Chronic Pain

Chronic Pain: Excerpt from In a Page: Signs and Symptoms

Chronic pain is historically undertreated and underdiagnosed. It is defined as pain that persists beyond the recognized time for the body to heal (usually 4–6 weeks). Although acute pain serves a physiologic purpose, chronic pain without a physiologic role becomes a disease state in and of itself. It is usually categorized as diffuse or regional depending on the symptom distribution. Be aware of the high rate of psychiatric co-morbidities that exist with these conditions.

Differential Diagnosis

• Headache
  –Migraine headache
  –Cluster headache
  –Tension headache
  –Cervical radiculopathy
  –Temporomandibular joint syndrome
• Low back pain
  –Myofascial pain
  –Lumbar radiculopathy
  –Spinal stenosis
  –Facet syndrome
• Musculoskeletal
  –Soft tissue injury
  –Repetitive strain syndromes
  –Myofascial pain syndrome
  –Fibromyalgia
  –Arthritis
• Neuropathic
  –Diabetic neuropathy
  –Post-herpetic neuralgia
  –Cervical radiculopathy
  –Reflex sympathetic dystrophy (chronic regional pain syndrome)
  –Phantom limb
  –Postoperative thoracotomy
• Cancer pain syndromes
  –Bony pain secondary to metastasis
  –Visceral pain secondary to mass effects
  –Postradiation neuritis or mucositis
• Pelvic/abdominal
  –Endometriosis
  –Fibroids
  –Irritable bowel syndrome
  –Interstitial cystitis
• Psychiatric
  –Depression
  –Anxiety
  –Somatization
  –Physical, sexual, and/or emotional abuse
  –Malingering

Workup and Diagnosis

• History of symptoms should include onset, location, character, intensity, duration, radiation, aggravating and alleviating factors, and associated symptoms, as well as detailed past medical and surgical histories, how the symptoms affect the patient's life, and any previous evaluations and treatments
• Physical examination should include a comprehensive evaluation of each region where symptoms are described, including all affected joints and soft-tissue regions; complete mental status examination including affect, mood, ideation, and insight; and comprehensive evaluations of individual systems consistent with the patient's description of presentation
• Labs may be indicated depending on the distribution of symptoms and associated organ systems, possibly including CBC, BUN/creatinine, electrolytes, glucose, and calcium
  –ESR or CRP to evaluate for inflammatory conditions
  –CPK to evaluate for myopathies
• Imaging may be helpful, but should be targeted to specific conditions (e.g., plain films or CT scan for bony abnormalities or radiculopathy, MRI for soft-tissue mass or neural lesions, bone scan for reflex sympathetic dystrophy)
• Consider EMG

Treatment

• NSAIDs are often used, especially for inflammation
• Narcotics are usually reserved as adjuvant therapy after more conservative measures have failed; concern about addiction is a common barrier to use
• Tricyclic antidepressants and anticonvulsants are useful for neuropathic pain
• SSRIs are effective for fibromyalgia
• Spinal delivery of pain medication may be useful for radicular pain and reflex sympathetic dystrophy
• Tramadol is often used as a bridge between NSAIDs and narcotics
• Physical/occupational therapy is often very useful in a variety of conditions, especially reflex sympathetic dystrophy, low back pain, and fibromyalgia
• Alternative therapies may be useful as primary treatment or adjuvant therapy for chronic pain syndromes
• Psychiatric evaluation may be indicated for potential primary psychiatric conditions and co-morbidities
• Consider referral to a pain specialist

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Pain

• Back to disease: Pain: Introduction
• Next Book Extract About Pain: Abdominal Pain in Lower Quadrants (In a Page: Signs and Symptoms)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: Abdominal Pain in Lower Quadrants (In a Page: Signs and Symptoms)

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