Clinical Evaluation of Chronic Pain

Patients referred for chronic pain treatment usually have been seen by a number of specialists, and have had numerous diagnostic tests and therapeutic procedures, all without obtaining the results they anticipated or expected.

They may have been labeled as professional patients or failures of the medical system. It is important to obtain a complete history and physical examination to assess the factors contributing to the patient's complaints, and to assess the impact of the pain to the patient's functional capacity.

Searching for a single cause to explain all of the patient's symptoms, after numerous other specialists have already tried this, is usually futile. It can, in fact, be counterproductive because it reinforces the patient's perception that there is something seriously wrong with me and they cannot figure out what it is.

History

The history should focus on the time course, intensity, and location of the pain. The functional state of the patient before the onset of the problem should be established, as it is usually unrealistic to obtain improvement beyond this level. Reactions to diagnostic and therapeutic interventions should be noted, as they can be predictors of responses to future treatment.

Physical Examination

A complete physical examination should be done, focusing on the neurological and musculoskeletal systems. The cranial nerves should be assessed, and exteroceptive sensations of pain, temperature, and touch documented.

Anatomical patterns of pain and sensory loss often provide clues to the level of lesion or to the lack of an organic basis for the complaint. For example, loss of light touch in a hand and arm, but retained ability to identify objects and perform fine motor movements, which requires intact sensory input, suggest a functional overlay, malingering or somatization.

While motor system examination can be limited by pain, the assessment of strength, muscle bulk, and muscle tone should provide valuable diagnostic clues. Autonomic dysfunction such as vasomotor instability can be assessed by comparison of skin temperature, perspiration, and hair and nail changes in the extremities.

These abnormalities can be signs of ongoing sympathetic over activity, especially if localized to painful areas. Changes in reflex responses can be one of the earliest signs of central nervous system dysfunction, and reflex testing is often one of the most objective parts of the neurological examination of pain patients. In addition to these standard evaluation techniques, it is important to use other assessment and diagnostic tests as indicated, bearing in mind that endless repetition of tests is generally not very likely to turn up a previously undiagnosed problem.

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