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PART THREE  EVALUATION OF THE PAIN PATIENT

that Xa 1

, Xa

. . . Xa

an refer to biomedical factors at the end

whether there is any medical or surgical treatment that has a reasonable chance of reversing the pathophysiologic processes underlying the patient’s pain, (5) determine whether there are any symptomatic treatments that should be prescribed if a re- versal of pathophysiology is not possible, and (6) establish the objectives of treatment. The specific procedures that physicians perform and the dif- ferential diagnostic possibilities they entertain vary enormously with patients’ symptoms and presumed medical disorders. For example, the medical evaluation of a patient with pelvic pain is entirely different from the evaluation of a patient with neck pain. Also, the medical evaluation of a pain patient depends on the chronicity of the patient’s symptoms and the physical evaluations and diagnostic testing that the patient has already undergone. In order to be reasonably specific, the discussion here fo- cuses on the medical evaluation of patients with persistent neck pain, especially in the aftermath of a “whiplash” injury. There is no uniformly accepted algorithm for evaluating neck pain patients. In fact, as will be discussed, clinicians differ sharply about some aspects of such evaluations. The approach discussed in the following section is summarized in Figure 23.1, which identifies key questions that should be asked in the eval- uation of a patient with persistent neck pain. ARE THERE RED FLAGS? Although the assumption in this section is that the patient is undergoing evaluation for residuals of a neck injury, occasion- ally, the physician will find that the patient has misattributed his or her symptoms and is actually symptomatic because of a disease rather than because of any injury.

2

organ where the patient reports pain; Xb 1 refer to alterations in nervous system function (especially CNS sensiti- zation [CNSS]) that perpetuate pain after nociceptive impulses from the end organ have diminished or ceased; Xc 1 , Xc 2 . . . Xc cn refer to psychological variables; and Xd 1 , Xd 2 . . . Xd dn refer to social or contextual variables that influence pain behavior. 7 The prediction equation emphasizes the multiplicity of fac- tors that influence patients’ expressions of pain and highlights the dilemma facing an evaluating clinician. The dilemma is that it is extremely difficult to determine the weights that should be assigned to various factors for an individual patient. To make matters even worse, there is no consensus about what the pos- sible variables within various categories are (e.g., to specify the types of psychological factors that may affect a patient’s pain behavior). In accordance with the model, the discussion is organized around the assessment of medical factors, CNSS, psychologi- cal factors, and social factors in chronic pain patients. We also consider the assessment of the severity of functional incapaci- tation in these patients. Assessment of Medical Factors A careful medical evaluation is a basic element in a multidisci- plinary evaluation of a patient with chronic pain. The general goals of such an evaluation are to (1) make a medical diagnosis, (2) determine whether additional diagnostic testing is needed, (3) make a judgment about the extent to which medical data re- garding a patient adequately explain his or her symptoms and the severity of his or her apparent incapacitation, (4) determine , Xb 2 . . . Xb bn

Step 1. Are there “red flags” to suggest symptoms are secondary to a disease process rather than an injury?

YES

NO

Step 2. What is the nature of the injury?

Neurologic Injury Major Skeletal Injury (fracture; instability)

Musculoskeletal—Axial Spinal Pain

a. Discogenic b. Ligamentous

c. Facet joint d. Myofascial e. Widespread “nonanatomic” pain

Step 3. Are there risk factors for delayed recovery?

a. Systemic musculoskeletal disorder (e.g., rheumatoid arthritis) b. Relevant general medical conditions (e.g., stroke)

c. History of prior spinal injuries d. Evidence of severe spondylosis e. High pain intensity f. Severe functional limitations on exam g. Chemical dependency h. Sleep disturbance i. Evidence of severe emotional distress j. Disability and/or litigation issues

FIGURE 23.1  Key issues to address in the medical eval- uation of chronic pain patients.