Hi everyone, my name is Dr. Melissa Weimler from Yale School of Medicine and happy to talk with you today about basics of chronic pain evaluation. Some housekeeping, this presentation is brought to you by PCSS MOUD and the content and discussions during the event are prohibited for promoting or selling products or services that serve professional or financial interests of any kind. The overarching goal of PCSS MOUD is to increase healthcare professionals' knowledge, skills, and competence in providing evidence-based practices in the prevention, treatment, recovery, and harm reduction of opioid use disorder. Here are the disclosures. I do not have any relevant disclosures related to this event. Our educational objectives today, so at the conclusion of the activity, we hope that you will be able to identify different types of acute and chronic pain and how to characterize them, name risk factors for the development of chronic pain, describe how to perform a comprehensive pain assessment that integrates a biopsychosocial approach, and identify the impact of psychosocial factors, including mental health, on the pain experience. So before we begin, let's talk a little bit about and define the difference between acute versus chronic pain. Before we start, I want to mention that some of the slides in this presentation have been adapted from scope of pain with their permission. So you will see in slides that were adapted from them this reference to scope of pain, and I would certainly encourage you to check out that training if you haven't ever participated in that before. So let's go back to definition. So what's the definition? How do we define acute versus chronic pain? Well, acute pain is really protective. It is a life-sustaining symptom, and in that way, it's adaptive by eliciting motivation to minimize harm and allow healing. So if we experience a harmful stimuli, our body is telling us that there's something we need to do in order to prevent further pain. So this is something that we need to sustain our life. Chronic pain, however, is a pain that persists beyond expected healing and can become a disease in and of itself. Generally, when we're talking about chronic pain, we're talking about pain that persists greater than or equal to three months in time, and this does include cancer and non-cancer-related pain. Chronic pain is quite complex. It is a complex disorder that is influenced by genetic, epigenetic, and psychosocial factors. There are three different discrete types of pain, which we are going to describe further in this presentation, but it's important to recognize that although there are three different types of pain, any of these together could be combined, and again, this speaks to the complexity of what can happen with chronic pain. So going through those specific types of pain individually, nociceptive pain is a very common type of pain. This generally describes pain in the tissue or potential tissue damage that includes somatic sources, such as bones, joints, or muscles, and also includes visceral sources, such as mucosal injury, distension, ischemia. We could be talking about heart attack pain, pancreatitis-related pain, as examples. Neuropathic pain is a disease or injury affecting the nervous system, which can be central. Such as trauma, stroke, or node degenerative sources, and peripheral, which could be related to nerve compression, nerve trauma, or ischemia in the peripheral or outside of the central nervous system. Nocioplastic pain is the third type of pain, which I would call probably the most complex pain. Nocioplastic pain is also a relatively new term, and this signifies amplified processing of or decreased inhibition of pain stimuli at multiple levels in the nervous system, including diffuse sensitization, which could be something such as fibromyalgia, functional visceral pain, such as irritable bowel syndrome, or regional somatic sensitization, which could be described, or an example of that would be complex regional pain syndrome. And we're going to describe each of these in more detail in the next few slides. So put all together, again, important to recognize there are three types of pain. Again, they can all be combined, and one person could certainly have more than one type of pain. So nocioceptive, you know, muscles, bones, viscera, neuropathic, generally related to nerves, and then nocioplastic, which is this amplification of pain with or without injury. So let's start with that nocioceptive pain. Again, we talked about this generally relates to somatic pain of bones, joints, or muscles. Examples of this are low back pain, osteoarthritis, or myofascial pain, generally described as sharp, stabbing, localized, aching, burning, or throbbing pain. Visceral pain generally relates to organ systems, such as the pancreas, the heart, the, you know, liver, something like that. An example of this could be peptic ulcer disease, myocardial infarction, or pancreatitis, generally described as generalized, an ache, cramp, or pressure. When we're thinking about how someone experiences pain, I think it's important to think about how the body interprets it, how it feels it, and then transduces that and transmits it to the central nervous system. So in nocioceptive pain, there is generally a high-intensity stimulation that transduces a pain signal in the receptors, generally in the peripheral region, and it has a pain signal that transmits along nerves across synapses in the spinal dorsal horn of the brain in the central nervous system. And then we go up to the brain. So again, you have this transduction from the peripheral area, which goes along these different fiber neurons to the spinal cord, where generally it's hitting the dorsal horn and then the lateral and anterior lateral spinothalamic tracts, and then goes up the spinal cord to the brain where there's perception of the pain. It's important to recognize that there are lots of different things that determine the modulation of the pain and how it is interpreted by our bodies. So in the peripheral nervous system, you can have sensitization by these different neurotransmitters and different factors, such as hypoxia, prostaglandins, in the spinal cord, norepinephrine, serotonin, glutamate, and MDA can affect how the pain is modulated. And then in the brain, we have multiple synapses, lots of interconnections. And in the brain, perception in the pain signal is modulated by meaning, thoughts, feelings, and memories. So you can think about how this could be very different from one person to another. You could have the same pain stimulus in one person that is perceived quite differently to another person who has different meanings, thoughts, feelings, or memories. For diagnosis of nocioceptive pain, for somatic pain, we talked about how it's generally described. It's generally related to some type of injury, trauma, degeneration, or overuse. For the viscera, usually this is related to some sort of underlying medical condition. On exam, you would examine the affected body part. You might have advanced imaging or blood work that's needed to determine the cause of pain. Moving along to neuropathic pain, again, we talked about this is a disease or injury affecting the nervous system, which could be central or peripheral. Examples of different neuropathic pain syndromes are diabetic peripheral neuropathy, postherpetic neuralgia, radicular pain, peripheral nerve injury, complex regional pain syndrome, limb pain, or spinal cord injury. So let's think about how is neuropathic pain transmitted and interpreted by the various systems we have. So neuropathic pain occurs due to aberrant, sometimes spontaneous conduction along nocioceptive pathways with or without acute tissue injury. So this is where we actually start to see stimuli that are occurring, even if there's not an actual injury that's occurring in the tissue. So here we have transduction from a peripheral or central source going along those same nons, transmitted and then perceived by the brain. And again, we have these different areas that are modulating how pain is experienced. What's different is that along these pathways, you could have increases in these signals, which could accentuate or worsen the pain experience. For neuropathic pain, our diagnosis is generally based a lot on history as well as exam. So we describe that people will generally describe their pain as burning, tingling, electric-like, numb, or shooting pain. They could experience sensitivity to cold, heat, and touch. You could see changes in the hair, nails, or skin. They could have balance problems if they have an ability to feel the bottom of their feet, for instance. On exam, you would assess physical touch. Are they able to interpret how you're feeling, different parts of the body? Like, what are you touching? Is there an accentuated pain at that area that you might be only minimally touching? Do they feel that as pain? That would be an example of allodynia or hyperalgesia. You can assess vibration sensation, pinprick, cold, and warmth. You would certainly want to rule out known causes. So is this someone who has diabetes that hasn't previously been diagnosed? You may need to consider different types of evaluation such as nerve conduction studies or MRIs, or any laboratory testing that can sometimes go along with neuropathic pain, and we will discuss this later in the talk. So nocioplastic pain, as I discussed, this is that amplified processing of or decreased inhibition of pain stimuli at multiple levels in the nervous system, and we gave some examples. It can occur in isolation or in addition to nocioceptive and neuropathic pain. Some examples of this, fibromyalgia, tension headache, irritable bowel syndrome, complex regional pain syndrome, or diffuse nonspecific myofascial pain. This was a busy slide, and my apologies if you're not able to see the font here, but I'll just go through and describe a few of the various things that are happening at the different levels of the nervous system. So similar to nocioceptive and neuropathic pain, there are different factors and different modulating features at each pathway in the nervous system. And in nocioplastic pain, you have these features that are amplified to basically increase sensitization of pain or have the pain feeling be more intense. Some of these peripheral features are this peripheral sensitization. So you could see an expansion of receptive fields, elevated cytokine and chemokine concentrations, particularly in people who've had very severe ongoing chronic pain for a while. You could have what we described as that hyperalgesia, dysesthesia, aledenia. So someone who feels a very non-noxious stimuli as being extremely painful, that means that there is some aberration in pain sensation and modulation and transduction. In the spinal cord, you could have different mechanisms such as regional clustering and convergence of signals from different pain stimuli. You could have reorganization of the spinal cord. You have these amplified spinal reflex transmissions. So the signals that are coming are amplified. You could have actually reduction of spinal inhibition, which is important to reduce pain signals that are going to the peripheral nervous system. You see a lot of this sort of wind up in temporal summation. So again, increasing of pain signals. In the central nervous system, in the brain, we see a hyper-responsiveness of pain stimuli, hyperactivity and connectivity. You can have decreased activity of brain regions involved in pain and inhibition. So as you can see, there are multiple changes that are occurring within the different pain pathways to create the painful feeling that the person is experiencing. So it's important to understand that there is a biological mechanism within pain signaling that is causing this pain to be very severe and experienced generally causing severe pain, a reduction of function over time. History, patients generally describe this neurosioplastic pain as widespread, diffuse, difficult to describe. They may feel that it kind of hurts all over. There's not one place that's worse than another. It is just a painful feeling overall, feels very uncomfortable. Generally, there are associated features such as fatigue, sleep disturbance, cognitive and memory disturbances and frequently mood symptoms that co-occur. On exam, you will see that patients have allodynia and hyperalgesia. You'll wanna evaluate for nociceptive and neuropathic pain syndromes that could be associated. You wanna assess for other associated features that may be going along in the biopsychosocial approach. And you may want to consider imaging and blood work in your evaluation of the patient. So before we move on, let's talk a little bit about how psychiatric comorbidities can go along with pain syndromes and can have a bidirectional relationship. So we can see here that different types of conditions frequently co-occur with chronic pain. So these conditions are sleep disorders, depressive disorders, generalized anxiety disorders, personality disorders, post-traumatic stress disorder and then substance use disorders. Can be increased in prevalence in people who have chronic pain and in individuals who have these different disorders, they can have higher rates of chronic pain as well. What we see in symptom overlap with pain is that individuals will describe a negative affect and pain that are correlated. So if they're feeling more depressive symptoms, they may report that their pain is more severe. They will report difficulties in sleeping, poor concentration, low energy, cognitive impairment. They may describe decreased interest or even suicidal ideation. Additionally, we wanna think about what are some of the barriers for individuals to receive comprehensive pain evaluation and pain treatment? And one of the reasons is that pain is quite prevalent in our society. About 21% of US adults are reporting pain almost most days or every day. Pain can lead to emergency department visits for pain-related complaints, and pain can cost billions of dollars per year in medical costs, lost wages, and lost productivity. So pain was a big deal, not just acute pain, but chronic pain. And it can contribute to disparities by disproportionately impacting certain individuals, such as women, the elderly, and those with lower socioeconomic backgrounds. So it's important to recognize that pain is all around us. It's going to be something that you're going to treat in your practice. And it's important that we are addressing it when it comes in, and we're understanding that these disparities are important to address so that all individuals are getting adequate pain evaluation and treatment. Other barriers to adequate pain care, we know that in primary care, clinicians are overburdened. They have many competing priorities. Most of us had inadequate training in managing patients with chronic pain. That's why we're doing these modules. And I would encourage you to not only listen to this module, but all of the multiple modules that we've developed and updated in this new series on PCSS MOUD. There could be lack of decision support for chronic pain management. There's, let's face it, a financial misalignment that favors the use of medications. And really only considering the biological perspective of pain, which we know is not adequate, particularly after taking this didactic, you're going to find that there's a huge component of psychosocial needs that we need to address. There could be a lack of access to pain specialists and comprehensive pain care that includes psychosocial treatments. And then there are also negative attitudes and disparities in pain care. So altogether, this can cause us to really inadequately treat pain. And unfortunately, this is very bad for patients with pain. There are also patient, clinician, and system factors. So for patients, there could be language barriers, cultural differences in communication, health literacy that could all lead to poor pain treatment outcomes. For clinicians, we could have false beliefs and implicit bias that could result in racial and ethnic disparities in pain assessment and treatment. And our systems many times lack geographic or financial access to care for us to be able to provide the best treatment available to our patients. So let's go through a case, and let's think about how we would describe this person's pain, how we would evaluate it. And then potentially, that's going to set up how we are going to treat pain. So within this module, what you're really going to hear about is how you walk through determining what type of pain someone has. And then once you know that, then you can apply what you're going to learn from the other modules to understand what are the best treatments for this person. So this case is Jessica. She is a 38-year-old female with no known past medical history. She was lifting multiple heavy boxes during a move and developed low back pain. She describes having difficulty walking and not being able to go to work due to this pain. So how would we approach assessing her pain? There are a few different ways that we can set up an approach for this. One of the mnemonics that we recommend is Socrates. And I'm going to talk about another in a moment. But the Socrates assessment basically goes through sight, the site of pain, onset of pain, character of pain, radiation, any associations, any signs or symptoms related to pain, time course or pattern, exacerbating relieving factors, and severity. And importantly, in the context of doing this evaluation, we want to understand this quote here that many factors influence self-reported pain, including gender, social support, clinical characteristics, and trust. So of course, all of this is built on a framework of us hearing our patients, understanding their perspective, as well as assessing their pain. Another mnemonic you might consider is PQRST. So this stands for provocation, what triggers the pain or makes it better? Quality, what does the pain feel like? Region, where is it located? Severity of pain, how intense is the pain on a scale of 0 to 10? And timing, when does the pain occur and how long does it last? So again, these two mnemonics don't need to be memorized. Perhaps you create a template in your evaluation of pain that goes through these various factors so that you're really understanding what type of pain are we talking about? How does the patient feel? And that's going to help you with diagnosis. I can't tell you how many times I will see a patient or see a patient after a colleague or do a precepting with a resident or a fellow. And a lot of this information isn't provided. So these are not hard questions to ask as part of the history. But if you don't have a framework, you potentially will miss really understanding, where is this pain? What are we talking about? Are we talking about foot pain? Are we talking about arm pain? So again, having a framework is helpful so you don't miss key information. So in asking Jessica these questions, we find out that her pain is on the left side of her lower back. There's no pain over the spine. She has a normal range of motion of the spine on physical exam. The pain occurred after lifting a heavy box three days ago. The pain is described as throbbing, aching, and sharp. It goes into her left hip. She does have an elevated pulse and she appears restless and uncomfortable. The pain has been worsening over the last 24 hours. It's constant pain. It is exacerbated by flexion, lifting, and walking makes it worse, rest makes it better. She describes the pain on a scale of zero to 10 as five out of 10. Here's the scale that we might use to ask about pain intensity. You can use a visual analog scale, an emoji-based visual analog scale, or the numeric reading scale on zero to 10. I think it's important if you are using any of these that you might define or provide examples of what we're talking about. We're talking about mild versus moderate versus severe pain to put it in context, but also recognize that one person's experience of pain is going to be different from another's. So through our evaluation, we diagnosed her with acute myofascial low back pain. This is nocioceptive in nature. It involves the muscles and the fascia. The inciting factor was this heavy repeated lifting. This type of myofascial low back pain is likely to be self-limited. Treatments include gentle stretching, ice heat, NSAIDs, and or acetaminophen, potentially alternating. We really want to limit bed rest for her. We want her to be active, and that's likely to help her actually heal faster. And she might consider alternative treatments such as massage or acupuncture to help with treatment. Let's go along now to two years later. This is Jessica again. Her low back pain persists and worsens. She starts to have numbness and tingling in her feet. Unfortunately, she has gained 50 pounds and is less active overall. She's only able to work part-time, and now is unfortunately experiencing financial difficulties related to this. So let's go back to our definitions. Is this acute pain or chronic pain? Well, based on our definition, this is two years of persisting pain. We are well into the chronic pain bucket here, and then we need to decide what type of pain is this. Is this ongoing nocioceptive pain? Has there developed a neuropathic component? Are there nocioplastic components? And we need to do an evaluation to better understand what's going on. Before we do that, we also want to think about why might someone like Jessica have progressed from acute to chronic musculoskeletal pain? And there are some different questionnaires that we could use to help us identify modifiable risk factors for pain disability related to musculoskeletal pain. And so this START musculoskeletal screening tool would be one that you could consider. Did Jessica ever get better from her first pain episode, or did she continue to feel this ongoing, troublesome muscle pain in more than one part of the body? Did it start to expand? Was she only walking short distances for a very long period of time? Was it affecting other parts of her function, such as dressing? Were there other health problems that were going on? Did it start to cause fear avoidance and catastrophization? Was she feeling unsafe to be physically active over time? Was she having worrying thoughts about her pain a lot of the time? Was she afraid that her pain condition would last a long time? Did she stop enjoying multiple things related to the pain? And then did pain continue to just be very, very bothersome over time? Had we seen Jessica in follow-up, perhaps a month or two months after the inciting event, we might have been able to say, wow, we really need to increase some treatments that we're doing so we don't have this progression to chronic pain that occurred over the last two years. We see this with post-surgical pain as well. So these are some risk factors that are important for you to recognize if you're seeing people in your practice who may have had a surgery and were really not doing well after the surgery for their acute post-surgical management. These are individuals who may be at risk to have persistent pain after a surgery. For example, patient-related factors would be those who are younger, women, a patient with a history of anxiety, depression, catastrophizing, pre-existing pain syndromes, or preoperative opioid use. Different intraoperative variables such as the surgical procedure or technique, if there was any sort of nerve ligation or injury, ischemia that occurred during the operation, and when the anesthetic modality can also contribute to ongoing persistent pain. And then post-operative pain, did the person have uncontrolled high intensity of pain that was unrelieved and they had this longer duration? So we're not talking about persistent, I'm sorry, about post-surgical pain for Jessica, but important to recognize that there are multiple different risk factors that can cause individuals to go or shift from these acute pain episodes to chronic pain episodes. And this can cause these alterations that go on to develop chronic pain, and these expressions of the neurotransmitters, receptors, ion channels, that really do affect the structure connectivity of the neurons, and we talked about this in the various pathways, that individuals can then start to go on to develop these mercioplastic pain symptoms. So Jessica's here, she's had pain for two years. We really wanna understand what's going on with Jessica that's led her to have this ongoing persistent pain for this long. And in doing the evaluation, there's actually quite a few things that we're gonna recommend that you do, and this can take a fair amount of time. So it doesn't have to happen all at once. You could certainly see her for the period of time that you have available and recognize that in the next visit with her, you're gonna wanna get more specific evaluation. And what that evaluation's gonna entail is a multidimensional pain assessment, a sociopsychobiological assessment, recognizing that we wanna know really a lot about that sociopsycho components. We probably have a fair amount of information about a biological components. There may be some things we wanna understand, but we wanna make sure we're not addressing the sociopsychological components that could be quite important in how she's experiencing pain. So we wanna know more about her function. We wanna evaluate for any underlying medical conditions. We wanna talk about her sleep and her quality of life. And then we also wanna address any underlying mental health and substance use disorders that may have occurred. We wanna specifically look at her mood, history or current history of trauma, and assess for substance use. And we'll talk about how to do that now. So when we talk about a multidimensional pain assessment, what do we mean? What we talked about before, the numeric rating scale, zero to 10, that's really a unidimensional scale. That's just usually limited to one period of time. It just tells us how the patient's feeling at that one limited time. And I think we can all recognize that that's pretty limited in what it's providing to us. So there are some other multidimensional scales, such as the McGill Pain Questionnaire, the Graded Chronic Pain Scale, and the Brief Pain Inventory. Many of these scales are pretty impractical for routine use in most primary care settings, though. So there is one brief multidimensional tool that has been validated for use in general medical clinics, and this is the Pain Enjoyment and General Activity, or PEG, scale. And this can tell us more about pain on average, enjoyment of life, general activity, and provide a lot more information about how the patient is doing with their pain. So if we ask this of Jessica, she tells us that in the last week, her pain on average has been 10 out of 10, as bad as she can imagine. It is nearly completely interfering with her quality and enjoyment of life, and it is nearly completely interfering with her general activity. So this is very severe pain that is very much affecting Jessica's life. Now, you might say, how could some back pain really cause that much of a problem for her? Well, that's her experience, and it's important that we recognize her experience. It's also important to recognize that maybe she feels that she needs to, that you may not believe how severe this pain is unless she says it's 10 out of 10 or 20 out of 10. So patients may assume that you do not believe the severity of their pain complaints unless they really tell you they're the absolute most severe. So this can be demonstrated by exaggerated pain scores and exaggerated functional limitations. Does this mean the patient's lying to you or they can't be believed about their pain? No, in fact, it means that maybe the patient doesn't trust that you're going to take their pain seriously. So you may see that patients are, you know, giving higher numbers than you would expect. But again, this doesn't mean that they're lying. It just means that there is an issue of trust, and you need to learn more to understand. And that's why we recommend a thorough pain evaluation so we're not only thinking about these small factors, you know, just one scale, zero to 10, how's your pain? We're really thinking and looking at the whole patient. So we do this by building trust. And so after you complete a thorough pain history and appropriate diagnostic testing, you can show that you trust the patient by showing empathy for their experience. It must be difficult to enjoy life with such severe pain and validate that you believe them and that their suffering is real. I believe you, and I want to help. Those, you know, two phrases are going to go a really long way for you to building trust and partnership and collaboration with the patient to better understand their experience. So now let's talk about how do we do all of those various things that we want to better understand why Jessica could be having this ongoing pain and what other factors could be modulating it. So we're first going to screen for depression. We're going to do that starting with the PHQ-2. Many of you are probably quite familiar with this screening tool and if she answers greater than or equal to or has greater than or equal to three points on this test, then that's positive and then you would want to administer the PHQ-9. Screening for PTSD or post-traumatic stress disorder, we generally use these this screening tool here which is a primary care PTSD screen and if they any three yes answers that would then lead to further evaluation. Screening for anxiety, we start with the GAD-2. Again many of you are probably familiar with this and it would be positive if there were greater than or equal to three points on the answer to this. If the patient scored positive or screened positive on this test, you would then want to follow that up with the GAD-7 to better understand or think about an underlying anxiety disorder. Jessica mentioned that she was having a lot of trouble sleeping so we want to better understand is there a component of sleep disorder breathing. So a screening questionnaire for this would be the STOP-BANG questionnaire. This would also help us determine the potential risk for certain types of medications such as opioids if we're considering prescribing them. So we'd want to assess for sleep disordered breathing as well. A screening test for insomnia is the insomnia severity index and if the this would be a positive screen if they were greater than or equal to seven points on this scale and then you could administer the full ISI-7 if they were positive on this initial screening. Again to better understand how sleep could be contributing to worsening pain or vice versa. There are multiple different screening tools for substance use. I'm going to mention two that you could consider that could be easily integrated into primary care. One is the TAPS tool which assesses for tobacco, alcohol, prescription medication, and other substance use in basically one question here. So you could go through and ask in the past 12 months how often have they used tobacco, had four, I'm sorry, five or more drinks if they're a man, four or more drinks if they're a woman, of alcohol, used any prescription medications just for the feeling more than prescribed or that were not prescribed to you, and used any drugs including marijuana, cannabis, cocaine or crack, heroin, methamphetamine, hallucinogens, ecstasy, MDMA. A positive screen should be followed up with additional information to better understand and potentially diagnose a substance use disorder. There are also single screener items for alcohol and drugs that you could consider. The single screener for alcohol starts with asking the patient if they sometimes drink beer, wine, or other alcoholic beverages, and if they say yes, then you would follow up that question with how many times in the past year have you had five, four if it's a woman, or more drinks in a day. And if the answer is greater than never, then you would want to follow that up with the Audit C. For drugs, we ask how many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons, and a positive screen would be greater than never. And you would potentially want to follow that with the DAST screening, or again, additional evaluation thinking about substance use disorder and providing a flu diagnosis of a substance use disorder would require the use of the DSM-5 evaluation. We have a whole module about doing this if you have questions of how you would determine if a patient has a substance use disorder, so please refer to that module if you have additional questions about how to do this. So again, using that mnemonic of our framework of how we're going to assess Jessica's chronic pain, we could use the Socrates mnemonic. So the site of pain is the left side of the lower back and the bilateral feet, as well as the upper and lower extremities. The onset was two years after moving. The character is throbbing, dull, aching, and she has pins and needles in her feet. Radiation is into her left back and down her left leg at times. Associations, it is worsened with weight gain, worsening depression, and physical deconditioning, and it's worsened over the last year. It is exacerbated by flexion, lifting, and walking makes it worse. Rest makes it better, and the severity is 10 out of 10. On physical exam, you note that she has normal vital signs. Her weight is increased at 225 pounds. She appears depressed and is tearful at times. She's rubbing her back throughout the exam. She denies any suicidal ideation. She has a normal cardiopulmonary exam. The spine has normal alignment, no point tenderness. She has a positive straight leg raise. Muscle strength is 5 out of 5 in the upper and lower extremity. Arms and legs and lower back are exquisitely tender to light touch. She's unable to walk, heel to toe, has normal gait otherwise. She has no Achilles tendon reflex bilaterally. You do a diabetic foot exam. There's no lesions or ulcerations. She has normal pulses, but she has lost protective sensation by vibration and pressure. Your biopsychosocial assessment continues. You ask her about family history. She does have a family history of diabetes mellitus type 2, no other family history. Her depression screen is positive, which you follow up with PHQ-9. Her anxiety result is positive. PTSD screen is positive, and she tells you that she has a history of sexual assault at age 25. Her substance use disorder screening is negative. For sleep, she states she sleeps three to four hours a night. She has a positive insomnia severity index, but a negative stopping evaluation. Her quality of life is quite impacted. She has reduced mobility, limited exercise. She has limited social support and lives alone. And again, she's only been able to work part-time. And again, we talked about this is a lot of evaluation to do, so if you needed to break it up into one or two visits, that's perfectly acceptable. Or provide screening in the interim, have her do some of these evaluations on her own prior to coming in for a visit. You also decide that you're pretty concerned about her weight gain and the food exam, so you obtain hemoglobin A1c, which comes back at 9.5, which is high. You check a vitamin D level, which is less than 10, which is low. Her vitamin B12 is 200, which is low. She has normal liver function, kidney function, and electrolytes. And she does have an MRI done of the spine, which shows L4-5 facet arthropathy. Again, this evaluation is not going to happen potentially in one visit. So again, if you need to take several visits, that would be appropriate. So what type of pain do you think she has? Does she have nociceptive pain, neuropathic pain, noceoplastic pain, a combination? Well, her diagnosis is complex pain, which is a combination of features of nociceptive, neuropathic, and noceoplastic pain. So for nociceptive pain, she has this ongoing myofascial low back pain. She also has low vitamin D and B12 that have likely contributed to worsening pain. Neuropathic pain, she shows signs of rhumba radiculopathy and diabetic peripheral neuropathy, which are also worsened by the vitamin D and B12 deficiencies. Noceoplastic pain, she shows signs of diffuse pain sensitization. She has mood symptoms that need further evaluation. She has poor restorative sleep. These are likely worsening her pain overall. She has a new diagnosis of diabetes type 2. She has developed, unfortunately, physical deconditioning and obesity related to her pain. She has a concern for PTSD and a reduced quality of life. So there's a lot going on, and a lot has happened in the two years that she has developed this pain. Again, it takes a lot of evaluation, but this is what's needed to better understand that it's not just about the pain. It's about these other factors, these other things that are going on in her life. So of course, the treatment approach is going to become more complicated. You're going to likely have an interprofessional team of people that are going to help you address her complex pain, such as yourself, the clinician, engaging social work, nurse educator, physical therapy, occupational therapy. You might engage a clinical pharmacist, psychologist. You could have complementary alternative approaches that you're recommending, and you're thinking about multimodal treatment. In the modules that follow this, you will learn more about what are the best appropriate treatments for her. So Jessica did get an MRI. That MRI showed she had facet arthropathy. You could have stopped there. You could have said, oh, well, this is obviously related to her facet arthropathy, but you could see by the multiple things that we uncovered in her evaluation that that would have been very narrow-sighted for us to only talk about the MRI findings, right, because there was a lot of other things going on with Jessica. So remember that seeing something on an MRI, this pathology we see on imaging does not always correlate with pain, and in fact, you know, when we look at MRIs of people who have low back pain, you know, we could see many of them have findings. So, you know, the percent of a hundred pain-free adults with lumbar dysbulge or protrusion is quite high. So just because you see something on an MRI does not mean that that is the cause of the pain, and again, if you didn't look at all these other factors, you are likely to miss other modifiable risk factors and treatments and understand the underlying causes of the pain that we also need to address. So I think it's safe to say you understand that chronic pain is complex, and it is different between one patient and another. So patient A with a pain of 8 out of 10 could be highly motivated by the factors listed here and the figure, you know, maybe it's mostly around the physical injury with these other components of environmental stresses, genetics, cognitive dysfunction, depression, anxiety, social disability, functional disability, and their culture. Whereas for patient B, perhaps the physical injury is really a small component, and it's the pain experience is more driven by genetics, stressors, social disability, maybe substance use, depression, anxiety. So that's why it's important for us to think about all the myriad of factors, because each individual is different, and they're going to have different factors that are causing their pain experience to be different. We've talked a lot about this, but, you know, this, as we just said, chronic pain is shaped by several different factors, these biopsychosocial factors, and that is why it's important for us to think about not just the physiology, but the context in which the patient is experiencing this to understand what's contributing to their experience of pain. And also recognizing that our patients could, you know, ongoing avoidance of certain activities can lead to ongoing disability. So these different psychosocial components can lead to further deconditioning, increased pain, fear of injury, fear of movement, less movement, and this can all be wrapped up in a patient who's really socially kind of isolating and not able to actively address their underlying pain condition. So this can be a fear avoidance cycle that can take on its own facets and worsen disability over time. So it's important for us to talk to our patients about how do we help them gradually start to move more so they're able to have more conditioning and it could be that part of this is related to treating their depression or treating their anxiety or treating their diabetes so they don't feel so terrible and they are more interested in engaging in those ways. So let's talk a little bit about how depression can affect chronic pain. So how are patients with depression and chronic pain different from patients with pain without depression? So compared to patients with pain without major depressive disorder, patients with comorbid major depressive disorder and disabling chronic pain report significantly poorer quality of life, greater somatic symptom severity, higher prevalence of panic disorder, and a six-fold greater prevalence of anxiety. Is there a difference in treatment response in patients with pain and co-recurring depression? Yes, there does tend to be poor adherence to treatment, worse satisfaction in the treatment. There could be a higher likelihood of recurrent pain syndromes and you could see reduced functional improvement. PTSD similarly and chronic pain can amplify each other so pain can serve as a reminder of trauma. This can amplify PTSD and cause more avoidance and social isolation. Physiologic arousal in response to traumatic recollection can amplify pain also leading to avoidance. This can lead to further physical deconditioning and increased odds of worsening pain experience. So we know that not only are there biological factors that affect the experience of pain, but these psychiatric comorbidities can very much affect chronic pain as well. So depression and anxiety are the most common psychiatric disorders seen in patients with chronic pain. Patients with these conditions report more severe pain and disability and are less likely to adhere to treatment and may have poorer outcomes. Attention to the assessment and treatment of chronic pain and concurrent psychiatric disorders is necessary to improve treatment outcomes. And then to conclude this module, in summary, we talked about utilizing a mnemonic or a framework for pain evaluation such as Socrates or PQRST to better understand the pain experience from the biological standpoint. This can help us accurately characterize pain and can then help us guide appropriate treatment options. In addition to this, a comprehensive pain evaluation has several components. We want to, again, understand the history of the pain. We want to do a biopsychosocial assessment focusing on that psychosocial components. We want to ask about mental health and substance use, utilizing validated screening tools. We want to perform a full physical exam. We want to do targeted laboratory and imaging tests as indicated. It may not always be indicated, but again, in this patient that we had in this module, we diagnosed unrecognized diabetes. And then, of course, these psychosocial factors and psychiatric comorbidities are important mediators of the pain origin, pain experience, pain perception, and pain treatment. So thank you so much for your attention. Here are some of the references for this module. And please reach out if you would like additional mentoring. We would love to get your feedback on this module and others, so please reach out and ask us if you have any questions. Thank you so much. Take care.

chronic pain

acute pain

nociceptive pain

neuropathic pain

nociplastic pain

biopsychosocial approach

pain evaluation

mental health

integrated treatment