What is the initial step in a comprehensive pain management workup in a pain clinic for a patient with a history of chronic pain and previous treatments?

Pain Management Workup in Pain Clinic

The initial step in a comprehensive pain management workup is a structured biopsychosocial assessment that includes detailed pain characterization (onset, duration, intensity, quality, location, exacerbating/relieving factors), functional impact evaluation, psychosocial screening, followed by targeted physical examination and diagnostic testing to determine pain etiology and pathophysiology. 1

Initial Pain Screening and Quantification

• Screen all patients systematically using two validated questions: "How much bodily pain have you had during the last week?" and "Do you have bodily pain that has lasted for more than 3 months?" 1, 2
• Quantify pain intensity immediately using a 0-10 numeric rating scale, categorical scale, or Faces Pain Rating Scale for patients with communication barriers 1
• Use the ultra-brief PEG tool (Pain intensity, Enjoyment of life, General activity) for rapid assessment in busy clinical settings, as it is comparable to the Brief Pain Inventory but more practical 1, 2

Comprehensive Pain History

Pain Characteristics

• Document chronology and symptomatology: onset, quality (aching, burning, sharp, shooting), intensity at rest and with movement, distribution, duration, course, and both sensory and affective components 1
• Identify temporal patterns: constant versus intermittent, breakthrough pain episodes, diurnal variations 1
• Determine pain location and radiation patterns: specific anatomical sites, referral patterns, whether pain is localized or diffuse 1
• Assess exacerbating and alleviating factors: activities, positions, medications, environmental factors 1

Associated Symptoms

• Screen for motor, sensory, and autonomic changes: weakness, numbness, tingling, temperature changes, sweating abnormalities 1
• Ask about accompanying symptoms: fatigue, nausea, anxiety, depression that may affect quality of life more than pain severity itself 1

Treatment History

• Review all previous diagnostic tests and results to avoid unnecessary repetition 1
• Document past and current treatments: medications (including doses and duration), physical therapy, injections, surgeries, complementary therapies 1
• Evaluate response to previous therapies: what worked, what failed, adverse effects experienced 1

Medical and Social History

• Obtain comprehensive medical history: comorbid conditions, surgical history, allergies, current medications 1
• Document substance use history: current and past use of alcohol, tobacco, illicit drugs, prescription medications 1
• Review family history: chronic pain conditions, psychiatric disorders, substance use disorders 1

Functional Impact Assessment

• Evaluate interference with activities of daily living: walking, climbing stairs, household chores, self-care activities 1, 2
• Assess impact on occupational status: ability to work, work modifications needed, disability claims 1
• Document effects on sleep quality: difficulty falling asleep, staying asleep, non-restorative sleep 1
• Determine impact on mood and interpersonal relationships: social isolation, family dynamics, sexual function 1

Psychosocial Evaluation

Psychological Screening

• Screen for psychiatric symptoms and disorders: anxiety, depression, anger, post-traumatic stress disorder 1
• Assess personality traits and coping mechanisms: catastrophizing, fear-avoidance behaviors, active versus passive coping 1
• Evaluate patient's pain beliefs: meaning of pain for patient and family, expectations about recovery 1

Risk Assessment

• Screen for substance use disorders: current or past opioid use disorder, alcohol use disorder 1, 2
• Identify risk factors for aberrant medication use: personal or family history of addiction, psychiatric comorbidity 1
• Recognize risk factors for undertreatment: cultural beliefs about pain expression, fear of addiction, stoicism 1

Social Context

• Document family and social support systems: caregivers, living situation, social isolation 1
• Identify vocational and legal issues: workers' compensation claims, litigation, disability applications 1
• Note involvement of rehabilitation agencies: physical therapy, vocational rehabilitation, case management 1

Physical Examination

• Perform targeted neurologic examination: mental status, cranial nerves, motor strength, sensory testing (light touch, pinprick, temperature, vibration, proprioception), reflexes, gait 1
• Conduct focused musculoskeletal evaluation: inspection for deformity or asymmetry, palpation for tenderness or trigger points, range of motion testing, provocative maneuvers 1
• Examine other systems as indicated: cardiovascular, respiratory, abdominal based on pain location and associated symptoms 1

Diagnostic Testing

• Order laboratory studies judiciously: complete blood count, erythrocyte sedimentation rate, C-reactive protein only when inflammatory conditions suspected 1
• Obtain imaging studies based on clinical findings: radiographs for suspected fracture or structural abnormality, MRI for neurologic deficits or red flags 1
• Consider diagnostic interventional procedures when appropriate: facet joint blocks (positive predictive value 25-77%), sacroiliac joint blocks (positive predictive value 18.5-72%), diagnostic nerve blocks, provocative discography (positive predictive value 42-60%) 1

Pain Classification and Diagnosis

• Categorize pain by pathophysiology: nociceptive (somatic or visceral), neuropathic, or centralized/nociplastic 1, 2
• Identify nociceptive pain characteristics: aching, throbbing, well-localized for somatic; diffuse, cramping for visceral 1
• Recognize neuropathic pain features: burning, sharp, shooting, electric-like quality with sensory abnormalities on examination 1
• Determine if multiple pain types coexist: many patients have mixed pain mechanisms requiring different treatment approaches 1

Goal Setting and Treatment Planning

• Establish realistic functional goals collaboratively: specific activities patient wants to accomplish (e.g., walk two blocks, return to work part-time) 1, 2
• Discuss patient's expectations about pain management: clarify that goal is improved function and quality of life, not complete pain elimination 1, 2
• Set measurable outcomes: pain intensity reduction, functional improvement, quality of life enhancement, reduction in adverse events 1

Common Pitfalls to Avoid

• Never dismiss patient's subjective pain report: pain is inherently subjective and patient self-report is the gold standard 1
• Don't focus solely on pain intensity: functional impairment and quality of life impact are equally or more important outcomes 1
• Avoid ordering extensive imaging without clinical indication: this delays evidence-based treatment and increases costs without improving outcomes 2
• Don't overlook psychosocial factors: these are critical determinants of treatment success and must be addressed 1, 2
• Never assume new pain in chronic pain patients just needs more medication: new pain requires complete reassessment to rule out new pathology 1, 2
• Don't neglect screening for substance use disorders: unrecognized addiction undermines pain management and requires specialized consultation 1, 2

Documentation Requirements

• Record comprehensive pain assessment findings: all elements of history, physical examination, diagnostic test results 1
• Document functional limitations specifically: use concrete examples rather than vague descriptions 1, 2
• Note psychosocial factors and risk assessment: psychiatric comorbidity, substance use history, aberrant behaviors 1
• Create written treatment plan: specific interventions, goals, follow-up schedule, medication regimen 2

Interdisciplinary Team Involvement

• Develop interdisciplinary care team from the outset: especially for complex chronic pain and patients with co-occurring substance use or psychiatric disorders 1, 2
• Include appropriate specialists: physical therapy, occupational therapy, psychology/psychiatry, case management, pain medicine consultation 1, 2
• Establish multimodal treatment approach: combine non-pharmacological interventions (exercise, cognitive behavioral therapy, physical therapy) with judicious pharmacotherapy 1, 2, 3