Assessment Issues in Chronic PainSpring Scientific Meeting

16th May 2008www.nbpa.org.uk

Queen Mother Conference Centre

NBPA May 2008

When to get worried?Missed pathology in the pain clinic

Outline

Causes and consequences Role of AssessorWhy diagnose? Back pain when to worryConclusionQuestions

Causes of missed diagnosis

Assessor Patient DiagnosisInstitution/philosophy

CONSEQUENCES OF MISSED DIAGNOSIS

patient

illness

professional

institution

Assessment

Role of initial assessorWho performs initial assessment? TriageSingle vs. team assessmentGoals of assessmentDiagnosis vs symptom management

Reasons to pursue diagnosis?

• Serious illness• Treatable diagnosis• Disease progression• Onward referral• Patient anxiety• Ability to progress • Therapeutic investigation

Problems with pursuing diagnosis

• No diagnosable illness• Anxiety and catastrophising• Fuels cure searching• Cost• Duplication of investigations• False positives• Use of resources

Age under 20 or over 55 Bony tendernessNon-mechanical pain (capsular)(Thoracic pain) PMHx: Ca, steroids, HIVUnwell, wt loss Structural deformity Persistent night painWidespread neurology bilateral leg signs Saddle anaesthesiaSphincter disturbance

Back Pain

1) Non specific low back pain2) Back pain potentially associated with radiculopathy or spinal stenosis.3) Back pain associated with another specific spinal cause

Look for differentiating factorsAmerican College of Physicians 2007

Breakdown of Back pain

Group 1>85% non specific.

Group 2Spinal stenosis 3%, radiculopathy 4%Cauda equina syndrome 0.04%

Group 3Compression fracture 4%Cancer 0.7%, spinal infection 0.01%Ankylosing spondylitis 0.3-5%Other

Radiculopathy

Typical sciatica historyLocationMotor assessmentStraight leg raise, crossed SLR

Spinal Stenosis

PseudoclaudicationRadiating leg painDownhill treadmillPain relieved by sittingAge >65

Cauda equina syndrome

Rapidly progressive, severe neurological deficitMotor deficits >1 levelFaecal incontinenceBladder dysfunction

Malignancy risk factors

History of cancer*Unexplained weight lossFailure to improve after 1 month>50 year old

Vertebral infection

FeverIV drug useRecent infectionSpecific Risk factors

Fracture

AgeYoung: traumaticOlder: osteoporoticSteroid use

Ankylosing spondylitis

Young, maleMorning stiffnessImprovement with exerciseAlternating buttock painWakening with pain in the second part of the night

Psychosocial factors

DepressionPassive coping strategiesJob dissatisfactionHigh disability levelsDisputed compensationSomatisationCatastrophising

Group 1

No routine imaging or tests required.Assess psychosocial overlay

Investigation of 2) and 3)

Signs of progressive/severe neurological deficitsSerious underlying diseaseDeciding on further treatment (symptoms > 1 month)MRICTXRay

Resources

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. 2007 American College of Physicians

International Headache Society Classification Subcommittee. The International Classification of Headache Disorders. 2nd edition. Cephalalgia 2004; 24 (Suppl 1): 1-160

Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, Second Edition, IASP

Assessment Issues in Chronic PainSpring Scientific Meeting

16th May 2008www.nbpa.org.uk

Queen Mother Conference Centre