Assessment & Diagnosis

In this session you will learn about the components of the multidimensional assessment essential to development of a multimodal treatment plan for patients with pain. The basics of a comprehensive pain assessment and the elements of the physical exam needed to generate a differential diagnosis are reviewed.

Principles of Assessment

  • Regularly screen all patients for pain and perform a comprehensive pain assessment when pain is present
  • Set the Stage. Reassure patients that you take their pain seriously, understand its impact and the need for treatment. Maintain a respectful and professional attitude. It is important to believe the patient's reports of pain and distress, particularly in the case of patients with chronic non-cancer pain who may have had difficult encounters with previous health care professionals. Even if psychological issues or addiction are present, respectful validation of the patient's suffering is invaluable to assessment and will lead to more effective treatment planning.
  • Understand that pain is a multidimensional phenomenon which is an attention grabbing sensation that can produce strong emotional reactions that adversely affect a patient's function, quality of life, emotional state, social and vocational status, and general well-being. Therefore, pain assessment should also be multidimensional. Evaluate these various elements during the interview and examination, and include them in the diagnostic formulation.
  • A thorough history and physical exam are essential for the medical and pain diagnosis and treatment planning. Careful attention to the patient's reported symptoms will help direct the physical examination and narrow the pain differential diagnosis.
  • Include thorough neurological and musculoskeletal examinations. Additional testing, such as imaging and laboratory studies or electrodiagnostic testing (EMG/nerve conductions), may be ordered as needed based on the results of the history and examinations.

Assess Pain Intensity

Use a numeric pain rating scale in most clinical settings. The most common is an 11 point scale where 0 = no pain and 10 =worst pain imaginable. Since this is an ordinal scale, a score of 8/10 is not twice as severe as a score of 4/10. Many use a 0 to 5 faces scale for children.

  • Important: Pain is a subjective experience (the experience is unique for each individual person) with a different meaning to each person. The pain rating reflects a patient's interpretation of what that pain means for him/her at that moment and it is a combination of the patient's physical discomfort and emotional interpretation. Changes in pain intensity are valuable when measured for single individuals (for example, before and after a treatment), but they should not be used to compare pain between different individuals. One person's 4/10 might be another's 10/10.
  • Nonverbal patients, such as those in coma or with dementia or other cognitive impairments, must be assessed for pain by observational means, such as body language, movement, autonomic arousal, and nonverbal pain behavior. Similar approaches should be used when assessing pain in young children or infants. Consult someone with expertise in pain assessment if you are unsure whether a patient is experiencing pain.

The Pain History Interview

A pain history should include location, quality, intensity, temporal characteristics, aggravating and alleviating factors, impact of pain on function and quality of life, past treatment and response, patient expectations and goals. Table 2 summarizes the general categories that should be addressed during a pain assessment, along with examples of questions that may be useful during the interview. The mnemonic "QISS TAPED" may help you remember the various elements.

Physical Examination

  • A comprehensive sensory examination (Table 3) encompasses tests for light touch, pinprick, pressure, vibration, joint position, heat and cold sensation. At a minimum, the sensory examination must screen for function and integrity of large (A beta) and small (A delta and C) nerve fibers and dorsal columns and spinothalamic tracts by testing for a minimum of two sensory modalities, i.e., vibration (tests large fibers and dorsal columns) and pinprick (tests small fibers and spinothalamic/ trigeminothalamic tracts). Light touch testing by itself has limited diagnostic value unless supplemented by additional information obtained by testing other sensory modalities.
  • Carefully examine the musculoskeletal area in question. Be sure to address all the elements that are related. For example, if there are knee problems, be sure to assess structures which directly affect the function of the knee such as low back, hip, foot and ankle, in addition to examining elements that form the support structures of the knee such as ligaments, tendons, bones and muscles,
  • Functional and postural exam: Observe nonverbal and verbal pain behavior, gait, comfort and position while seated or standing, balance, ability to change positions, use of assistive devices (e.g., cane).