Chronic Pain Workup
Background
Affects 20% of the population
Often due to a sensitised nervous system than structural damage
Common
Chronic back, neck, or shoulder
Chronic wide-spread pain
Nerve pain
Headache
Facial pain
Atypical chest pain
Abdominal pain
Pelvic pain
Red Flags 🟥
Fracture - Major trauma or minor trauma in elderly
Cancer - Age < 20 or > 50, History of cancer, fever, weight loss, IV drugs, Immune suppressed, night pain
Nerve - Severe or progressive sensory changes or weakness, bladder or bowel dysfunction, neurological deficit on exam
Assessment
Site, onset, character, radiation, associated, relieving, time, severity, exacerbating
Impact on sleep and mood
Previous tests
Medication use
Previous treatment and outcomes
Story around onset and any stressful life events
Impact on functioning
Work, ADL, leisure, exercise, and relationships
Beliefs
Unhelpful believes - pain is unbearable and uncontrollable, hurt equals harm, exercise makes the pain worse, when in pain you should rest, returning to work worsens pain, only medication can help
Fear avoidance behaviour - Fear of movement, activities,
Behaviour factors - Doctor shopping, illness behaviours e.g. adopting the sick role
Psychosocial Factors 🟨
Mental health and suicidality
Susbtance abuse
Social factors - work problems, life events, lack of support
Family context - advice from relatives, over or under supportive family or carers
Trauma
Life style
Physical activity levels
Sleep
Nutrition
Medications
Current and past medications
Examination
As dictated by history and red flags
Investigation
As dictated by history, exam and red flags
Management
1) Red Flags 🟥
Targeted treated of any identified underlying conditions
2) Urgent Referral to pain service
Pain has significant impact on sleep, self-care, mobility, work, school, receration, relationship, and/or emotions
Early neuropathic pain not responding to GP management or early signs of Chronic Regional Pain Syndrome
Harmful psychological indicators - Belief pain is harmful, fear avoidance, low mood, no active treatment
K10 score > 19/50 or DASS > D=9 A=7 S=14
3) No serious pathology
Semi-urgent pain referral if pain < 1 year, frequent exacerbations, unresponsive neuropathic pain, persistent pain after trauma or surgery, marked emotional distress
Focus management of retraining nervous system
Discuss multifactorial nature of chronic pain - Watch the Brainman video – Understanding Pain [5 minutes].
4) Develop a pain recovery plan
Using a whole person approach
Consider using a pain recovery plan template
5) Mind body
6) Connection
7) Activity and sleep
8) Nutrition
Consider using the Hunter Integrated Pain Service patient resources
9) Biomedical
Time-limited use of pain medications
10) Referral
Allied health as appropriate e.g. exercise physiologist, physiotherapist
Psychologist referral
Online self help pain programs
Specialist pain services
Resources:
Chronic Pain - HNE Community Pathways
Chronic Pain - RACGP