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Chronic Post-surgical Pain Syndromes: Prediction and Preventive Analgesia

Introduction Chronic post-surgical pain (CPSP) is a growing area of study in pain medicine. An increasing number of patients undergoing surgery each year, multiplied by a variable reported incidence (5%–85%), produces an increased number of patients with new chronic pain. In recognition of CPSP as an important global health problem, the International Association for the Study of Pain (IASP) named 2017 the Global Year Against Pain…

Disability Assessment

Introduction The transition from acute to chronic pain and disability because of multiple factors has been well documented in the literature. According to a morbidity and mortality weekly report from the Centers for Disease Control and Prevention (CDC), one in four United States adults, 61 million Americans, have a disability that impacts major life activities. These numbers are likely to increase in the next few decades…

Psychological and Behavioral Assessment

Psychological and Behavioral Assessment Chronic pain presents two broad challenges to proper assessment: 1) pain is personal and subjective, and 2) chronic pain impacts a wide range of patient functioning. These challenges necessitate a systematic approach to the standardized assessment of multiple domains of functioning using several assessment techniques, including interviews, questionnaires, behavioral observation, psychophysiologic measurement, diary data, and reports of significant others. This chapter will…

Biomarkers of Pain: Quantitative Sensory Testing, Conditioned Pain Modulation, Punch Skin Biopsy

Introduction Identification of potential biomarkers for chronic pain is essential for correct diagnosis, prediction, and evaluation of treatment response. A biomarker is defined as a “characteristic objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention.” The establishment of a new biomarker should follow a standardized process and requires the definition of the exact objective, i.e.…

Radiologic Assessment of Patient With Spine Pain

Imaging is a significant but not independent component of the multifaceted evaluation of a patient with spine or limb pain. Imaging must be interpreted in concert with the history, physical exam, electrodiagnostic evaluation, and responses to image guided anesthetic or provocative procedures. Imaging alone should not be considered; it can only be understood in its proper context: the individual patient’s unique syndrome of pain or neurologic…

Electromyography and Evoked Potentials

In almost all instances, tests and/or studies can help elucidate the cause of a problem. However, of equal, and possibly greater, importance is the potential for a test to introduce data that clouds the picture and adds complicating factors that can result in a delay in diagnosis or in arriving at the wrong conclusions. In the evaluation of a patient with pain, particular caution must be…

History and Physical Examination of the Patient With Pain

This chapter provides an overview of appropriate history taking and a structured approach to the physical examination of a pain patient, along with the anatomic and physiologic basis of the physical findings. Physical examination serves to further explore and confirm the findings from the clinical history. Data obtained from the history are essential to pair with the physical exam to create a thoughtful differential diagnosis of…

Placebo and Nocebo Effects in Clinical Trials and Clinical Practice

The Magnitude of Placebo Analgesia Pain is by far the most studied placebo condition, and a large number of studies on the placebo effect have been performed in experimentally induced pain in healthy subjects or patients experiencing a painful condition. There are at least two explanations for this finding. First, pain is a subjective experience that undergoes psychological and social modulation more than any other condition.…

Mechanism-Based Treatment and Precision Medicine

Introduction The advancement of pain medicine is driven by the continual search for new and innovative solutions to a wide range of chronic pain conditions that affect more than 50 million Americans. An important approach is to better understand the mechanisms of pain and factors that determine the transition from acute to chronic pain states. By doing so, new and effective mechanism-guided preventive measures and therapeutics…

Comprehensive Approach to Evaluating Patients With Chronic Pain

Introduction In the United States, chronic pain is one of the most common reasons adults seek medical care. It has been linked to anxiety, depression, poor mobility, dependence on opioids, and poor perceived health and quality of life. Based on epidemiologic data from the 2016 National Health Interview Survey, the Center for Disease Control and Prevention (CDC) estimated that approximately 20% of adults had chronic pain,…

Psychosocial and Psychiatric Aspects of Chronic Pain

Introduction When a patient presents to a healthcare provider with a symptom of pain, the initial focus is on the patient’s medical history and the underlying pathology—a search to identify the “broken body part” that once identified is treated to eliminate the symptom. When pain is not easily alleviated and becomes chronic, it can cause a patient (provider and significant others) significant distress with many other…

Pharmacogenetics in Pain Management

Case13.1 A 58-year-old Asian-American male with no other significant past medical history presents to the clinic with acute herpes zoster in the left T4 dermatome. The patient endorsed severe localized pain and tactile allodynia associated with a vesicular eruption. After three months, the rash resolves, but he complains of severe burning pain, allodynia, and hyperalgesia in the left T4 dermatomal region, suggesting that he has developed…

Communication and Clinician Relationships to Improve Care for Patients With Chronic Pain

Introduction In March 1927, Dr. Francis Peabody, Harvard Medical School educator and Boston surgeon, published a seminal article in the Journal of the American Medical Association with the oft-quoted maxim, “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” Caring, by optimizing therapeutic relationships between clinicians and patients,…

Individual Differences in Experience and Treatment of Pain: Race, Ethnicity, and Sex

Though the experience of pain is nearly universal, the experience and burden of pain vary across race, ethnicity, sex, and gender. This chapter will discuss the disparities in the experience and burden of pain and variability in responses to treatment across these groups. Clarification of Terminology Race and ethnicity are often used interchangeably in both colloquial language and research. However, these represent two different constructs. Race refers…

Neuroimaging Techniques

Introduction Pain, defined as the conscious subjective experience associated with real or potential tissue damage, is a product of coordinated activity across large portions of the brain. In contrast, the concept of nociception refers to the objective neural processes triggered by nociceptive stimuli and does not imply consciousness. Therefore one important goal of neuroimaging is to understand how nociception leads to pain and explain what happens…

Neurochemistry of Nociception

Origins of the Pain Phenotype For heuristic purposes, we can distinguish the three mechanistically distinct sources of a pain state: (1) high intensity stimulation, (2) local tissue injury and products released secondary to injury and inflammation, and (3) injury to the peripheral nerve. These conditions may achieve further distinction by being characterized as acute or chronic, where chronic pain is defined as persistent or recurrent pain…

Neurophysiology of Pain: Peripheral, Spinal, Ascending, and Descending Pathways

Introduction The neural circuits that are responsible for pain and the reactions to pain can be termed the pain system, or perhaps more appropriately, the pain systems . The pain systems include (1) peripheral neurons with a set of peripheral receptive elements, the nociceptors, (2) numerous central neuronal relay pathways, and (3) sets of integrative neurons that impose excitatory or inhibitory influences on nociceptive information at…

Education, Training, and Certification in Pain Medicine

The Evolution of Pain Medicine as a Subspecialty As medical knowledge expands, there is a natural progression toward specialization. No physician can become an expert in every field, yet there is discomfort with this inevitable narrowing of focus. The urge to both specialize and remain unspecialized dates back to the earliest recorded history in medicine. The first specializations were between barber surgeons and internists; a rivalry…

Quality Assessment, Improvement, and Patient Safety in Pain Management

This chapter covers challenges in defining, measuring, and improving quality in pain management as well as patient safety issues. These are in some cases distinct and in others inextricably interrelated. They are each debated on national and international levels, and both are fundamental elements of the daily practice of pain management. The first section considers quality assessment and improvement programs and practical steps to measure quality…

The Healthcare Policy of Pain Management

Rationale for Pain Management Being a Healthcare Policy Priority Chronic pain is a major cause of suffering, disability, lost productivity, and diminished quality of life across the entire life span and around the world. The global burden of chronic pain is increasing in parallel with the aging worldwide population and the greater prevalence of pain-associated medical conditions like diabetes and obesity. In its seminal report, “Relieving…