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40 Paul J. WRIGLEY, Philip J. SIDDALL
time. An individual may have many life roles to
play, e.g. income provider, father and husband.
Most roles can be broken down into four basic
areas namely: self-maintenance (activities of daily
living), rest (including sleep and relaxation), leisure
(activities undertaken for their intrinsic value) and
productivity (paid and unpaid employment) (Table
4.06). Problems within any of these areas affect the
ability of a person to carry out the roles they play
in everyday life [9].
History Taking
Establishing rapport
It is tempting to jump ahead to taking a history,
the first step required in an assessment. However,
prior to this, it is important to establish a rapport
with the patient. is may seem so basic, as to be
unnecessary. However, it cannot be emphasised
enough. Trust is a much valued commodity by
the patient who has seen many practitioners and
engaged in multiple failed treatments. Patients may
harbour a degree of scepticism and bitterness from
previous attempts to “cure their pain” and carry
with them unhelpful cognitions such as, “ey
thought the pain was all in my head.” Engaging
the patient in effective treatment may be difficult if
they do not feel their problem has been adequately
assessed and that the clinician is worthy of trust.
Conversely, many patients are grateful even in the
absence of effective treatment if they feel they have
been treated with consideration, thoroughness and
care.
In developing rapport, it is important to
communicate competence in your field, interest
in the patient and their problem, and a desire to
work to find an answer that will not necessarily
cure but help the patient. It is also important to
give an indication of what will be involved in the
evaluation process as well as the aims.
Details of pain history
Taking a patient history is usually the first step
towards identifying the main contributors and
consequences associated with a person’s pain
problem. A history provides information that
allows some direction as to whether the pain is
primarily somatic, visceral or neuropathic and the
contributing psychosocial factors. For example,
lumbar spinal pain precipitated by a lifting
incident, which is related to movement, eased by
rest, with no radiation to the legs, no numbness
or paraesthesia and a positive response to simple
analgesics, including anti-inflammatory drugs, all
suggest a primarily somatic nociceptive pain. In
addition, sleep disturbance, loss of appetite and loss
of enjoyment of activities suggest an accompanying
mood disturbance.
A clear history will then provide the basis for further
examination and investigations which further refine
these preliminary observations. Indeed, a carefully
obtained history provides the foundation on which
examination and other investigations are built. In
addition, the history will provide clues on other
aspects of the person’s presentation. e patient’s
manner, tone, emphasis of certain facts, expressions
and language will all help to convey important
aspects of their expectations, understanding of
their problem and emotional state. Although there
are many variations on taking pain history, the
Table 4.06 Areas of functional performance
Functional
performance
Examples
Self-
maintenance
(activities of
daily living/
ADLs)
• PADLs (personal ADLs),
e.g. showering, dressing,
grooming, mobilising and
transferring
• DADLs (domestic ADLs),
e.g. cooking, cleaning and
shopping + laundry, money
management
Rest The pursuit of “non-activity”, e.g.
sleep, rest, relaxation
Leisure Activities performed for
their intrinsic value, e.g.
entertainment, creativity and
celebration
Productivity Activities performed for
some extrinsic value, e.g. to
provide support for self, family
or community through the
production of goods or provision
of services
Problems within any of the above domains can interfere with an
individual’s ability to carry out their life roles (based on [9]).
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The Clinical Evaluation of Pain 41
basic elements consist of the following: history of
the presenting pain problem; effect of the pain on
the person (associated consequences and effect on
function); previous pain management; and general
history (past medical, family, developmental,
psychological, social, educational and vocational
history (Table 4.07).
Table 4.07 Outline of pain history (based on [15])
Overview
• Reason for referral
• Demographics details (including other health
providers, medicolegal status)
Pain description
• Onset — mechanism of initiating event. This
may provide a clue to what the person thinks
is the cause.
• Location
visceral/somatic
radiation (referred/radicular)
• Nature/qualities/descriptors
nociceptive
neuropathic
• Temporal characteristics
constant
episodic
• Duration (overall and of episodes)
• Intensity (use appropriate intensity scale,
present and recent past average)
• Aggravating factors
• Relieving factors
Pain associated consequences and functional
ability
Problems with self management, rest, leisure and
work are determined by assessing the following
domains:
• Biological (gastrointestinal dysfunction,
fatigue, sleep, sexual activity, menstruation,
etc.)
• Psychological
mood (anxiety, depression, anger, despair etc.)
cognitions (helpful or unhelpful,
concentration, memory etc.)
beliefs (regarding pain, illness, self and others)
coping strategies (passive, active, fear
avoidance etc.)
• Social (activities, involvement with others,
finance, occupation, leisure, litigation) and
physical environment
• Spiritual — new life plans, sense of purpose
and meaning
Physical Examination
Physical examination assists in:
• Developing rapport with the patient
• Obtaining further information to support the
assessment of pain contributors (structural
pathology and psychological behavioural
contributors)
• Assessing the impact of the pain on physical
function.
Given the limited time usually available during
a clinical assessment, the physical examination is
usually relatively focused. A carefully conducted
pain history provides significant guidance as to
where to direct most attention during examination.
Despite this, a general screening examination is
also important to check for secondary effects of
pain beyond the main reported site.
Physical pain generators can be broadly divided
into nociceptive or neuropathic. erefore, the
physical examination can be broadly divided
into musculoskeletal (or less commonly visceral)
and neurological. Other bodily systems (e.g.
cardiovascular, respiratory and gastrointestinal)
Pain management
• Other treatments (present and past, including
response)
• Medications and substances (present and past,
including response)
prescription medications
complementary and alternative
recreational — alcohol, caffeine, tobacco
and illicit adverse reactions
• Assessment of practitioners’ responses to this
patient
• Obtain past documentation/collaborative
information
General history
• Medical problems past and present
• Medical problems — family
• Personal development
• Psychological history
• Social context
• Educational history
• Vocational history including workers
compensation issues
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42 Paul J. WRIGLEY, Philip J. SIDDALL
may also require examination, depending on the
individual’s presentation. For example, a poor
cardiovascular history in a person with low back
pain should alert the clinician to the possibility
of an underlying vascular cause. is would then
warrant careful examination of the vascular system
and potentially further investigation.
e aim of a physical examination is to identify,
where possible, the structural problem or the
nervous system lesion giving rise to the pain. In
addition, any secondary consequences or features of
the pain, such as muscle deconditioning, allodynia
or hyperalgesia, may need to be a focus of treatment
in themselves.
Table 4.08 Assessment of negative and positive symptoms or signs in neuropathic pain (modified from [30])
Sensory symptoms/signs Bedside examination Laboratory examination Proposed mechanism
Negative (reduced)
• Touch Touch skin with cotton
wool
Graded von Frey hair A-beta fibres
• Pin prick Prick skin with pin Specific von Frey, e.g.
5.88 (745mN)
A-delta fibres
• Cold/heat Apply cool (20˚C) and
hot (45˚C)
Detection/pain threshold
cold/warm
A-delta/C fibres
• Vibration tuning fork on malleoli vibrameter A-beta fibres
Positive (Spontaneous)
• Paraesthesia NRS 11 (i.e. grade 0–10) Measure area in cm
2
+
NRS 11
spontaneous activity LT
A-beta afferents
• Dysaesthesia NRS 11 Measure area in cm
2
+
NRS 11
spontaneous activity C/A-
delta afferents
• Paroxysms Number/time + NRS 11 Threshold for evocation spontaneous activity C-
nociceptors
• Superficial burning
pain
NRS 11 Measure area in cm
2
+
NRS 11
spontaneous activity C-
nociceptors?
• Deep pain NRS 11 Measure area in cm
2
+
NRS 11
spontaneous activity
joint/muscle nociceptors
Positive (Evoked)
• Touch evoked
allodynia
Brush skin with painter’s
brush
CS — increased or loss of
C fibre input
• Static allodynia Gentle mechanical
pressure
Evoked pain to pressure PS
• Punctate hyperalgesia Prick skin with pin von Frey hair CS — A-delta fibre input
• Punctate repetitive
hyperalgesia (wind-
up-like)
Prick skin with pin 2 s
for 30 s
von Frey hair CS — A-delta fibre input
• Aftersensation Measure pain duration
after stimulus
Measure pain duration
after stimulus
CS
• Cold allodynia Apply metal roller to
skin 20oC
Threshold and tolerance
to cold stimulus
central sensitization/
disinhibition
• Heat allodynia Apply metal roller to
skin 45oC
Threshold and tolerance
to heat stimulus
PS
• Chemical
hypersensitivity
Topical capsaicin Topical capsaicin PS
• Sympathetically
maintained
None Sympathetic block,
modulation sympathetic
outflow
?
NRS = numerical rating scale, LT = low threshold, CS = central sensitisation, PS = peripheral sensitisation.
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The Clinical Evaluation of Pain 43
When no underlying cause can be identified to
explain the pain or an identified underlying disease
cannot be cured, conventional examination findings
become less useful in guiding management [30].
In these circumstances, a specific pain-focused
examination aimed at defining the characteristics
of the pain and thereby determining the underlying
mechanism(s) of the pain has been suggested (Table
4.08).
General physical examination
A general physical examination commences
with meeting the patient. Often, a great deal
of information can be gleaned even before the
patient is seated. Physical observations regarding
appearance, posture and gait can be made in
addition to informal observations regarding the
patient’s mental state including speech, thoughts/
beliefs, orientation, concentration/attention,
insight/judgements, affect and illness behaviours.
Examination of pain behaviours
People presenting with pain often express distress
in a verbal manner, including crying, moaning
or complaining. ey may also exhibit distress in
more physical modes including body postures,
facial expressions, medication taking or even
visiting health professionals. Systematic approaches
for assessing pain behaviours are available and
can provide a further measure to assess the pain
experience [32]. Observations regarding pain
behaviours should not be interpreted in isolation
but be part of a more complete multidimensional
assessment (biopsychosocial-spiritual). e analysis
of pain behaviours can assist in determining the
variables influencing behaviour and therefore assist
in developing a treatment plan.
Examination of the painful
region
Inspection
Careful attention is paid to the appearance and
colour of the skin over the site of pain. Oedema or
discolouration may be present, as well as dystrophic
changes such as hair loss, increasing sweating,
“goosebumps”, pallor or mottling.
Palpation
Light touch over the region first detects the presence
of allodynia. If present, the area of disturbance can
be mapped and the distribution (local, regional
or dermatomal) determined and correlated with
known pathology. e region of hypersensitivity
will provide important clues as to whether the
pain is due to inflammation, mononeuropathy,
polyneuropathy or a central nervous system
lesion. If tolerated and musculoskeletal or visceral
pathology is suspected, deep pressure using one
or more digits can be applied to determine the
region of deep tenderness and if possible related to
underlying structures.
During palpation, the clinician should also observe
for any localised or regional responses such as
alterations in colour, temperature or sweating,
piloerection and muscle spasm. Note is also
made of the patient’s generalised reactions such as
grimacing, withdrawal, groaning or vocalisation.
Musculoskeletal examination
Inspection
e patient is inspected anteriorly, posteriorly
and from the sides to reveal abnormalities in body
shape and symmetry including spinal curvature.
Abnormal posture, guarding, stiffness and gait also
give clues regarding pathology. Having the patient
walk across the examination room allows the
detection of gait abnormalities. ese may be a result
of structural problems such as limb shortening, or
may stem from postural changes, weakness or the
avoidance of pain. As a screening method for more
generalised dysfunction, it is often useful to ask
the patient to actively range selected major joints
(shoulder, elbow, wrist, hips, knees and ankles)
and the spine. An initial “hands off” approach can
provide a general assessment of motor function and
degree of pain inhibited movement. It also provides
another opportunity to observe the patient’s pain
behaviours.
Palpation
Palpation of the region where the pain is perceived
will help to detect structures that may be giving
rise to pain. Tenderness over specific structures that
increases as pressure is applied and giving rise to
pain of a similar nature to that reported suggest
the generation of pain from these structures.
Nonspecific tenderness (generalised or regional)
suggests more generalised sensitisation of the
nervous system.
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44 Paul J. WRIGLEY, Philip J. SIDDALL
Movement
Movement of regions involved in the pain will help
to determine further the source of the pain (e.g.
joint, ligament, etc.) as well as quantify the impact
of the pain on function. Joints possibly affected
by the pain should be assessed noting active and
passive range of motion, pain and other features
such as crepitus.
Neurological examination
Consensus regarding the best approach to use when
assessing neuropathic pain does not exist. Many
international clinicians and scientists, however,
are attempting to develop a clinically relevant
mechanistic-based approach to guide subsequent
management decisions. Of central importance to
the diagnosis of neuropathic pain is the presence
of a sensory transmission disturbance resulting in
loss of neural input with corresponding negative
sensory symptoms (hypoaesthesia). is reduced
sensory input can also initiate broader changes
centrally including nerve fibre regeneration
and disinhibition resulting in positive sensory
symptoms (hyperaesthesia). Positive and negative
sensory symptoms can be demonstrated both at the
bedside and in the laboratory (Table 4.08) [30].
Sensory
Basic evaluation of sensory function includes the
assessment of large- and small-fibre function in
the region of pain compared with non-painful
regions. Testing should at least cover the sensations
of touch and pain, using the brush and pin prick
tests. Consideration should also be given to the use
of other modalities such as proprioception, cold
(e.g. applying a metal tuning fork) and heat for a
more comprehensive evaluation of fibre and tract
function (Table 4.08).
Reduction or absence of sensation suggestive of a
nerve lesion should be noted. It is also important
to note any region of increased sensation
(hyperaesthesia), the modality (thermal or
mechanical) and the degree of increase (allodynia
or hyperalgesia).
Positive sensory changes such as allodynia are often
used as a diagnostic indicator of neuropathic pain.
Such changes however are also present in nociceptive
pain conditions and therefore cannot be relied on
to identify neuropathic pain. Quantitative sensory
testing (described below) may be used in some
situations and enables comparison with normative
data as well as changes over time.
Motor
e object of motor assessment is to determine the
impact of pain upon motor function and to provide
further information about a possible neurological
lesion. One aspect of motor function is muscle
power. Muscles may be tested individually or in
groups using standardised dynamometers or more
commonly a subjective (five-point) scale. Muscle
wasting may be evident through discrepancies in
muscle circumference. Other changes in motor
function such as increased tone, spasm or tremor
should also be noted.
Reexes
Deep tendon reflexes and the presence or absence of
a Babinski response are assessed to determine the site
and level (peripheral or central) of a nerve lesion.
Autonomic function
is is particularly important in conditions such
as complex regional pain syndromes where pain is
associated with alterations in autonomic function.
e location and nature of changes in temperature,
sweating, skin colour, nail and hair growth and
oedema should be noted.
Investigations
A wide range of investigations may be indicated
to complete an assessment of a patient presenting
with persistent pain. Unfortunately, while most
investigations are able to demonstrate sinister
pathology (e.g. fracture, infection, cancer and
progressive neurological problems), they do not
usually assist in identify the mechanisms underlying
persistent pain. For example, in patients with spinal
pain, a poor correlation between pain report and
the presence of pathology has been shown with
anatomical imaging (magnetic resonance imaging
of the spine [29, 46]).
erefore, in ordering further investigations, the
clinician needs to be clear as to what information
they will provide and whether this information is
likely to be of benefit in formulating a diagnosis.
Continuing to seek a cause for the pain may make
the patient and clinician feel that something is
being done. However, a nonspecific investigative
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The Clinical Evaluation of Pain 45
approach tends to yield less information over time,
adds considerably to medical costs and may delay
pain management and functional upgrading.
A detailed description of the investigations used in a
pain assessment is beyond the scope of this chapter;
however, several special investigations, relevant to
pain medicine are worthy of further comment. A
detailed account of psychophysical measures can be
found in Flor (2001) [17].
Clinical neurophysiology
Clinical neurophysiology includes electrodiagnostic
techniques such as electromyography, nerve
conduction studies and somatosensory evoked
potentials. ese techniques are most likely to be
useful for the investigation of neuropathic pain
conditions. ey may help to provide greater
precision in identifying the site of a nerve lesion.
Unfortunately they do not assess small-fibre
function.
Quantitative sensory testing
Quantitative sensory testing involves a detailed,
systematic assessment of cutaneous peripheral
nerve function (Table 4.08). It is one of the few
quantitative ways of assessing small-fibre sensory
function [25]. A variety of stimuli are applied to
the skin (mechanical, thermal and chemical) which
allow more precise information to be obtained
regarding the sensory changes associated with
pain.
e commonly used stimuli include:
Mechanical
• von Frey hairs/Semmes-Weinstein
Monofilaments: a series of calibrated
monofilaments that when applied to the skin
produce a calibrated force. ese can be used
to determine touch (A-beta fibre function)
and pain (A-delta/C fibre function) thresholds
to a static mechanical stimulus [10].
• A soft brush drawn over the skin can be used
to detect the presence of dynamic mechanical
allodynia (i.e. pain in response to light touch
with movement). Dynamic mechanical
allodynia is a measure of central sensitisation,
thought to be due to A-beta fibres synapsing
with sensitised spinal neurons [30].
• A vibrameter can be used to measure the
vibration threshold (A-alpha/beta fibre
function) [10, 43].
Thermal
• Computer-driven thermal testing devices that
deliver cold (A-delta fibre) and hot (C fibre)
thermal stimuli through a thermode applied to
the skin can be used to determine thresholds
for sensation and pain [10].
• ermal rollers, which are kept at a constant
temperature (one hot and the other cool),
can also be used to detect a decreased
(hypoaesthesia) or increased (hyperaesthesia)
responsiveness to these stimuli.
Chemical
• Capsaicin/menthol/histamine can be applied
to assess the function of specific A-delta/C
fibre subpopulations [30].
Quantitative sensory testing requires specialised
equipment and requires additional time
to administer. It also relies on the use of
normative data, which for some modalities are
quite variable. In addition, it relies on patient
perception and is therefore more subjective than
other neurophysiology investigations, e.g. nerve
conduction studie s. While it has b een used clinic ally
for over three decades [58], time constraints often
restrict its use to the research setting.
Thermography
Significant controversy surrounds the use of this
technique in the assessment of persistent pain[34].
ermography does not indicate the presence
or magnitude of pain but reveals alterations in
skin temperature that may be due to changes in
vascular or neurological function. Differences
in skin temperature can be detected by using
an infrared thermometer at different measuring
points or with infrared thermal imaging.
Measurement of temperature differences may be
useful in conditions such as complex regional pain
syndrome to detect autonomic dysfunction [45]. It
is important to note, however, that the diagnostic
sensitivity of static temperature measurement is
quite poor in detecting temperature differences
between the affected and normal sides. Controlled
thermoregulatory studies (where temperature is
systematically changed using a thermal suit) are
much more sensitive and specific for detecting
disturbed autonomic function [55, 56]. is
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46 Paul J. WRIGLEY, Philip J. SIDDALL
highlights the importance of assessing dynamic
thermal responses. While formal thermal testing
may not be possible in the clinic, repeated
measurements using, for example, an infrared
thermometer in different thermal environments
may provide a simpler way of detecting side-to-
side temperature differences [45].
Brain imaging
Conventional neuroimaging techniques based on
computer tomography and magnetic resonance
imaging are well established in the assessment of
gross anatomical structure. More recently, a great
deal of interest has been shown in the assessment
of function within the central nervous system.
Several blood-flow-based neuroimaging methods
have become available including positron emission
tomography, single positron emission tomography
and functional magnetic resonance imaging [17].
In addition, imaging of chemical changes within
the central nervous system is possible using
magnetic resonance spectroscopy and investigation
of changes in electrical activity can be performed
using electroencephalography.
e use of these newer neuroimaging techniques
is still largely confined to research studies. Until
further specificity, sensitivity and validity studies
are performed relevant to specific disease states,
the cost and availability of these investigations will
generally preclude use in the clinical setting.
Response to intervention
Response to interventions may provide helpful
information that further defines pathological
processes underlying a pain condition. ese
include response to drug administration (e.g.
phentolamine or intravenous lignocaine) and neural
blockade (peripheral and sympathetic nerves).
Diagnostic neural blockade may be used to guide
pharmacotherapy choices, the use of therapeutic
blocks or surgical therapy. e temporary changes
afforded by neural blockade may help prior to
performing longer-term lesions.
e use of a nerve block to identify a particular
nerve pathway as a source of a patient’s pain
assumes [12]:
• A discrete peripheral location generating the
pain coupled to a unique neural route
• e block will totally and selectively interrupt
the sensory function of the targeted nerves
• Any reduction in pain following the block is due
to the blockade of the targeted neural pathway.
ese assumptions are limited by the interaction of
many variables:
• Variation in anatomy
• Variation in physiology
• e psychology of pain
• e variability of local anaesthetic blockade,
which is rarely an all-or-none response.
Assessment of Special
Populations
While the principles described so far are generally
applicable to most pain assessments, there are several
populations that require more specific assessment
tools or approaches. ese include children, older
people, those with intellectual disabilities and other
populations sharing additional factors such as
impairment in cognition, physiological differences
and communication difficulties. e management
of pain in older people, children and adolescents will
be discussed in more detail in Chapters 18 and 19.
Pain assessment tools specific to these populations
have already been discussed in Chapter 3.
Conclusion
e clinical evaluation of pain remains an imperfect
science. e effectiveness of an evaluation is highly
dependent on the health care provider’s pre-
existing concept of pain, which is itself influenced
by personal experience, education and training,
and perceived role in the person’s care. While the
traditional Western medical model tends to focus
on biological pathology and disease management,
a purely disease focused approach is inadequate for
the management of chronic conditions including
persistent pain. It is suggested that a change in focus
is required to a biopsychosocial-spiritual model
(or wellness model), a model that incorporates
predisposing, precipitating and perpetuating
factors from the biological, psychological, social/
environmental and spiritual domains and their
effect on a person to carry out their life roles. is
complex model favours a team approach to patient
assessment and care.
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The Clinical Evaluation of Pain 47
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Introduction
Epidemiological principles are applied by health care workers
as the basis for disease surveillance and investigation.
Historically, epidemiology was concerned mainly with
investigating epidemics of communicable diseases. Now
the application of epidemiological methods has extended to
chronic diseases, occupational health and other areas of health
care. ey are extremely relevant in pain medicine today as it
becomes increasingly clear that chronic pain is a major health
care concern and public health burden.
Epidemiology is defined as the study of the distribution and
determinants of health-related states or events in specified
populations, and the application of this study to the control
of health problems [62]. Descriptive epidemiology provides
information regarding the health state, personal characteristics
of those affected, time and place relating to the occurrence of
the event. Analytical epidemiology on the other hand, provides
the cause and factors that may influence the event.
What Does Epidemiology Tell Us
about Chronic Pain?
Epidemiologists employ sound scientific methodology to
determine the frequency and pattern of a health-related event
in a population and design strategies to control and prevent
the event in the community. e distribution of chronic pain
is not uniform across different populations and samples, and
varies with age, gender, social class, ethnicity, culture and even
geography. In studying the epidemiology of chronic pain,
many early studies have addressed the question of prevalence,
but less attention has been focused on the distribution of
chronic pain conditions among different groups in society
INTRODUCTION
WHAT DOES EPIDEMIOLOGY TELL
US ABOUT CHRONIC PAIN?
Epidemiological study designs
Application of epidemiology in
pain medicine
Prev
alence of c
hronic pain
GENDER AND PAIN
ETHNICITY AND CUL
TURAL
ASPECTS OF PAIN
Pain reporting
Pain relief treatment
Reasons for ethnic and r
acial
differences
SUMMARY
REFERENCES
Epidemiology in Chronic Pain, Gender
and Cultural Aspects
5
Mary CARDOSA, Phoon Ping CHEN
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