What additional factors are contributing to the pain? For most of the last 300 years. For example. The emotional impact and distress caused by pain differs from person to person. B. Viewed from this perspective. Therefore. In some cases. migraine headaches probably represent a mixture of neuropathic and nociceptive pain. it is rare that the psychological factors represent the exclusive etiology of the patient's pain. Is there an underlying sprain. Experience is a function of the mind. Chronic pain. including their social-cultural background. may cause the development of ongoing representations of pain within the central nervous system which are independent of signals from the periphery. 4. infection. it is critical to remember that pain is an experience. phantom pain may respond to transcutaneous nerve stimulation (TENS). When assessing a complaint of pain. physical pain is a function of the mechanics of the body. reversible causes can be identified. therefore. the cause or specific source of the pain. we have come to appreciate that pain is an experience rather than a bodily function. but the abnormal muscle activity may be the result of neuropathic conditions. may also be reversible.but even in these circumstances. This is called the centralization or encephalization of pain. the next step is to determine. the experience of pain cannot be separated from the patient's mental state. For example. but partial improvement is often possible with proper treatment. and I won't be depressed. Depression can significantly intensify the experience of pain and the associated suffering. our understanding of pain has been dominated by the Cartesian model. Some of these.38 We now understand some of the mechanisms of how the brain can influence the spinal processing of pain via descending inhibitory and facilitory neural pathways. Therefore it is valuable to investigate the appropriate mental and environmental factors: 1. neuropathic problems are not fully reversible. strangulated by scar tissue. Is there a primary cause of the pain? After determining if the pain is most likely nociceptive or neuropathic. fracture. or inflamed by infection. "Cure the pain. Mixed Category Pain-In some conditions the pain appears to be caused by a complex mixture of nociceptive and neuropathic factors. rather than a bodily function. In the last 30 years. Different patients may report very different intensities of pain for similar injuries.

Malingering occurs in those rare situations where the patient is consciously lying about their condition for reasons of gain. They also incur benefits which may be financial or involve emotional support from friends and family. depression may even be the primary etiology of the pain. then there may be motivational factors impeding the recovery. on occasion. Are treatments available for the primary cause of the pain? 28. Anxiety disorder-Again. Emotional distress is often felt and expressed as physical distress. lead to excessive somatic attention and communication in the forms of somatization and hypochondriasis. These factors are frequently unconscious. These patients are prone to misinterpreting normal bodily sensations and to exaggerating the symptoms of illness. but often they are part of depressive or anxiety disorders.depression manifests primarily with somatic symptoms and complaints. 4. and impaired relationships. Also rarely. Other physical factors Other physical factors may also contribute to the experience of pain. and they are not usually the "cause" of the pain. but without conscious benefit or gain--this represents a factitious disorder. They are therefore more likely to believe that they are suffering from a catastrophic illness or complication. Somatization and hypochondriasis34-Stress affects the bodily functions and sensations in all people. These processes. the patient may be consciously lying about symptoms. 2. Secondary gain15-Patients with chronic pain undergo many losses--financial. Therefore.36 . recreational. These can sometimes be primary psychiatric disorders or tendencies. when predominant. 14 3. If the secondary gains outweigh the secondary losses. 5. including: • • • • sleep disturbance inactivity and poor muscle conditioning weight gain other injuries or illnesses D. vocational. more than 50% of chronic pain patients suffer with anxiety disorders which may alter the experience of pain and suffering.

and terazosin may be helpful in decreasing allodynia and hyperalgesia. in part. TENS (transcutaneous electrical nerve stimulation) units and relaxation training may also benefit the patient suffering with nociceptive pain. synergistic effects can be achieved by combining these medications. Psychotherapy may also help the patient to . the clinician must be diligently searching for underlying sources of tissue injury. Therefore. nonsteroidal antiinflammatory drugs. and thereby decrease ectopic or abnormal firing with in damaged. Nociceptive pain is usually quite responsive to treatment with classical analgesics such as narcotics. Antiarrhythmics. malfunctioning. but we must pay attention to this factor. Other treatments might include nerve blocks. be the result of the production of increased numbers of adrenergic receptors on sensory nerve terminals and on surrounding inflammatory and mast cells. Appropriate therapy with antidepressants or anxiolytics. sympatholytics such as clonidine. Clearly. nor is it treated. is a relatively poor candidate for invasive treatments. psychological and physical therapies. or inflammation. but less robustly than does nociceptive pain. Subsequent chapters in this handbook will help to find information regarding available therapies. If depression or anxiety are contributing. pain producing parts of the nervous system. prazosin. here too. 31 Secondary gain is not an illness. The physician must be careful not to alter the balance of secondary losses versus secondary gains in such a manner that tips the scales in the direction of greater illness and disability. should be instituted early in the treatment process. E. together with psychotherapy. Somatization and hypochondriasis are more chronic and relatively more refractory conditions. since such interventions are likely to exacerbate the patients somatic concerns and preoccupation. Neuropathic pain also typically responds to treatment with narcotics. For example. these are highly treatable conditions. may alter neuronal sodium channel conduction. nociceptive pain. regional or nerve block techniques may also be effective. irritation. The allodynia (pain in response to a non-noxious stimulus) and hyperalgesia present in some neuropathic conditions may. Frequently. psychotherapeutic and possibly psychopharmacologic interventions may be critically helpful components of the treatment for the chronic pain patient. or acetaminophen. TENS units. For acute. Are treatments available for the additional factors which contribute to the pain? For pain treatments to be fully effective it is critical that all factors be treated simultaneously. biofeedback. An understanding of these factors will also help to guide all aspects of the patients treatment. the patient who is prone to high levels of somatization. Referral to a Pain Clinic may be helpful in guiding further treatment or complex pharmacotherapy for the patient with chronic neuropathic pain. most notably mexiletine. Anticonvulsants and tricyclic antidepressants may be particularly beneficial.The physician will find it valuable to have some familiarity with the treatments available for various pain syndromes. while analgesia is being provided. However.

IV. in a vicious cycle. such as spinal dorsal column stimulators and intrathecal morphine pumps.recognize that disability is associated with greater losses and fewer gains than the patient might consciously or unconsciously realize. such as sleep. THE METHODOLOGY OF THE PAIN ASSESSMENT The previous section reviewed the overall questions that the care provider should keep in mind when assessing a complaint of pain. 15. but recognition of malingering can help to avoid unnecessary. be exacerbated by these same problems. a history of recent drug abuse indicates a need to avoid narcotics or benzodiazepines where possible. When treating the patient it is important to consider what other conditions or factors (which are not directly contributory to the pain) might influence the choice of treatment. Some of the newer and more invasive pain therapies. such cardiac or pulmonary disease. 12 . Examples include arrhythmias (especially bundle branch blocks) as a relative contraindication for tricyclic antidepressants or for right stellate ganglion blocks. and pulmonary disease in general as a cautionary note regarding the use of narcotics (especially intravenous narcotics). The next section provides some of the specifics of the data gathering process. Appropriate medical management focused on these problems can be most beneficial. may be relative contraindications for some medications or for various blocks. Are there other medical or psychosocial conditions which should influence the choice of treatment? 31 The previous questions have focused on understanding the nature of the patient's pain and the additional factors contributing to the problem. and high levels of somatization or anxiety argue against the use of invasive techniques or therapies. and potentially dangerous treatments. require that the patient have a good understanding of the medical condition and be highly compliant with complex treatments. History6. Other medical conditions. A history of mania or bipolar disorder is a relative contraindication for the use of antidepressants. A. pain can cause these problems and then. Like most of the above associated factors. weight. bullous emphysema as a contraindication for intercostal nerve blocks. Factitious disorders. F. and overall conditioning can also contribute to the problem. 31 Other health factors. costly. Malingering is a moral and legal problem rather than a medical problem. Psychiatric conditions may also influence the choice of treatment. when identified. indicate that treatment must focus on intensive psychotherapy (although it is difficult to get the patient to be compliant with such treatment).

or sensations of hot or cold in the affected area? . The patient's choice of adjectives may also provide clues regarding the emotional impact of the pain. Has the condition been stable or deteriorating? Ongoing deterioration mandates a more aggressive search for underlying pathology and possible interventions. or major stress associated with the start of the pain? This may give clues regarding any underlying pathology.See the previous section on categories of pain. chronic low back pain. What are the adjectives used to describe the pain? The patient's description of the pain can help determine the type of pain. flushing. Is the pain associated with any treatment or medication? Headaches may occur as a rebound phenomena. Worsening low back pain. 2. associated with the use of analgesics. Did the pain start immediately after the injury or was there a delay of weeks or months? Neuropathic pains such as entrapment neuropathy or complex regional pain syndromes (RSD) frequently development weeks to months after the injury. physically manipulative therapies may exacerbate a painful condition. illness.1.Occasionally. where more conservative measures are usually more appropriate. Are there associated symptoms. Description of the pain. How the pain developed? Was there an injury. such as nausea or sweating. may require surgical intervention. as opposed to stable. especially with deteriorating neurologic signs.

No pain Worst possible pain The patient is presented with a 10 cm line.10. The Visual (or Verbal) Analog Scale (VAS) is the most common method for assessing pain intensity. possibly quite distant site. Similar scales are available for children. The FACES scale shows cartoon-like pictures of faces in various degrees of distress. labeled as above. implies a systemic etiology. This is most commonly seen if the site of painful stimulation or irritation is visceral or muscular. 3. The child is asked to choose the one that shows how much pain she is having. Could the pain be referred from another site? Possibly because of the convergent structure of the nervous system. Standardizing the pain description. The downside to this approach is that it asks to the patient to maintain a focus on their pain. "On a scale of 0 to 10. and its change over time. The McGill Pain Inventory is the most commonly used of these. with 0 meaning no pain. how much pain are you having now?" These scales can also be used to assess the range of the patient's pain by asking them to indicate their level of pain at its worst. The same scale can be given verbally by asking the patient. or if bilateral with a peripheral neuropathy. Pain which does not have a limited distribution. The result is then measured with a metric ruler and scored between 0 . Yet obtaining this information is very important to help gauge the impact of the pain. It may also be useful to ask the patient to keep a diary of their pain problem. How intense is the pain? There is tremendous individual variation in the perception of the intensity of pain. especially in a pain clinic setting. it is common for pain to be referred from a separate. its best. Pain drawings. but instead occurs in multiple sites or has a diffuse distribution. and asked to mark an `X' on the line indicating the intensity of their pain.Such a distribution is entirely consistent with a Complex Regional Pain Syndrome (RSD or causalgia). and 10 meaning the worst pain you can imagine. Is the pain in a stocking or glove distribution? A stocking or glove distribution does NOT indicate a psychogenic etiology. Standardized. multiple choice lists of pain adjectives are also useful. and its average.These symptoms may indicate a autonomic or sympathetic component of the pain. this may be counterproductive to their treatment. 7 . The location of the pain and any spread. and for the monitoring of change or progress. Is the pain limited to the distribution of a root or peripheral nerve? Such distributions help to isolate the site and possibly the source of the pathology. Ask the patient to draw the distribution of their pain on an outline of the human body.

Is there any daily. Some headache syndromes are triggered by specific dietary elements such as alcohol or monosodium glutamate (MSG). monthly. Migraine headaches may have occur in patterns associated with a variety of factors such as stress or menstrual cycling. Arthritic conditions may be worse in the mornings and during cold seasons. Identifying and avoiding these triggers can be most helpful. What are the patient's daily activities? Understanding the day-to-day activities of the patient and what activities are limited by the pain will help the clinician to focus the physical and psychological rehabilitation process. It is usually a priority to enable the patient to return to work as soon as possible-vocational rehabilitation may be a crucial part of the treatment. Low back pain which is worse walking uphill suggests a discogenic etiology. If the patient has acquired a totally disabled lifestyle. this points more to facet disease or foraminal stenosis. What is the overall level of patient function? Are there changes in the patients weight and sleep pattern? Such changes suggest the need to investigate further regarding possible depression or cancer. What is the patient's employment status? Issues of lost productivity and income or workers compensation may affect the patient's emotional and motivational state. 5. or seasonal pattern associated with the pain? The physician is looking for clues as to the etiology of the pain. Are there aggravating or alleviating factors which lead to exacerbation or reduction of the pain? Understanding aggravating and alleviating activities can help to pinpoint the diagnosis or refine the treatment.4. How does the pain fluctuate over time. If the pain is worse when walking downhill. then it may be important to help the patient understand that he is capable of some productive functioning. Is the patient engaging in any exercise and physical activity? .

Current Medications 1. have there been any recent medication changes associated with the onset of the problem. Effectiveness Note the effectiveness of medications. Exercise is often a crucial part of the treatment process. if a variety of sympathetic blocks have not. For headaches or abdominal pain. however. alleviated the pain. Past Medical History In the assessment of the patient with pain. Overly solicitous responses may reinforce the patient's pain behaviors and undermine the relationship. In some patients it may not be possible to use narcotics except in the most dire circumstances. Drug tolerance . the patient's medical condition may present relative contraindications to various medications or procedures. 6. What treatments have been attempted? Identifying prior treatment failures will not only prevent unnecessary repetition. even briefly. Do other medical problems potentially affect the choice of pain treatments? As noted above. B. Such problems should be identified so that interventions can be initiated. Analgesics (even if only partially effective) should lead to some increase of function in at least one sphere of the patient's life. 2. Dosage and pattern of use Obtain a complete list of the patient's medications and usage. What is the quality of the family and personal relationships? Chronic pain may lead to irritability and personality changes. since some activities may exacerbate the problem. the past medical history should include the following information: 1. Does the patient have any prior or current substance abuse history? Treating chronic pain with narcotics requires special caution with the addiction prone patient. a history of diabetes or alcoholism point towards diagnoses of neuropathy. Families typically need some education regarding adaptive responses to chronic pain. 3.Physical activity is critical for preventing further physical deterioration. 3. Such changes may in turn lead to the deterioration of personal relationships. C. For example. then perhaps the pain is not sympathetically mediated. Do other medical problems relate to the patient's complaint of pain? For example. it is important that the patient's physical activities be reviewed. Include over-the-counter medications. 2. but can also help guide the diagnosis.

These patients and the elderly are at increased risk for renal damage from NSAIDs. There is the potential for hepatic toxicity. therefore. Tricyclic Antidepressants 9. Hypertension and hyperpyrexia may occur secondary to administration with sympathomimetics. These drugs inhibit platelet function and are associated with increased bruising. but the development of physiologic tolerance can be hard to distinguish from inappropriate drug seeking behavior. sedatives. methylphenidate. Potential for drug interactions and toxicity Acetaminophen 13 The analgesic ceiling for a single oral dose is reached at 1000 mg. Potentially fatal interactions may occur if tricyclics are given to patients on monoamine oxidase inhibitors (MAOIs). Nonsteroidal Antiinflammatory Drugs (NSAIDs) 22. cimetidine. 4. Tolerance does not imply addiction. Neuroleptics. the daily use should not exceed 4 grams. Prostaglandins help maintain gastric mucosal integrity. There is increased risk of gastrointestinal bleeding and coumadin levels may be altered secondary to displacement from protein binding sites. All NSAIDs may provoke asthmatic reactions in patients with underlying asthma or sensitivity to aspirin or other NSAIDs. Additive side effects may occur with alcohol. NSAIDs are relatively contraindicated in patients treated with anticoagulants. therefore. 25 Prostaglandins are important factors in the maintenance of renal perfusion in those patients with hypovolemia or reduced renal blood flow. especially fluoxetine and paroxetine.The chronic use of some drugs is associated with tolerance (the gradual need to increase the dose to maintain the same effect). . and extra caution is warranted if the patient is malnourished or abuses alcohol. they should be discontinued before surgery or other invasive procedures. Tricyclic levels are increased by the selective serotonin reuptake inhibitors. or other anticholinergic medications. and estrogens may also increase tricyclic levels. 16 The side effects and toxicity of tricyclics can be exacerbated secondary to drug interactions. NSAIDs may also produce gastroduodenal damage.

Propoxyphene may also cause seizures. Sudden discontinuation of opioids is associated with influenza-like symptoms of withdrawal: . furthermore. is associated with the additional risk of seizures. Propoxyphene may increase carbamazepine levels. and may alter digoxin levels. 32 Opioid side effects can vary from one narcotic drug to another in an unpredictable manner for each individual. Meperidine combined with monoamine oxidase inhibitors (MAOIs) can trigger a fatal hyperpyrexic reaction. Check for altered levels of other antidepressants. Phenytoin may displace coumarin from protein binding sites. it may weakly potentiate tricyclic side effects and have there is a risk of interactions with MAOIs. at doses greater than 1 gram per day. Meperidine. Opioid side effects may be enhanced by alcohol or sedatives.Anticonvulsants 1. Disulfiram and isoniazid may increase phenytoin levels. Opioids 31. overdose may also cause fatal heart block. 16 Carbamazepine has a similar structure to tricyclic antidepressants. propoxyphene may increase carbamazepine levels.

For example. 1. the physical exam will often lead to the selection of the primary diagnosis. When preparing to do a physical examination it is important to warn the patient as you approach potentially painful areas. and occasionally a test will help to confirm this diagnosis. there are rarely tests available that will "make the diagnosis." Instead the clinician must rely upon the presenting signs and symptoms. 12 Introduction In pain assessments. D. an MRI scan which reveals an L5-S1 disc herniation is only helpful as far as it confirms or contradicts the findings of the history and physical examination. Physical Examination 6.• • • • • • • • • • restlessness & insomnia nausea & vomiting diarrhea backache leg pain yawning lacrimation rhinorrhea mydriasis muscle cramps If it is necessary to withdraw a patient from an opioid medication. Mental status exam cognitive functions--impairment implies the presence of delirium or dementia mood and affect--provide clues regarding the emotional state of the patient and the presence of anxiety or depression . It is also good policy to use chaperones whenever examining patients of the opposite sex. it is best to decrease the dose by approximately 10% every 24 to 72 hours--further individual tailoring may be necessary. The history will often generate a differential diagnosis.

and pain with compression or distraction 5. alpation & Musculoskeletal exam temperature changes--indicates inflammation or altered perfusion associated with sympathetic dysfunction. Affected areas will not wrinkle into fine lines. The extent of the tenderness and the amount of pressure required to elicit pain should be observed. This indicates neural injury with denervation or sympathetic dysfunction. piloerection. require intact judgment and insight 2. poor healing--indicates poor perfusion possibly associated with ischemic injuries. 3. these behaviors may compound and exacerbate the pain problem. 4. such as the prescribing of narcotics or the use of relaxation training. nail changes--evidence of neuropathic injury or sympathetic dysfunction.thought process & content--check if the patient is having suicidal ideation. sweating--abnormal or asymmetric sweating indicates sympathetic dysfunction. but will look more dimpled. inflammation. atrophy--may indicate guarding and lack of use. gooseflesh (cutis anserina)--areas involved in neuropathic pain may briefly demonstrate this after disrobing. 30 . like orange peels. guarding. or if there are signs of thought disorder and possible psychosis judgment and insight--many treatments. Neurologic Cranial nerve assessment--is especially crucial in the evaluation of head and neck pain. edema--subtle. or a prior herpes zoster eruption. Physical examination for radiculopathy 20. or sympathetic dysfunction. hair. or denervation. color and pigmentary changes--these skin changes may indicate sympathetic dysfunction. as the patient places abnormal stresses on the body. joints--can be examined for effusions. swelling. Reproduction of the patient's characteristic pain is particularly noteworthy. muscle tenderness--examination of muscles may reveal tender areas or actual trigger points. Inspection posture. Vital signs Vital signs are often elevated in acute pain. ROM. splinting--if chronic. diabetic neuropathy. edema--indications inflammation or sympathetic dysfunction. subcutaneous edema can be appreciated by wrinkling the skin over affected and unaffected areas.

lateral arm.) medial forearm. interosseus n. front and back of forearm & into middle finger thumb index pinch (ant. off median n.) triceps (radial n.) upper.) brachioradialis (radial n.) deep pain in axilla & shoulder w/ some radiation down inside of arm medial forearm (antebrachial cutaneous n.) lower lateral arm.) over triceps.) upper. LOWER EXTREMITIES: . possibly into thumb elbow extension (radial n.) lateral forearm (musculocutaneous n. into the 2 medial fingers finger abduction (ulnar n. C5-6 disc protrusions are the most common cervical disc problems. and middle finger deep pain in triceps. mid-forearm. never below elbow elbow supination (radial n.) biceps (musculocutaneous n.) / pronation (median n. at the elbow) Cervical spondylosis or disc protrusion can produce cord compression (upper motor neuron signs) or root compression (lower motor neuron signs).UPPER EXTREMITIES C5 Motor Reflex Sensory Pain C6 Motor Reflex Sensory Pain C7 Motor Reflex Sensory Pain C8 Motor Reflex Sensory Pain T1 Motor Reflex Sensory Pain medial arm (brachial cutaneous n. near/over deltoid (axillary n. they can compress the C6 root and also produce C7 upper motor signs.) raised elbows (axillary n. lateral arm.

) knee jerk (femoral n. esp. anterior midthigh (femoral n. Gait . femoral cut br.) medial lower leg across knee & down to medial malleolus dorsiflex great toe (deep peroneal n. Hyperreflexia is a sign of disease or injury at a higher level. & lat.) often no loss.L2 Motor Reflex Sensory Pain hip flexion (femoral n.) often no loss. anterior thigh just above the knee cap across thigh inversion of the foot (tibial & peroneal n. big toe eversion of the foot (peroneal n.) especially dorsum of the foot (peroneal n.) back of thigh to lateral lower leg. thigh adduction (obturator n hip adductors (obturator n.) across thigh knee extension (femoral n.) ankle jerk (tibial n. dorsum & sole of foot.) behind the lateral malleolus back of thigh and calf to lateral foot L3 Motor Reflex Sensory Pain L4 Motor Reflex Sensory Pain L5 Motor Reflex Sensory Pain S1 Motor Reflex Sensory Pain It is important to note that lumbar disc lesions can only cause root (lower motor neuron) syndromes. in the spinal cord or brain.). 95% of lumbar disc lesions involve L5 or S1.

Absence of pain in response to stimulation which would normally be painful. The examiner should test the involved areas for at least one function of large fibers. light touch. and vibration. such as temperature (using and ice cube or alcohol swab) or sharp/dull discrimination. DeGowin RL: Bedside Diagnostic Examination. such as vibration or light touch. An increased response to a stimulus which is normally painful. A painful syndrome characterized by an abnormally painful reaction to a stimulus. Motor dysfunction--Assessment of motor strength can help identify neural injury and the roots or peripheral nerves involved. Distortion of the patient's gait may also lead to improper muscle use and strain. Dysesthesia Hyperalgesia Hyperesthesia Hyperpathia Hypoalgesia Hypesthesia = Hypoesthesia Noxious stimulus Paresthesia Peripheral Nerve & Dermatome Map From DeGowin EL. Frequently. 3rd edition. An abnormal sensation. whether spontaneous or evoked. Pain due to a stimulus which does not normally provoke pain. Decreased sensitivity to stimulation.809-10. The examination should also make note of the presence and distribution of abnormal pain responses. whether spontaneous or evoked. A stimulus which is damaging to normal tissues. as well as an increased threshold. 1976.Observation of gait can help identify weakness or pain (antalgic gait). leading to further pain. Sensory dysfunction Neuropathic pain is associated with nerve injury or dysfunction. position. Anesthesia dolorosa Pain in an area or region which is anesthetic. Table of Terms 26 Pain Allodynia Analgesia An unpleasant sensory and emotional experience associated with actual or potential tissue damage. excluding the special senses. An unpleasant abnormal sensation. p. sharp/dull discrimination. Increased sensitivity to stimulation. especially a repetitive stimulus. Diminished pain in response to a normally painful stimulus. Macmillan Publishing. New York. and one small fiber function. Grading of Muscle Strength Grade 0 Grade 1 Grade 2 Grade 3 0% 10% 25% 50% Zero Trace Poor Fair No evidence of contractility Slight contractility but no joint motion Complete motion but with gravity eliminated Barely complete motion against gravity . it is possible to demonstrate sensory impairment in one or more modalities including temperature. excluding the special senses.

Diagnostic Testing 37 . E. Macmillan Publishing. Hyperreflexia --focal: indicative of upper motor neuron pathology. 3rd edition. 3rd edition. DeGowin RL: Bedside Diagnostic Examination. p. DeGowin RL: Bedside Diagnostic Examination. New York. frequently associated with upgoing toes on testing of the Babinski's sign--this cannot be secondary to lumbar spine disease since there are no UMNs in the lumbar spine --generalized: suggestive of increased arousal. Abnormal Reflexes 39 Hyporeflexia --focal: indicates lower motor neuron pathology at the level of the peripheral nerve or root --generalized: peripheral neuropathies--diabetic. New York. inflammatory (Guillain-Barre). drug toxicity Grading Deep Reflexes Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 0 + ++ +++ ++++ +++++ Absent Diminished but present Normal Normal Hyperactive Hyperactive with clonus From DeGowin EL. 1976. alcoholic. p. 1976.791. Myopathy may also cause hyporeflexia. Macmillan Publishing. 768.Grade 4 Grade 5 75% 100% Good Normal Complete motion against gravity and some resistance Complete motion against gravity and full resistance DeGowin EL. hyperthyroidism.

and Paget's disease. osteomyelitis. avascular necrosis. Radiographic No matter which radiographic technique is used. 21. and can help identify which peripheral nerves may be involved. somatic from sympathetically mediated pain. Also best for evaluating spinal alignment. 18. This can help to guide treatment with further blocks or with other medical and surgical interventions. 23. myelinated nerves. radiographic tests are far from perfect and serve best to confirm a clinically suspected diagnosis. As the above table2. fractures. 4. 2. 27. 19. Such tests of function can be followed over time and complement the anatomic radiology studies. central from peripheral pain. 24. the results must always be correlated with clinical findings. or tumor. omputerized Tomography (CT)--more bony detail and superior to MRI for bone or joint disease of the spine. 11. Bone scans--radionuclide bone imaging identifies osteoblastic activity and can help with the diagnosis of bone tumor or metastatic disease. faster. 40 of diagnostic tests for low back pain demonstrates. joint disease. 3. CT or MRI are superior and free of the risk of post-dural puncture headaches. NCS generally reflect conduction in the larger. including foraminal bony stenosis Magnetic Resonance Imaging (MRI)--superior soft tissue contrast and superior to CT or myelography for diagnosis of spinal disc disease or neural compression secondary to spinal stenosis. Electromyography & Nerve Conduction Studies (EMG / NCS) These studies can assist in identifying and localizing functional lesions of peripheral nerves. Somatosensory evoked potential testing (SSEP) . some soft tissue tumors can be seen Myelograms--involve the injection of contrast into the intrathecal space. 35. Plain films--value is limited to demonstrating bony pathology.1. motor units and muscle lesions. 17. Diagnostic blocks 3 Nerve blocks with local anesthetics can help to distinguish focal from referred pain. For most of the common spinal diagnostic problems. infection. 4.

sympathetic postganglionic . 29 Myelin +++ ++ ++ ++ + Mean Mean Conduction Diameter (_m) Velocity (m/sec) 15 8 6 3 3 1 100 50 30 20 7 1 A-alpha (II) Primary motor & propioception A-beta (II) A-gamma A-delta (III) B C (IV Cutaneous touch & pressure (& motor fibers) Muscle tone (spindle efferents) Mechanoreceptors. position. SSEP testing involves the senses of touch. thermoreceptors. mechanoreceptors. 5. nociceptors.F. Such testing is less invasive and may also be useful to monitor hyperesthetic responses. and vibration. It is particularly valuable to inquire regarding: • • • • • • • • • • • • • Neurovegetative symptoms sleep disturbance appetite disturbance loss of energy loss of libido anhedonia impaired concentration suicidal ideation Impact of the pain on the patient's day-to-day activities work & finances personal relationships recreational pursuits Factors suggesting the need for more formal psychological evaluation include: • • • • • • • Evidence of mood or anxiety disorders Evidence of substance abuse Evidence of psychotic disorder Evidence of cognitive impairment Evidence of overwhelmed coping capacities or suicidal ideation Evidence of prominent secondary gain Problems with hostility. rather than pain or temperature. Testing of small fiber function is possible with devices which test thermal or electrical thresholds to perception and pain. and the emotions surrounding the pain problem. or spinal cord ischemia. or personality disorder . Other Quantitative Sensory Testing (QST) Pain syndromes may represent dysfunction more specific to the small A-delta and C fibers. anger. and thermoreceptors Sympathetic preganglionics Nociceptors.SSEPs are better than EMG / NCS tests for assessing upper motor neuron diseases such as MS. syringomyelia. Fiber Type (Group) Innervation/Function 5. 8. Psychological Evaluation As discussed earlier. the clinician should always assess the patient's psychological state.

If the clinician can answer the six questions listed at the start of this chapter. To meet the special pain-related needs of this fastest growing segment of the population. as the information obtained guides the plan of care. CONCLUSION Due to barriers in the health care system. Do the signs and symptoms indicate the nature of the pain? nociceptive--suggesting tissue injury or inflammation · neuropathic--indicating central or peripheral dysfunction of the nervous system pain with mixed features --such as migraine or possibly myogenic or myofascial pain H. A thorough pain assessment is critical. SUMMARY A careful assessment of the patient with pain should include efforts to categorize the pain. . and to consider associated medical. nurses must be able to assess and treat pain in elderly persons. Differential Diagnosis After completing the data gathering process. The clinical and basic sciences of pain are rapidly progressing--what is not understood today may be understood tomorrow. Be wary of obvious diagnoses or therapies that were missed by other clinicians. the patient. and society. but beware that the emotional turmoil which surrounds chronic pain may falsely suggest these diagnoses. to determine its etiology. emotional and psychological factors. inconsistent findings) Prolonged and extensive course of treatment failures Need for high dose opioids for non-malignant pain Assessment of suitability for aggressive invasive treatments G. elders are at great risk for undertreatment of pain.g. including both pharmacologic and non-pharmacologic therapies. Be cautious about reaching a psychogenic diagnosis simply because the pain symptoms cannot be understood physiologically. it is time to consolidate the findings into a differential diagnosis. social. then the patient will be well on the way towards receiving appropriate and comprehensive treatment.• • • • Suspicion of malingering or factitious disorder (e. During this process the clinician should consider: • • • • • • • The meaning of inconsistent findings? Consider psychogenic or malingering diagnoses. Check with prior physicians about their findings.