Evaluation and Management of Chronic Pain for Primary Care: A Pocket Guide for the Primary Care Provider

Part IGeneral Evaluation and Management of Chronic Noncancer Pain

© Springer Nature Switzerland AG 2020

B. Huang Hall, MD, PhD (ed.)Evaluation and Management of Chronic Pain for Primary Carehttps://doi.org/10.1007/978-3-030-47117-0_1

1. History Taking for Chronic Pain

Bonnie Huang Hall¹  

(1)

UCSF, Department of Family and Community Medicine, Fremont, CA, USA

Bonnie Huang Hall

Keywords

History of chronic painSystematic differential diagnosisDescription of pain

Helpful Tips

1.

Obtain a detailed description of pain (OPQRST) and document it

2.

Form a differential diagnosis for the cause of the chronic pain in terms of large, systematic categories (Neoplastic, Autoimmune, Neuropathic, Endocrine, Musculoskeletal, etc.)

3.

Ask about medications tried, side effects, psychiatric history, opioid risk factors when opioids are under consideration

4.

Chronic pain patients requiring opioid medications require detailed documentation of benefits and side effects of their opioid dosages, whether there is the presence of a health jeopardizing psychiatric diagnosis or substance abuse, and whether there is diversion of opioid prescriptions. Taking this detailed history will provide justification for the current opioid treatment plan.

Introduction

Chronic non-cancer pain has been widely defined as pain existing for more than 12 weeks, which is beyond normal tissue healing time. This, however, does not mean that this pain has no organic cause or that its etiology cannot be narrowed down. Consequently, taking a history of chronic non-cancer pain must be approached with the same scrutiny as with other serious conditions such as dyspnea on exertion or chest pain. It is not acceptable to solely write in the history of present illness, that the patient has chronic pain and desires refill of medications. Without taking a proper pain history, one opens the door for litigation as standard of care has not been followed. Multimillion dollar judgments against healthcare professionals and institutions have resulted from neglecting to obtain a satisfactory pain evaluation [1].

Most importantly, however, a thorough history will enable the clinician to obtain a reasonable diagnosis and thus a targeted, often more effective treatment plan. As an internal medicine intern, it was ingrained in me that 90% of the time, a correct diagnosis can be obtained from history alone. This rule may not be so widely successful in chronic pain patients, but the principles and thought processes can still apply. For example, a complete history can help elucidate a chief cause for the pain. It can provide clues to decide if the pain is primarily neuropathic in nature or nociceptive. In addition, one can also determine if the medications prescribed are indeed benefiting the patient or not. Furthermore, a thorough history can help risk stratify a patient if opioids are under consideration.

Thorough Description of Pain

To begin with, a thorough pain history includes a thorough description of the pain. Recall the mnemonic: OPQRST

Onset

Provocation and Palliation

Quality

Radiation and Region

Timing

How did the pain start? Was there trauma, motor vehicle accident, or repetitive injury that preceded the pain? What makes it better or worse? Is it burning? Does it radiate? Are there associated symptoms such as fever, diarrhea, etc.? How long does it last, and when does it occur – with meals, with movement, with stress?

Formulating a Differential Diagnosis

In addition, the aim of history taking is to formulate a differential diagnosis, if not reach the actual diagnosis causing the pain. Remember, pain comes from somewhere. (Albeit, the pathophysiology of chronic non-cancer pain is complex and beyond the scope of this book. For detailed, but brief overview of the mechanisms of pain, refer to Abd-Elsayed 2019 [2].) A systematic organized method of obtaining a differential diagnoses relies on categorizing diagnoses from a systems, etiological point of view. The origin of pain, like other chief complaints, can be thought of in terms of large systems-based/etiological categories such as:

Neurological

Rheumatoid/autoimmune

Infectious

Traumatic

Musculoskeletal

Neoplastic

Endocrine

Internal organ derangement: Gastrointestinal, Gynecological, Renal, Pulmonary

Vascular/Cardiac

Psychiatric

Toxins: drugs, alcohol, medication, poisons

The purpose of utilizing this process is so that one can consider a comprehensive differential diagnosis and have an organized method of accomplishing this [3]. But practically speaking, it is impossible to retain a complete list of differential diagnoses for every pain complaint encountered. For example, this is a list of differential diagnosis for anterior knee pain derived in part from a recently published, reputable, peer-reviewed journal [4]:

Articular cartilage injury

Bone Tumor

Chondromalacia patellae

Hoffa disease

Iliotibial band syndrome

Loose bodies

Lateral patellar compression syndrome

Osgood-Schlatter disease

Osteochondritis dissecans

Patellar instability/subluxation

Patellar stress fracture

Patellar tendinopathy

Patellofemoral pain syndrome

Pes Anserine bursitis

Quadriceps tendinopathy

Referred pain from lumbar spine or hip joint pathology

Saphenous neuritis

Sinding-Larsen-Johansson syndrome

Symptomatic bipartite patellae

There are almost 20 different diagnoses listed, some of which are not as frequently encountered or used in primary care. Now, these same diagnoses are reorganized in broader etiological categories as seen in Table 1.1.

Table 1.1

Anterior knee pain etiologies arranged in systems based categories

As evidenced by the table above, only a few etiological categories are needed to cover the almost 20 diagnoses. One may not remember all the diagnoses in the musculoskeletal and traumatic pain categories, but many of them can be summarized by broad terms such as bursitis, tendinopathy, muscular issue, bone fracture and abnormalities. Once the etiology has been narrowed down, further history, physical exam, or investigations can narrow down the differential.

And as an added bonus, if the differential diagnosis is generated through larger etiological categories, other diagnoses can also be added that were previously missed (Table 1.2). Items in italics show differentials that were added in addition to those listed above once larger etiological categories were used in generating a differential.

Table 1.2

Differential diagnosis of anterior knee pain generated using larger etiological categories

In order to facilitate the recall of the above categories (and others such as congenital or toxin), various mnemonics have been suggested [3]. Furthermore, it may be helpful to develop checklists to reduce diagnostic errors [5, 6].

Of course, making the right diagnosis is not solely reliant on history and physical exam alone: it often relies on a team of healthcare providers and specialists, obtaining past records and tests, reducing barriers in effective communication, and improving health literacy [7].

In addition, a pain history will include medications or interventions that have helped in the past and any side effects the patient experienced. Furthermore, it is also important to obtain a psychiatric history including depression, suicidal ideation or attempts, and substance abuse. There are opioid risk stratification tools that may be helpful when contemplating whether a patient is an appropriate candidate for chronic opioid therapy.

Patients Managed with Opioid Medication

Prior to the Visit

If a chronic pain patient on opioid medication is new to your practice, it may be helpful to have the front office staff ask the patient to sign a release of records form, or bring all records in prior to the appointment if they are wishing to obtain an opioid prescription. Indeed, it may be helpful to require the presence of prior records as a standard office policy prior to even having an appointment. In addition, proper expectations for this initial consultation should be set. The appointment will be for initial pain evaluation and management, including the consideration of opioid medication refill. It may be prudent to inform the patient that the purpose of the visit is to evaluate the appropriateness of their current treatment regimen. The evaluation may or may not result in a refill of opioid medication, and if refilled, the dosage maybe adjusted. See Chap. 9, the opioid requiring patient: office level management for further details.

Initial Evaluation

The initial evaluation should include discussions concerning goals of treatment, referencing the controlled substance prescription database, and discussions of risks and benefits of opioid use [8]. A signed pain contract or perhaps, less punitively, Pain Treatment Agreement between the provider (and his associates) and the patient can be used to document the discussion of the risks and benefits, purposes of opioid medication, expectations and goals of treatment, and terms for discontinuation of medication [9].

If a patient is already on opioid medication and has already had a thorough evaluation already, history taking can then focus on several factors that will enable you to determine if continuation or adjustment of opioid medication is necessary [8].

1.

Level of pain prior to opioid dosage, description

2.

Level of pain post opioid dosage

3.

Activities of Daily Living (ADLs) increased or decreased with opioid medication

4.

Side effects of opioids

5.

Aberrant behavior

6.

Depression

Quantification of Pain

It is important to document the efficacy of opioid medication given there is little evidence to support its use long-term in noncancer chronic pain. Consequently, quantifying the nature (burning, achy, duration, etc.) and level of the pain (e.g. scale 1–10) before and after opioid medication administration can help support your reasons for either continuing the opioid medication or adjusting its dosage. Discontinuation of opioid medication can be supported with a history of the opioid medication being not helpful in controlling pain (e.g. no change in pain scale, or nature/duration of pain). In addition, increasing opioid medication may be reasonable if despite maximum dosages of other classes of analgesics, pain is still not well controlled. Consequently, it is important to also document in the history whether the patient continued to take other pain medications and their effect as well.

ADL’s and Side Effects

In addition the benefits and side effects of opioid medication usage should be documented to substantiate your clinical decision. Patients may have an increase in ADL’s from taking opioid medication with little side effects. This may help to support the decision to continue opioids. On the other hand, if the patient is suffering from sedation and constipation while gaining little in function, it may be wise to reconsider the current opioid dosage.

Aberrant Behavior and Depression

Lastly, a complete history also requires evaluating for the presence or absence of behavior that would jeopardize the health of the patient. For example, diversion of opioid prescriptions (e.g. sharing or selling opioid prescriptions) is illegal. In addition, it is recommended that there be documentation of the absence of concurrent alcohol or other substance use. Marijuana is legal in some states, but is a schedule 1 drug under United States federal law. Consequently, it is up to individual healthcare systems to decide whether recreational marijuana is considered behavior that could lead to jeopardizing the patient’s health while taking opioid medications. Please see chapter on Marijuana and chronic pain later in this book for further guidance. Finally, it is often prudent to document the presence or absence of depressive symptoms as opioid medication can be ingested in lethal quantities. For a more in depth discussion of managing the opioid requiring patient, see Chap. 8.

Helpful Links

CDC opioid checklist. https://​www.​cdc.​gov/​drugoverdose/​pdf/​pdo_​checklist-a.​pdf

CDC prescribing opioid guidelines summary. https://​www.​cdc.​gov/​drugoverdose/​pdf/​Guidelines_​Factsheet-a.​pdf

References

1.

Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human right. Pain. 2004;112(1–2):1–4.Crossref

2.

Abd-Elsayed A, editor. Pain: a review guide. Cham: Springer; 2019.

3.

Zabidi-Hussin ZA. Practical way of creating differential diagnoses through an expanded VITAMINSABCDEK mnemonic. Adv Med Educ Pract. 2016;7:247–8.Crossref

4.

Gaitonde DY, Ericksen A, Robbins RC. Patellofemoral pain syndrome. Am Fam Physician. 2019;99(2):88–94.PubMed

5.

Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011;86(3):307–13.Crossref

6.

Chew KS, van Merrienboer JJG, Durning SJ. Investing in the use of a checklist during differential diagnoses consideration: what’s the trade-off? BMC Med Educ. 2017;17(1):234.Crossref

7.

Balogh EP, Miller BT, Ball JR. Improving diagnosis in health care. Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine. Washington, D.C.: National Academies Press (US); 2015.

8.

Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep. 2016;65(RR-1):1–49.Crossref

9.

Centers for Disease Control and Prevention. Quality improvement and care coordination: implementing the CDC guideline for prescribing opioids for chronic pain. Atlanta: National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention; 2018.

© Springer Nature Switzerland AG 2020

B. Huang Hall, MD, PhD (ed.)Evaluation and Management of Chronic Pain for Primary Carehttps://doi.org/10.1007/978-3-030-47117-0_2

2. Physical Examination for Chronic Pain

Bonnie Huang Hall¹  

(1)

UCSF, Department of Family and Community Medicine, Fremont, CA, USA

Bonnie Huang Hall

Keywords

Physical examinationChronic painSuboccipital musclesTemporomandibular joint disorders (TMJ)Carnett testBrachial plexus compression

Helpful Tips

1.

Examine from a systems point of view in order to narrow down a wide range of diagnoses (infectious, inflammatory, autoimmune, musculoskeletal, neurological, metabolic, etc.).

2.

When examining an orthopedic pain, always check joints above and below.

3.

Bear in mind that both internal organ and muscle dysfunction can be the source of pain.

4.

Impingement on nerves anywhere along their path from brain to spinal cord and down to target end organ can cause pain.

5.

If there is limited ROM and pain, consider not only the nerves and muscles that perform the motion, but also that the etiology may also be a tight painful muscle that counters (and therefore limits) that motion.

Introduction

The goal of history taking is to generate a list of differential diagnosis. The goal of the physical exam is to examine the patient in the light of this list and make conclusions as to what are the most likely causes of the patient’s chronic pain. Consequently, the physical exam is often targeted to the systems of interest [1]. However, whether the systems in question are neurological, abdominal, musculoskeletal, rheumatic, or a combination – always begin by assessing the vitals.

Vitals

Vitals include temperature, blood pressure, pulse, height and weight. (Pain quantification has already been discussed in history.) A patient who is hypertensive may be experiencing chronic daily headaches. Abnormalities in pulse can be a sign of thyroid disease. Acute pain itself can manifest as tachycardia and hypertension. Fever may disclose an underlying infection or belie a rheumatic illness.

Targeted Physical Exam

Although a full review of physical exam techniques for each system is out of the scope of this book, a discussion of useful clinical pearls categorized by physical exam technique will be given instead.

Inspection

Start first with inspecting the area of concern. Inspection can help determine if there are dermatological problems causing pain, or infectious etiologies. There may be neuromuscular problems as evidenced by atrophy, hypertrophy, and asymmetry. Deformities may provide evidence for inflammatory/arthritic processes or orthopedic issues.

Palpation

Palpation is one of the most valuable tools in chronic pain physical assessment. When palpating the area the patient experiences pain, keep in mind the systems based differential: for instance, examine for masses, arthritic/rheumatic changes, warmth and inflammation, and tense musculature. In addition, palpate with both light and deep touch. Neuropathic pain often can be elicited with just light touch. In addition, examine for pain caused by nearby structures, or referred pain. For example in knee pain, examine above and below the joint: hip, thigh, lower leg, ankle, and feet. Again, this section is not meant to be a thorough treatise on physical examination techniques, but a listing of a few clinical pearls. This collection of lesser known or more helpful physical examination techniques have proven to be quite useful in aiding the diagnosis of chronic pain. A few of these techniques and considerations will be given for each region of the body in the following sections.

Head and Neck

Although there are other causes of pain in this region, such as neuropathic (trigeminal neuralgia) and infections (chronic sinusitis), key sources of chronic pain in this region can be musculoskeletal in origin. Palpation of tender muscles located in the back of the head can be invaluable in helping to identify a musculoskeletal component to migraines. These muscles are called the suboccipital muscles. Palpation can reproduce the patient’s symptoms. Refer to the chapter on myofascial trigger points for information on treatment.

In addition, inclusion of temporal mandibular joint disorders (TMJ) in the differential is often very helpful in evaluating pain in the head and neck region. In one study 96% of TMJ patients had facial pain [2]. In addition, 50% of TMJ is manifested as only myofacial pain [3]. Consequently, palpation of the muscles of mastication (masseters, pterygoids, temporalis) is also emphasized in a patient with chronic head/neck pain. TMJ can be divided as articular (muscle, joint) or nonarticular (arthritis, gout, infectious, etc.) in origin. One particular physical diagnosis technique is palpation of the temporomandibular joint via the external auditory canal.

TMJ Palpation

1.

Provider places gloved fifth finger in patient’s bilateral external auditory canal

2.

Ask patient to open and close mouth slowly

Interpretation: Feeling a click anteriorly (the location of temporomandibular joint) can confirm articular dislocation and relocation.

TMJ Musculature Palpation

1.

Palpate muscles of mastication with thumb inside mouth and second and third finger on the exterior (gentle squeezing of muscles of mastication between thumb and second and third fingers). Palpate the bony zygomatic arch with the index finger. The muscles of mastication are located inferior to this bony landmark.

Interpretation: tenderness may indicate myofascial origin of pain.

Upper Extremity

Performing a thorough orthopedic exam (inspection for deformity, atrophy, and asymmetry; range of motion; provocative maneuvers; reflexes; strength; pulses) is a good start to an initial evaluation of pain in the upper extremity. One clinical pearl is to keep in mind the nervous system as a source of pain. It may be helpful to examine if the pain has a dermatomal distribution. Pathology can arise from the level of the spinal cord, brachial plexus, to compression at the carpal tunnel. In particular, the brachial plexus (and its branches) which innervates the upper extremity is often a culprit for chronic pain in this region.

When the brachial plexus is compressed or injured (thoracic outlet syndrome, pectoralis minor syndrome), it can cause pain and paraesthesias in the upper extremity [4]. Recall that the brachial plexus travels under the scalene muscles in the neck, beneath the clavicle, and then under the pectoralis minor in the chest on its path to innervate the upper extremity. These are areas where the brachial plexus can become compressed. Tenderness at the scalene muscles and pectoralis minor can be helpful in confirming a neuromuscular etiology.

Brachial Plexus Compression Provocation Tests

The principle behind these tests is elongation of a compromised brachial plexus and its branches leading to symptoms.

Neck Rotation

1.

Ask patient to turn head to left or right.

2.

Wait

Interpretation: symptoms (pain, paresthesias) appear in opposite extremity (that is, turn head to left, right brachial plexus is stretched, and symptoms occur on right upper extremity).

Neck Tilt

1.

Ask patient to tilt head (ear to