1. What are the key elements in taking the clinical history of a patient with a complaint of pain?

The first step in taking the clinical history of a patient with a complaint of pain is to evaluate the pain complaint. Important factors are location; radiation; intensity; characteristics and quality; temporal aspects; exacerbating, triggering, and relieving factors; circumstances surrounding the onset of pain; and potential mechanisms of injury. Additionally, the clinician should ascertain if the pain is constant and steady, intermittent or sporadic, or constant with exacerbating circumstances by gathering information regarding the occurrence and characteristics of any breakthrough pain. Furthermore, one should ascertain the patient’s perception of why he or she has persistent pain, the duration of the pain, and changes in pain since its onset (e.g., any gradual or rapid progression in intensity or “spread” of location).

The patient should specifically be asked about any perceived exacerbation of pain with innocuous light touch, with sheets or clothes on the painful body part(s), with the wind blowing on the pain, and with external temperature changes (e.g., is the pain worse in winter?). Patients should be asked about any specific clothing they wear, aides they use, or behaviors or activities they engage in to function optimally with the pain.

The patient should be questioned about the function of the specific painful area and resultant changes in global physical functioning. Information should also be obtained regarding perceived restriction of range of motion; stiffness; swelling; muscle aches, cramps, or spasms, color or temperature changes; changes in sweating; changes in skin; changes in hair; nail growth; perceived changes in muscle strength; perceived positive (dysesthesias/itching) or negative (numbness) changes in sensation—including what may trigger these changes (if they are not constant) and when they are likely to occur.

Many aspects of the patient’s current life and perceived quality of life along with how this has changed because of pain should be questioned. Include the following:

2. If pain is a purely subjective phenomenon, how can its intensity be measured?

The only reliable measure of pain’s intensity is the patient’s report. Measures of pain intensity are not meant to compare one person’s pain with another’s; rather, they compare the intensity of one patient’s pain at any given time with its intensity at another given time. Thus, physicians and patients can judge whether pain intensity is increasing or decreasing with time and treatment. It is sometimes helpful to have the patient compare the intensity of the current pain experience with prior experiences.

3. How should pain intensity be recorded?

There are a number of different measurements for pain intensity (see Chapter 6, Pain Measurement), and it is not clear that any particular scale is universally better than any other. Some patients have greater ease with a verbal scale, some with a numerical, and some with a visual analog scale. It is, however, a good idea to use the same measure across time. Thus, verbal descriptors, such as “no pain, mild pain, moderate pain, severe pain, unbearable pain,” or numerical scales can be graded on each visit.

4. Can pain intensity be measured in children, the older person, and the cognitively impaired?

Once children reach an age of verbal skills, pain intensity can usually be quantified on a verbal scale. However, a number of scales work even for preverbal children (see Chapter 30, Pain in Children). Once children reach the preteen years, the same tools used in adults can be applied.

The older person may present more difficult problems. If the patient is cognitively impaired, it is often difficult to assess pain intensity on a precise scale, and it becomes more valuable to judge the functional impairments resulting from pain. Furthermore, medications used to treat pain may increase cognitive impairment and make assessment even more difficult. Older patients may tend to be more stoic about pain and are reluctant to report high intensities. One of the most helpful factors when assessing pain in children, older patients, and/or cognitively impaired patients is eliciting from the caregivers any changes from the patient’s baseline behavior.

5. What information can be gathered from the character of the pain?

The McGill Pain Questionnaire contains numerous descriptors for pain. Certain words that patients choose may help to infer a specific pathophysiology. For example, a burning, dysesthetic, or electric shock–like pain usually implies neuropathic pain. An aching, cramping, waxing and waning pain in the abdomen usually indicates visceral, nociceptive pain.

6. Why are the temporal characteristics of pain important?

The onset of pain is extremely important. The approach to pain of relatively recent onset should follow more closely the medical model, that is, a search for underlying cause. Acute pain usually indicates a new pathologic process, correction of which will relieve the pain. Chronic pain of long duration is less likely to be amenable to a standard medical model and requires a biopsychosocial approach (see Chapter 44, Physical Modalities: Adjunctive Treatments to Reduce Pain and Maximize Function). Chronic pain often outlives the initial cause and develops a life of its own; however, the events that initially resulted in the onset of pain may help guide potential therapeutic approaches to chronic pain.

7.

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