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PART THREE  EVALUATION OF THE PAIN PATIENT

We are not aware of standardized instruments to assess the vocational status of pain patients. In the absence of a stan- dard instrument, we recommend that clinicians assessing these patients address the following issues: (1) Is the patient currently working? (2) If the patient is not working, is this related to his or her health? (3) How long has the patient been out of the workforce? (4) Is he or she receiving any kind of work disability benefits? Which ones? Assessment of Social Factors Social factors are construed as factors in the social environment that influence people independent of their individual psycho- logical characteristics. A good example is the receipt of work- ers’ compensation benefits. Social factors include demographic variables that influence the presentation and clinical course of people with painful con- ditions. In particular, research indicates that an individual’s clinical presentation is associated with his or her age, sex, eth- nicity, 146,147 and education level. 148,149 The social factors that have attracted the most research atten- tion in relation to chronic pain are participation in work (includ- ing household activities), interpersonal interactions, litigation, and participation in a workers’ compensation system. 139,150 Important social factors also include influences from an in- dividual’s immediate social environment. For example, there is good evidence that pain patients generally demonstrate more dramatic pain behaviors when they are in the presence of solicitous spouses. 151 A significant proportion of individuals involved in injuries file personal injury claims. There is some evidence that injured workers with workers’ compensation claims respond more poor to a variety of treatments compared to individuals with these same medical conditions but without workers’ compensa- tion claims. 150 Research on the relation between litigation and clinical course, however, has been contradictory. For example, whereas several studies have reported a negative effect of at- torney involvement and litigation on recovery from whiplash disorders. 69,152 Others have not supported the prognostic role of these factors. 153 It is beyond the scope of this chapter to review the often contentious literature on the effect of litigation/attor- ney involvement on outcomes of chronic pain. 154–158 As discussed previously, the clinicians who might participate in multidisciplinary evaluations include physicians, psychologists, vocational rehabilitation counselors, physical and occupations therapists, and perhaps other professionals. An obvious ques- tion is “How do these clinicians orchestrate their evaluations and communicate with each other?” The model that has received the most attention in research literature has been multidisciplinary intensive pain rehabilita- tion. 159 In the United States, the multidisciplinary pain centers and functional restoration programs that provided intensive pain rehabilitation began in the late 1960s, flourished during the 1980s and early 1990s, and more recently have been in decline. 160 Given the decline in intensive pain rehabilitation programs, it will probably be necessary in the future for professionals in- volved in the evaluation of patients with chronic pain to de- velop a number of informal strategies for working together. There are almost certainly a variety of models that can succeed. The key issue is for professionals to work together in acquiring data on the multiple dimensions that affect chronic pain pa- tients and to communicate with each other so that the patients benefit from the data that are gathered. Organization of Multidisciplinary Evaluations

Conclusion Pain and associated symptoms are the results of a complex in- terplay of factors. Assessment and treatment of patients with chronic pain can be complicated by the web of influential fac- tors that modulate the overall pain experience and associated disability. Furthermore, traditional biomedical approaches with diagnostic tests are often not helpful because structural damage and persistent pain reports do not necessarily coincide. Pain research in the last half century has repeatedly shown that pain is not just a physiologic phenomenon and that a range of “person variables,” such as psychosocial, environmental, and behavioral factors, play a significant role in determining the oc- currence, severity, and quality of pain. Given the multifactorial nature of chronic pain, adequate assessment requires an inter- disciplinary team approach. In this chapter, we discussed the assessment of medical factors, altered CNS processing, psycho- logical factors, and social factors in patients with chronic pain. We introduced a number of self-report inventories that can be used in conjunction with interviews and medical examinations. As we have repeatedly stressed, an adequate assessment of pa- tients with chronic pain means the evaluation of the person with the symptoms. We must not just focus on the pathology or symptom report but must reach out to understand the per- son and his or her well-being. Although there is no shortcut in this, the delineation of relevant medical, psychosocial, and behavioral factors contributing to pain in a patient is critical in planning and executing a successful treatment plan. A number of national and international efforts have recom- mended minimal data sets composed of standardized measures that should be considered for use in clinical practice as well as research on specific pain disorders. 161,162 These efforts in- clude many of the multidimensional concepts and constructs reviewed in this chapter. The adoption of these recommenda- tions would permit the aggregation of assessment information across studies and advance the understanding of individuals with chronic pain and the evaluation of treatments. References 1. Dunn WR, Kuhn JE, Sanders R, et al; for MOON Shoulder Group. Symptoms of pain do not correlated with rotator cuff tear severity. A cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg AM 2014;96:793–800. 2. Jarvik JG, Hollingworth W, Heagerty PJ, et al. Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk fac- tors. Spine 2005;30:1541–1548. 3. Wiesel BB, Sankar WN, Delahay JN, et al. Orthopedic Surgery: Principles of Diagnosis and Treatment . Philadelphia: Lippincott Williams &Wilkins; 2010. 4. Flor H, Turk DC. Chronic Pain: An Integrated Biobehavioral Perspective . Washington, DC: IASP Press; 2011. 5. Buskila D. Genetics of chronic pain states. Best Pract Res Clin Rheumatol 2007;21:535–547. 6. Fordyce WE. Behavioral Methods for Chronic Pain and Illness . St. Louis, MO: CV Mosby; 1976. 7. Turk DC, Robinson JP. Assessment of patients with whiplash associated dis- orders: a comprehensive approach. In: Duckworth MP, Iezzi A, O’Donohue W, eds. Motor Vehicle Collisions: Medical, Psychosocial, and Legal Conse- quences . New York: Elsevier; 2008:187–227. 8. Chou R, Qassem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physi- cians and the American Pain Society. Ann Intern Med 2007;147:478–491. 9. Henschke N, Maher CG, Refshauge KM, et al. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum 2009;60:3072–3080. 10. Hakimi K, Spanier D. Electrodiagnosis of cervical radiculopathy. Phys Med Rehabil Clin N Am 2013;24:1–12. 11. Martin AR, Aleksanderek I, Cohen-Adad J, et al. Translating state-of-the- art spinal cord MRI techniques to clinical use: a systematic review of clin- ical studies utilizing DTI, MT, MWF, MRS, and fMRI. Neuroimage Clin 2015;10:192–238. 12. Nardone R, Höller Y, Brigo F, et al. The contribution of neurophysiology in the diagnosis and management of cervical spondylotic myelopathy: a review. Spinal Cord 2016;54:756–766. 13. Tan WQ, Wong BS. Clinics in diagnostic imaging. Cervical OPLL with cord compression. Singapore Med J 2015;56:373–377.