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tenderness on palpation Use the brush, pinch, pin prick, and/or scratch tests to assess for allodynia, hyperalgesia, or hyperesthesia Determine the effects of physical factors (e.g., motion, applied heat or cold, deep breathing, changes in position) on pain Other regions Examine other regions as directed by the patient history or assessment of pain site Neurological At minimum, perform a screening neurological examination (i.e., assess cranial nerves, spinal nerves, sympathetic system nervous system function, coordination, and mental status) to screen for: • Sensory deficits (e.g., impaired vision or hearing) or abnormal sensations (e.g., paresthesia, dysesthesia, allodynia, hyperpathia) • Motor abnormalities or deficits (e.g., weakness, exaggerated or diminished reflexes) • Lack of coordination • Evidence of sympathetic nervous system dysfunction (e.g., skin flushing, unusual sweating) • Abnormalities or deficits in orientation, recent or remote memory, parietal sensory function, language function, and mood Musculoskeletal Observe and/or identify: system • Body type, posture, and overall symmetry • Abnormal spine curvature or limb alignment and other deformities • Abnormal movements and/or irregular gait during walking • Range of motion (spine, extremities) For muscles in neck, upper extremities, trunk, and lower extremities: • Assess multiple parameters (e.g., tone, volume, contour, strength and power, range of motion) • Observe for any abnormalities (e.g., weakness, atrophy, hypertrophy, irritability, tenderness, trigger points) Source: Reference 8. Table 16. Examples of Diagnostic Tests Type Definition Potential Uses Screening laboratory tests Includes CBC, chemistry profile (e.g., Screen for illnesses, organ dysfunction electrolytes, liver enzymes, BUN, creatinine), urinalysis, ESR Disease-specific Includes autoantibodies, sickle Autoimmune disorders, SCD laboratory tests cell test Imaging studies Includes radiographs (x-rays), CT, Detection of tumors, other structural abnormalities MRI, US, myelography Diagnostic procedures Includes lumbar puncture, Detection of various illnesses thoracentesis, paracentesis, biopsy Electrodiagnostic Include EMG (direct examination of Detection of myopathies, some neuropathies, MS tests skeletal muscle via needle electrodes) • EMG and NCS (examination of conduction • NCS along peripheral sensory and motor nerves or plexuses) Diagnostic Nerve block (injection of a local Multiple uses,a including: nerve block anesthetic to determine the source/ • Identification of structures responsible for the pain mechanism of the pain) (e.g., sacroiliac or facet joint blocks) • Differentiation between types of pain Sources: References 19-20a. aDiagnostic neural blockade (pain blocks) with a local anesthetic may be useful in determining the anatomic source of the pain, nociceptive pathways, or the contribution of the sympathetic nervous system to the pain.20a They also may allow differentiation between local vs. referred pain, somatic vs. visceral pain, or central vs. peripheral pain. BUN: blood urea nitrogen; CBC: complete blood count; CT: computed tomography; EMG: electromyography; ESR: erythrocyte sedimentation rate; MRI: magnetic resonance imaging; MS: multiple sclerosis; NCS: nerve conduction studies; SCD: sickle cell disease; US: ultrasound. 28 Pain: Current Understanding of Assessment, Management, and Treatments Section II: Assessment of Pain Table 17. Unidimensional Pain Assessment Tools Scale Administration Advantages Disadvantages Comments Numeric Verbal or visual Easy to use Less reliable for some Most commonly used rating scale rating scale Simple to describe patients (very young or (NRS) High rate of adherence old; patients with visual, Flexible administration hearing, or cognitive (including by telephone) impairment) Validated for numerous settings and pain types (acute, cancer, CNCP) Visual Visual Efficient to administer Time-consuming scoring FPS generally preferred to the VAS analog Valid in patients with chronic Controversial validity for assessment in the elderly scale pain, older than age 5 years, Can cause patient (VAS) rheumatic disease confusion Poor reproducibility with cognitive dysfunction Faces pain Visual Perceived as easier Potential for distorted Good alternative for patients with scale (FPS) than NRS or VAS assessment (i.e., patients’ difficulty communicating No influence of culture, tendency to point to the gender, or ethnicity center of such scales) Useful in individuals with difficulty communicating Need for instrumentation (e.g., children, elderly, (i.e., a printed form) individuals with limited language fluency or education) Sources: Reference 7, 11-13, 16, and 21-27. CNCP: chronic noncancer pain; FPS: Faces Pain Scale; NRS: numeric rating scale; VAS: visual analog scale. Table 18. Multidimensional Pain Assessment Tools Scale Administration Advantages Disadvantages or Comments Brief Pain Visual Reliable and valid for many clinical Used both clinically and in research Inventory (BPI) situations (e.g., cancer pain, arthritis Good choice of measure in patients pain, pain associated with HIV with progressive conditions infection) and across cultures and languages Available in multiple languages Quick, quantifies pain intensity and disability Initial Pain Visual May be completed by patient Assessment or clinician Inventory
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