Assessment and Diagnosis
Download
1 / 26

Assessment and Diagnosis of Pain Disorders - PowerPoint PPT Presentation


Assessment and Diagnosis of Pain Disorders. Pain Assessment: Goals. Characterize the pain Identify pain syndrome Infer pathophysiology Evaluate physical and psychosocial comorbidities Assess degree and nature of disability Develop a therapeutic strategy.

Related searches for Assessment and Diagnosis of Pain Disorders

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha

Download Presentation

Assessment and Diagnosis of Pain Disorders

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Assessment and Diagnosisof Pain Disorders


Pain Assessment: Goals

  • Characterize the pain

  • Identify pain syndrome

  • Infer pathophysiology

  • Evaluate physical and psychosocial comorbidities

  • Assess degree and nature of disability

  • Develop a therapeutic strategy


Comprehensive Pain Assessment

  • History

  • Physical examination

  • Appropriate laboratory and radiologic tests


Pain and Disability

Nociception

Other physical symptoms

Physical impairment

NeuropathicPsychologic Social isolation

mechanismsprocessesFamily distress

Sense of loss or inadequacy

Adapted with permission from Portenoy RK. Lancet. 1992;339:1026.

Disability

Pain


Pain History

  • Temporal features—onset, duration, course, pattern

  • Intensity—average, least, worst, and current pain

  • Location—focal, multifocal, generalized, referred, superficial, deep

  • Quality—aching, throbbing, stabbing, burning

  • Exacerbating/alleviating factors—position, activity, weight bearing, cutaneous stimulation


Nociceptive pain

Neuropathic pain

Idiopathic pain

Psychogenic pain

Commensurate with identifiable tissue damage

May be abnormal, unfamiliar pain, probably caused by dysfunction in PNS or CNS

Pain, not attributable to identifiable organic or psychologic processes

Sustained by psychologic factors

Pathophysiology


Pain Assessment Tools

  • Pain intensity scales

    • Verbal rating

    • Numeric scale

    • Visual analogue scale

    • Scales for children

  • Multidimensional pain measures

    • Brief Pain Inventory

    • McGill Pain Questionnaire


Acute pain

Chronic pain

Breakthrough pain

Recent onset, transient, identifiable cause

Persistent or recurrent pain, beyond usual course of acute illness or injury

Transient pain, severe or excruciating, over baseline of moderate pain

Pain Syndromes


Identify Pain Syndromes

  • Syndrome identification can direct assessment and predict treatment efficacy

  • Cancer pain syndromes

    • Bone pain

    • Pathologic fracture

    • Cord compression

    • Bowel obstruction

  • Noncancer-related pain syndromes

    • Atypical facial pain

    • Failed low-back syndrome

    • Chronic tension headache

    • Chronic pelvic pain of unknown etiology


  • Neuropathic Pain: Clinical Assessment

    • A comprehensive diagnostic approach to patients affected by neuropathic pain

      • Medical history

      • Examinations: general, neurologic, regional

      • Diagnostic workup: imaging studies, laboratory tests, nerve/skin biopsies, electromyography/nerve-conduction velocity (EMG-NCV) studies, selected nerve blocks


    Medical History

    Ask patient about complaints suggestive of

    • Neurologic deficits: persistent numbness in a body area or limb-weakness, for example, tripping episodes, inability to open jars

    • Neurologic sensory dysfunction: touch-evoked pain, intermittent abnormal sensations, spontaneous burning and shooting pains


    Neurologic and Regional Examinations

    In patients with neuropathic pain, examination should focus on the anatomic pattern and localization of the abnormal sensory symptoms and neurologic deficits


    Diagnostic Workup: Lab Tests

    • Complete blood cell count with differential, erythrocyte sedimentation rate, chemistry profile

    • Thyroid-function tests, vitamin B12 and folate, fasting blood sugar, and glycosylated hemoglobin

    • Serum protein electrophoresis with immunofixation

    • Lyme titers, hepatitis B and C, HIV screening

    • Antinuclear antibodies, rheumatoid factor, Sjögren’s titers (SS-A, SS-B), antineutrophil cytoplasmic antibody


    Diagnostic Workup: Lab Tests

    • Cryoglobulins

    • Antisulfatide antibody titers, anti-HU titers

    • Heavy metals serum and urine screens

    • Cerebrospinal fluid study for demyelinating diseases and meningeal carcinomatosis


    Diagnostic Workup: Electrophysiologic Studies

    EMG-NCV and QST

    • To localize pain-generator/nerve or root lesion

    • To rule out

      • Axonal vs focal segmental demyelination

      • Underlying small-fiber or mixed polyneuropathy


    Biopsies

    • Nerve (eg, sural nerve): to diagnose vasculitis, amyloidosis, sarcoidosis, etc.

    • Skin: to evaluate density of unmyelinated fibers within dermis and epidermis


    Back Pain and Sciatica: Comprehensive Assessment

    • History

      • Medical

      • Psychosocial

      • Family

      • Previous trials

    • General examination

      • Musculoskeletal

      • Neurologic


    Back Pain and Sciatica:Pain Assessment

    • Description

    • Duration

    • Intensity

    • Alleviating factors

    • Aggravating factors


    Assessment of Patients With Low Back, Hip, and Leg Pain

    • Neurologic exam

      • DTRs, strength, sensitivity, gait

    • Regional exam of spine and leg

      • Inspection for scoliosis or skin rash, palpation for bone tenderness

    • Sciatic- and femoral-nerve stretching tests

      • SLR, reverse and contralateral SLR maneuver


    Assessment of Patients With Low Back, Hip, and Leg Pain

    • Provocative mechanical joint tests

      • Truncal flexion for discogenic pain or spine instability

      • Truncal extension for facet joint disease

      • Patrick’s maneuver for hip disease (FABER test of both hips for SI joint disease)


    Back Pain and Sciatica: Imaging Evaluation

    • Lumbosacral x-ray studies with flexion/ extension/oblique views

    • MRI of the spine

    • CT with 3-D reconstruction

    • CT plus myelography


    Assessment of Chronic Back Pain and Sciatica: Diagnostic Blocks

    • Facet blocks to rule out facet joint pain

    • Provocative diskograms or disk blockade to rule out discogenic pain and pain associated with segmental spinal instability

    • Selective root blocks to determine location of root pain generator


    Neoplasm

    Infection (diskitis, epidural abscess)

    Cauda-equina syndrome

    Compression Fx

    Assessment of Acute Back Painand Sciatica: “Red Flags”

    History

    Possible Diagnosis

    • Nighttime pain, fever, weight loss, history of cancer

    • Fever, IV drug abuse

    • Bladder, bowel dysfunction; leg weakness

    • Trauma


    Back Pain and Sciatica

    MRI of the spine if patient demonstrates

    • “Red flags”

    • Neurologic deficits or progressive neurologic signs and symptoms

    • Pain persisting more than 6 wk


    Headache Evaluation

    • History (duration, onset, frequency)

    • Is there a family history of headache?

    • Are there any known causes of headache?

    • What is the typical location(s)?

    • What does the pain feel like?

    • What makes it worse?

    • What makes it better?

    • What are the results of past evaluations?

    • Are there associated symptoms? Exam findings?

    • What is the patient’s sex?


    Headache: Diagnostic Red Flags

    • Rash, meningeal signs, or fever

    • Onset after age 50

    • Onset in a person with HIV or cancer

    • Abrupt onset

    • Worsening pain

    • Signs of focal neurologic disease


    ad
  • Login